New York State Medicaid Update - September 2024 Updates to New York State Medicaid Coverage of Coronavirus Disease 2019 Services Special Edition Volume 40 - Number 9
Updates to New York State Medicaid Coverage of Coronavirus Disease 2019 Services
The following guidance applies to coronavirus disease 2019 (COVID-19)-related services delivered to New York State (NYS) Medicaid fee-for-service (FFS) members and Medicaid Managed Care (MMC) enrollees after the expiration of certain provisions in the American Rescue Plan (ARP) Act on September 30, 2024, and the Public Readiness and Emergency Preparedness (PREP) Act on December 31, 2024.
Beginning October 1, 2024, providers are instructed to follow the coverage and billing guidance for COVID-19 related services below.
COVID-19 Vaccine and Vaccine Administration:
- Provider vaccine and vaccine administration billing will follow billing guidance used for all other routine vaccinations for NYS Medicaid members of all ages. Provider reimbursement for COVID-19 vaccine and vaccine administration will be in accordance with published procedure codes and standard reimbursement rates as contained in current fee schedules. Updated guidance will be published in the September 2024 issue of the Medicaid Update.
- Providers are reminded that COVID-19 vaccines are available to NYS Medicaid members younger than 19 years of age through the Vaccines for Children (VFC) program. Providers may not bill NYS Medicaid for the cost of vaccines that have been obtained via the VFC program.
- Effective through December 31, 2024, non-VFC enrolled pharmacies may bill the COVID-19 vaccine per the guidance posted in the New York State Medicaid Coverage for Coronavirus Disease 2019 Vaccines for Eligible Vaccine For Children Program Members at the Pharmacy article published in the August 2024 issue of the Medicaid Update.
- The reimbursement for Current Procedure Terminology (CPT) code "90480" billed for COVID-19 vaccine administration for NYS Medicaid members 19 years of age and older will be adjusted to align with other vaccine administration fees. For individuals enrolled in an MMC Plan, practitioners must check the MMC Plan of the enrollee for reimbursement and billing guidance.
- Pharmacy providers will follow the vaccine billing guidance found in the NYRx, the New York State Medicaid Pharmacy Program Pharmacists as Immunizers Fact Sheet.
- Effective December 31, 2024, PREP Act authority for pharmacist ordering of COVID-19 vaccines will expire.
- Please note: COVID-19 vaccines will continue to be covered when ordered by qualified practitioners by patient specific and non-patient specific orders.
- Effective December 31, 2024, PREP Act authority for pharmacy technicians administering vaccines will expire.
- Please note: Vaccines will continue to be covered at the pharmacy when administered by New York State Education Department (NYSED)-authorized pharmacy personnel (i.e. pharmacists and interns).
COVID-19 Testing:
- Practitioners will continue to be reimbursed for medically necessary Molecular/Polymerase Chain Reaction (PCR) tests, antigen tests, and multiplex tests, as outlined in the New York State Medicaid Program - Fee-For-Service Laboratory Procedure Codes and Coverage Guidelines Manual.
- NYRx, the NYS Medicaid Pharmacy program, will no longer provide coverage for COVID-19 testing when administered in a pharmacy. Additionally, NYRx will no longer cover COVID-19 over the counter (OTC) tests. Providers should refer to the New York State Medicaid Pharmacy Policy for Coronavirus Disease 2019 Testing article published in the August 2024 issue of the Medicaid Update, for additional information.
COVID-19 Treatment and Therapeutics:
- Providers will continue to be reimbursed for treatment and therapeutics that are medically necessary and U.S. Food and Drug Administration (FDA)-approved, as outlined in the following documents:
- eMedNY New York State Medicaid Provider Procedure Code Manuals and Fee Schedules on the eMedNY "Physician Manual" web page; and
- New York State Department of Health List of Medicaid Reimbursable Drugs.
- Effective October 1, 2024, treatment and therapeutics authorized under Emergency Use Authorization (EUA) will no longer be a covered service, unless they receive full FDA-approval.
- Effective December 31, 2024, PREP Act authority for pharmacist ordering of COVID-19 therapeutics will expire.
- Please note: COVID-19 treatment and therapeutics will continue to be covered when ordered by qualified practitioners.
COVID-19 Vaccine Counseling:
- COVID-19 vaccine counseling will no longer be billable by practitioners or pharmacies as a stand-alone service for NYS Medicaid members and can be included in the Evaluation and Management (E&M) visit.
- Pediatric vaccine counseling, which includes COVID-19 vaccine counseling, should be billed in accordance with the Early and Periodic Screening, Diagnostic, and Treatment Program Childhood Vaccine Counseling Coverage Benefit article published in the August 2024 issue of the Medicaid Update.
Please note: Effective through December 31, 2024, childhood vaccine counseling may be provided by a pharmacy in accordance with the Public Ready and Emergency Preparedness (PREP) Act.
COVID-19 Copays:
- Claims submitted for COVID-19-related services should not routinely be identified as emergencies. NYS Medicaid providers may collect copayments for COVID-19-related testing, evaluation, and treatment, including preventive therapies and specialized equipment for non-emergent care as appropriate. For undocumented individuals with coverage code "07", only claims for services that meet the federal definition of an "emergency medical condition" should be reported to make the services exempt from copays using:
- Emergency Indicators "Y", for professional claims; and
- Type of Admission Code = "1", for institutional claims.
Providers should refer to the Medicaid for the Treatment of an Emergency Medical Condition Fact Sheet, for more information. - For pharmacy providers, the use of "04" in National Council for Prescription Drug Programs (NCPDP) field 461-EU (Prior Authorization Type Code) for exemption of copay will no longer apply to COVID-19 copayments.
Questions and Additional Information:
- Practitioner billing information and fee schedules are found on the eMedNY "Physician Manual" web page.
- FFS coverage and policy questions should be directed to the Office of Health Insurance Programs (OHIP) Division of Program Development and Management (DPDM) by telephone at (518) 473-2160 or by email at FFSMedicaidPolicy@health.ny.gov.
- FFS billing/claim questions should be directed to the eMedNY Call Center at (800) 343-9000.
- MMC enrollment, reimbursement, billing and/or documentation requirement questions should be directed to the specific MMC Plan of the enrollee. MMC Plan contact information can be found in the eMedNY New York State Medicaid Program Information for All Providers - Managed Care Information document.
- NYS Medicaid Pharmacy policy questions should be directed to NYRx@health.ny.gov.
Kathy Hochul
Governor
State of New York
James McDonald, M.D., M.P.H.
Commissioner
New York State Department of Health
Amir Bassiri
Medicaid Director
Office of Health Insurance Programs
The Medicaid Update is a monthly publication of the New York State Department of Health.
