The Medicaid Update is a monthly publication of the New York State Department of Health. Long-term care. PDF Medicare and Medicaid Basics - Centers for Medicare & Medicaid Services Cell and gene therapies offer life-changing opportunities for patients suffering from blood cancers, genetic diseases and rare diseases. Take action to keep your Medicaid or CHIP benefits. Other services that promote physical and mental health and well-being. Other services that Medicaid will not cover in Kentucky can include, but are not limited to the following: Cosmetic surgeries and services. In commercial coverage, there are no federal requirements for plans to cover specific drugs, although plans in the individual and small group market are required to cover essential health benefits (EHBs) that set minimum standards for prescription drug coverage.11 With the emergence of cell and gene therapies, plans and employers are looking for ways to enable access for their beneficiaries while managing high upfront costs. MMC Plans must configure their payment systems no later than February 7, 2022 to pay claims for dates of service on or after December 1, 2021. These two individuals from Macomb and Oakland counties are the first human arboviral illness cases identified in the state this year. Federal Register. Payment will not be made to NYS Medicaid providers for the cost of COVID -19 vaccine because the vaccine is available at no cost to providers. The Medicaid program is jointly funded by the federal government and states. ASGCT. Division of Medicaid and Health Financing For additional information, providers can refer to the previously issued guidance regarding mental health counseling provided by Article 28 outpatient hospital clinics and free-standing D&TCs listed below: The NY State of Health, The Official Health Plan Marketplace (Marketplace) has launched a pilot program known as "NY State of Health, Care at Home" to help New Yorkers shop for safe and reliable home care services for themselves or their loved ones on a "private pay" basis. Medicare has also established a new DRG for chimeric antigen receptor (CAR) T-cell and other immunotherapies. Medical Assistance - Department of Human Services More than 6.3 million individuals one in three New Yorkersare enrolled in health coverage through the Marketplace. Department for Medicaid Services - Cabinet for Health and Family Services Article 28 clinics (including HOPDs and D&TCs) should bill an ordered ambulatory claim using the CPT code "99429" appended with the GQ modifier to indicate the service was provided via audio-only (telephonic) telehealth. The Center for Medicaid and CHIP Services (CMCS) is committed to working in close partnership with states, as well as providers, families, and other stakeholders to support effective, innovative, and high quality health coverage programs. Transplants. The new regulations would require insurers to study whether their customers have equal access to medical and mental . (n.d.). VBP arrangements for pharmaceuticals are getting off the ground, but as with Medicaid, progress has been in part limited by Medicaid rules, requiring drug manufacturers to provide best price to state Medicaid agencies. Cell and gene therapies seek to modify genetic material in order to treat an inherited or acquired disease. For more information, see https://www1.magellanrx.com/documents/2022/12/medical-pharmacy-trend-report-2022.pdf, 13 Hinton, E., Guth, M., Raphael, J., Haldar, S., Rudowitz, R., Gifford, K., Lashbrook, A., Nardone, M., Wimmer, M. (2022, October). Claim level identifiers are required for any 340B purchased drug billed to Medicaid fee-for-service (FFS), Medicaid Managed Care (MMC) Plan, or as a secondary claim. Two Michigan residents have tested positive for Jamestown Canyon virus (JCV), a mosquito-borne virus. (844) 778-2700. The NYS DOH will continue to monitor the use of these codes to ensure compliance. For more information, see https://www.medicaid.gov/medicaid/prescription-drugs/medicaid-drug-rebate-program/index.html, 7 Centers for Medicare & Medicaid Services. https://asgct.org/global/documents/asgct-citeline-q1-2023-report.aspx, 3 Gottlieb, S. (2019, January 15). Manatt, Phelps & Phillips, LLP var today = new Date(); var yyyy = today.getFullYear();document.write(yyyy + " "); | Attorney Advertising, Copyright var today = new Date(); var yyyy = today.getFullYear();document.write(yyyy + " "); JD Supra, LLC. Build a Morning News Digest: Easy, Custom Content, Free! Pharmacists may provide audio-only (telephonic) telehealth counseling and must document the couseling in the pharmacy record with the claim that is submitted for CPT code "99429". An accurate National Drug Code (NDC) and "UD" modifier must be reported for any physician-administered drug obtained at the 340B price that are billed on the Institutional claim form for either FFS or MMC. White House plan would bolster mental health coverage - STAT Medicaid Works - Cabinet for Health and Family Services The new regulations, which still need to go through a public comment period, would require insurers to study whether their customers have equal access to medical and mental health . Under this program, workers with disabilities who earn less than 200 percent of the federal poverty level can pay a monthly premium to buy into the Medicaid program. A provider submitting a professional claim should bill Current Procedural Terminology (CPT) code "99429", Unlisted Preventative Medicine Service, for reimbursement of COVID-19 vaccination counseling. *All FFS 340B claims must be submitted at acquisition cost, by invoice, inclusive of all discounts. Since the costs of cell and gene therapy to hospitals may be significantly higher than such reimbursement, this reimbursement structure could disincentivize hospitals from offering cell and gene therapies to patients. Diabetic test strips are not covered outpatient drugs and are not part of the Medicaid Drug Rebate Program (MDRP), and therefore are not eligible for a 340B discount. NYS Medicaid FFS and MMC also cover, without copayments, treatments for conditions that may seriously complicate the treatment of COVID-19 for individuals who have, or are presumed to have, COVID-19 during the period when they are diagnosed with, or presumed to have, COVID-19. Medicaid is the primary payer across the nation for long-term care services. 6 In practice, states sometimes delay coverage of . Other third parties generally pay after settlement of claims Medicaid is last payer for services covered under Medicaid, except in those limited Medicaid spending is shared by the federal government and states and . The federal government pays states for a specified percentage of program expenditures, called the Federal Medical Assistance Percentage (FMAP).States must ensure they can fund their share of Medicaid expenditures for the care and services available under their state plan. A physician-administered drug will not be paid under Ambulatory Patient Groups (APGs) if the claim does not include an accurate NDC. The article titled Reminder to Providers: New York State Requires Coordination of Benefits, published in the July 2020 issue of the Medicaid Update, directed providers to exhaust all existing benefits prior to billing the Medicaid program. (2023, May 26). If there is a responsible third party who should be paying for the Medicaid member's health benefits as primary payor, that responsible third party must pay first. Fact sheets are available in English, Spanish, Traditional Chinese, Russian, Haitian Creole, Bengali, and Korean. This coverage also includes treatment for post-acute-COVID conditions, which may be described as "long COVID". Similar guidance can be found in the May 2020 COVID-19 guidance titled New York State (NYS) Medicaid Fee-for-Service (FFS) Policy and Billing Guidance for COVID-19, Testing and Specimen Collection at Pharmacies As of 12/16/2021. Since the costs of cell and gene therapy to hospitals may be significantly higher than such reimbursement, this reimbursement structure could disincentivize hospitals from offering cell and gene therapies to patients. Editors Note: In a new white paper, summarized below, Manatt Health discusses emerging reimbursement models for cell and gene therapies. Medicaid Financing: The Basics | KFF If a Medicaid member has third-party insurance coverage, the benefits of those coverages must fully be used before billing the NYS Medicaid program. The first three therapiesKymriah, Luxturna and Yescartawere approved by the FDA in 2017. Down category as described in the Bureau's rules at 1200-13-14-.02. Medicaid | Department of Health | State of Louisiana Most Medicaid programs use a diagnosis-related group (DRG) system to reimburse hospitals for inpatient services, where a hospital receives a bundled payment for both the services provided and any drugs administered. Reminder: Medicine cabinet drugs and emergency kit replenishment is included in the LTC rate and may not be separately billed to Medicaid. (2022, August 10). A. NYS Medicaid Will Not Reimburse for the Cost of COVID-19 Vaccine 1. 11 For prescription drugs included in the EHBs, cost-sharing is capped by a plans maximum annual limit on cost-sharing. Medicaid | Medicare In addition, you have to possess Medicaid hospital insurance. Two or more hospital inpatient stays related to cancer, diabetes, heart failure, and/or HIV/AIDS within the last 12 months; Five or more ED visits related to cancer, diabetes, heart failure, and/or HIV/AIDS within the last 12 months; Fee-for-Service (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)4732160 or by email at. Coverage and Reimbursement - Medicaid: Utah Department of Health and (n.d.). MTM services can also be provided to enrollees as preventative intervention to reduce the rish and incidence of high-volume hospital inpatient stays and/or ED visits related to cancer, diabetes, heart failure, and/or HIV/AIDS, without reductions to PCA hours. Regulations may also be viewed on the NYS DOH unofficial Compilation of the Rules and Regulations of New York (NYCRR) "Recently Adopted Regulations" web page. During COVID-19, Financial Services Litigation and Enforcement, Intellectual Property Protection and Enforcement, Technology and Intellectual Property Litigation, Long-Term Care/Long-Term Services and Supports, https://asgct.org/global/documents/asgct-citeline-q1-2023-report.aspx, https://www.fda.gov/news-events/press-announcements/statement-fda-commissioner-scott-gottlieb-md-and-peter-marks-md-phd-director-center-biologics, https://innovation.cms.gov/data-and-reports/2023/eo-rx-drug-cost-response-report, https://asgct.org/education/more-resources/gene-and-cell-therapy-faqs, https://www.medicaid.gov/medicaid/prescription-drugs/medicaid-drug-rebate-program/index.html, https://www.federalregister.gov/documents/2023/05/26/2023-10934/medicaid-program-misclassification-of-drugs-program-administration-and-program-integrity-updates, https://www.govinfo.gov/content/pkg/FR-2022-08-10/pdf/2022-16472.pdf, https://www1.magellanrx.com/documents/2022/12/medical-pharmacy-trend-report-2022.pdf, https://files.kff.org/attachment/REPORT-How-the-Pandemic-Continues-to-Shape-Medicaid-Priorities-Results-from-an-Annual-Medicaid-Budget-Survey-for-State-Fiscal-Years-2022-and-2023.pdf. MMC reimbursement, billing, and/or documentation requirement questions should be directed to enrollee MMC Plans. Please note: All 340B claims are subject to audit and investigation; in addition, claims improperly identified as 340B and/or claims with unsubstantiated acquisition cost may be considered fraudulent claims. necessary prior authorizations or appeals; prescription alternatives (for a non-formulary or non-preferred drug); necessary changes (quantity or day supply, etc. https://files.kff.org/attachment/REPORT-How-the-Pandemic-Continues-to-Shape-Medicaid-Priorities-Results-from-an-Annual-Medicaid-Budget-Survey-for-State-Fiscal-Years-2022-and-2023.pdf, Accessing Cell and Gene Therapies: Insights on Coverage, Reimbursement and Emerging Models, Name Image Likeness (NIL) in College Athletics, Estate Planning and Personal Representation, Executive Compensation and Employee Benefits, Impact Investing and Community Development, Special Purpose Acquisition Companies (SPACs), California State Government and Regulatory Policy and Government Contracts, Federal Government Affairs and Public Policy, Government Litigation and Administrative Law, Investigations, Compliance and White Collar Defense, New York City Government, Policy and Government Contracts, New York State Government, Regulatory Policy and Government Contracts, Capabilities to Serve Clients The Medicare program, however, has not experimented with VBP arrangements or separate payments for therapies provided in the inpatient setting. Medicaid & You: Frequently Asked Questions | Medicaid.gov New York State Medicaid Update - July 2021 Volume 37 - Number 9 A Health Reimbursement Arrangement (HRA) isn't traditional health coverage through a job. FFS Pharmacy coverage and policy questions should be directed to the Medicaid Pharmacy Policy Unit by telephone at (518)4863209 or by email at PPNO@health.ny.gov. DISCLAIMER: Because of the generality of this update, the information provided herein may not be applicable in all situations and should not be acted upon without specific legal advice based on particular situations. Your employer contributes a certain amount to the HRA. These programs are intended to provide protection to Medicaid managed care organizations (MCOs), which, depending on their size, can face financial troubles if they pay a higher-than-expected number of cell and gene therapy claims. Medicaid regulations at 18NYCRR 540.6(e) require a provider to pursue any available other coverage prior to submitting a claim to Medicaid. A Report in Response to the Executive Order on Lowering Prescription Drug Costs for Americans. Effective January 1, 2022, all New York State (NYS) Medicaid-enrolled transportation providers must follow expanded accident/incident reporting protocol. II. The Biden administration proposes new rules to push insurers to boost State of New York, Mary T. Bassett, M.D., M.P.H. These claims must be submitted hard copy with a copy of the HMO Explanation of Benefits from the carrier that is on file with the state; Previously denied applications received prior to December 1, 2021, will not be automatically processed. https://files.kff.org/attachment/REPORT-How-the-Pandemic-Continues-to-Shape-Medicaid-Priorities-Results-from-an-Annual-Medicaid-Budget-Survey-for-State-Fiscal-Years-2022-and-2023.pdf. For those drugs or plans not subject to EHBs (e.g.,large group or self-insured plans), patients out-of-pocket costs for cell and gene therapies may be prohibitive. Accessing Cell and Gene Therapies: Insights on Coverage, Reimbursement A provider may not bill CPT code "99429": A pharmacist providing COVID-19 vaccination counseling should bill using the National Council for Prescription Drug Programs (NCPDP) D.0 claim format as outlined below. Medicaid spending (not including administrative costs) totaled $728 billion in federal fiscal year (FFY) 2021 (Figure 1). Health Care/ Medical Assistance. Medicare may pay additional funds to a hospital for a newly launched high-price therapy via New Technology Add-On Payments (NTAP) or outlier payments in the case of inpatient therapies or pass-through payments in the case of outpatient payments. The researchers study this variation in the magnitude of the reimbursement rate change, using data from the National Health Interview Survey, and find that the policy change expanded access to care. The pilot program initially launched to serve Nassau, Suffolk and Westchester counties and will be expanded statewide in the future. A list of all CMS ET3 Model Selected Applicants is available and includes twenty-four New York State (NYS) ambulance services. It includes CMS, state Medicaid agencies and ~780 drug manufacturers. Pharmacies should not submit claim level identifiers on non-340B eligible items, such as test strips. Medicaid & Health | Idaho Department of Health and Welfare Various cell and gene therapies have gained market approval over the past five years, creating the need for state Medicaid agencies and commercial payers to find financing solutions to cover therapy costs. NYS Department of Health (DOH) invited ambulance services selected by CMS to participate in the NYS DOH parallel model. As communicated in the December 2016 issue of the Medicaid Update cited and linked in the beginning of this article, 340B claim level identifiers are required on all 340B purchased drug claims for Medicaid members. Statement from FDA Commissioner Scott Gottlieb, M.D., and Peter Marks, M.D., Ph.D., director of the Center for Biologics Evaluation and Research on new policies to advance development of safe and effective cell and gene therapies. These programs are intended to provide protection to Medicaid managed care organizations (MCOs), which, depending on their size, can face financial troubles if they pay a higher-than-expected number of cell and gene therapy claims. Eligibility. Medicaid allows for the coverage of these services through several vehicles and over a continuum of settings, ranging from institutional care to community-based long-term services and supports (LTSS). Centers for Medicare & Medicaid Services. The NY State of Health, The Official Health Plan Marketplace (Marketplace) provides consumers quality, low-cost health insurance options, with a choice of Qualified Health Plans in every county and continues to offer expanded tax credits through the American Rescue Plan Act (ARPA). This change is effective January 1, 2022 for NYS Medicaid fee-for-service (FFS) and effective April 1, 2022 for Medicaid Managed Care (MMC). July 28, 2023. Counseling on second and subsequent doses is not billable. Manufacturers, however, have not yet embraced these arrangements. COBRA shall mean health insurance coverage provided pursuant to the Consolidated Omnibus Budget Reconciliation Act. In 2022, a CMS rule that allows manufacturers to report separate pricing in the context of value-based arrangements (multiple best prices) opened the door to such arrangements in the commercial market. It must be used in conjunction with Florida Medicaid's General Policies (as defined in section 1.3) and any applicable service-specific and claim reimbursement policies with which providers must comply.
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