Infertility benefits changed October 1 for Medicaid
New York State has mandated changes for infertility benefits for our Medicaid members. Effective Oct. 1, 2019, changes for Medicaid are limited to female infertility and offers certain drug coverage. For details about infertility and the state’s demonstration project, see the DOH website.
Change in Medicaid coverage for child annual wellness visits
Medicaid members less than 21 years old are now covered for an annual wellness visit once every calendar year. Previously, child wellness visits were only covered once every 12 months.
Permanent placement process for Medicaid members
For Medicaid members in need of long-term residential care, the facility must request increased coverage from the Local Department of Social Services (LDSS) via submission of the LDSS-3559 (DOH-5182) form (or equivalent) within 48 hours of a change in a member’s status.
The facility must also submit to the LDSS a completed Notice of Permanent Placement Medicaid Managed Care (MAP form) within 60 days of the change in status. The facility must also notify EmblemHealth of the change in status.
If requested, the facility must submit a copy of the MAP form to EmblemHealth for approval prior to the facility’s submission of the MAP form to the LDSS. Payment for residential care is contingent on the LDSS’ official designation of the member as a “Permanent Placement Member.”
New contact information for Long Term Support Service (LTSS) for Medicaid members
We have a new fax number and email address for you to request LTSS services for Medicaid members needing Personal Care Services, Consumer Directed Personal Assistance Services, Private Duty Nursing, Adult Day Health Care, and Personal Emergency Response Services. Please email: longtermsupportservices@emblemhealth.com or fax requests to: 212-510-5248. You may also use the email to send us your LTSS questions.
Informed consent required for Medicaid hysterectomy/sterilization
Federal regulations require Medicaid patients’ consent to hysterectomy and sterilization procedures. A signed consent form must be submitted for the claim to be processed.
Compliance: Home Care Worker Wage Parity Law
Organizations, hospitals, or hospital systems contracted with entities to provide home care services for EmblemHealth Medicaid, CHP, and HARP members in New York City as well as Nassau, Suffolk, or Westchester counties are required to provide the New York State Department of Health and EmblemHealth with quarterly written certification of their organization’s or hospital’s compliance with the minimum wage requirements of the Home Care Worker Wage Parity-Public Health Law of §3614-c. We will contact you via fax several times each year to ask you to fax us your wage parity certifications. Please comply with this regulation and send the information when requested.
Medicaid provider disclosure of ownership and control
The New York State Department of Health requires written disclosure regarding ownership, control, and criminal convictions related to certain controlling persons’ involvement in Medicare, Medicaid, or Title XX programs. Specifically:
- Section 42 CRF455.104 ‒ Requires Managed Care Organizations, like EmblemHealth, to collect the disclosure of complete ownership, control, and relationship information from certain entities identified in the statute. These include:
- all participating hospitals
- skilled nursing facilities
- home health agencies
- independent clinical laboratories
- renal disease facilities; and
- any entity (other than an individual practitioner or group of practitioners) that furnishes or arranges for health-related services for which it provides claims payment under any plan or program established under Title V or Title XX of the Social Security Act
- Section 42 CRF455.106 ‒ Requires Managed Care Organizations, like EmblemHealth, to collect and report health care-related criminal conviction disclosure information (initially and upon renewal of their contracts) of any managing employee who has been convicted of a criminal offense related to that person’s involvement in any program under Medicare, Medicaid, or a Title XX program.
Disclosure forms must be completed and submitted as part of the credentialing and recredentialing processes. This applies to both directly contracted providers and delegated entities. Disclosure forms must also be submitted when a reportable event occurs and upon request of the New York State Department of Health and EmblemHealth.
Required annual compliance certification on Office of the Medicaid Inspector General’s website
If you are a Medicaid provider, you are likely required to attest each December you have developed and implemented a compliance program to detect and prevent fraud, waste, and abuse in the Medicaid program. Depending on the type of provider you are, or the extent to which you treat Medicaid members, you may be required to complete one or both Office of the Medicaid Inspector General (OMIG) Annual Compliance Certifications. The certifications may only be done by completing the certification form available on OMIG’s website and clicking on the appropriate certification button (“SSL Certification” or “DRA Certification”). One attestation is needed for each Federal Employer Identification Number (FEIN) or Social Security number (SSN) used to receive Medicaid payments. You do not need to submit a copy of the compliance plan or self-assessment of your plan. With regard to the Social Services Law (SSL) certification, New York State’s (NYS’s) mandatory compliance program law applies to Medicaid providers subject to Public Health Law (PHL) Articles 28 or 36, or Mental Hygiene Law (MHL) Articles 16 or 31, regardless of the amount they bill, order, or receive from NYS’s Medicaid program. Plans will need to monitor network provider compliance with the SSL certification requirement.
In addition, a compliance program is required for other persons, providers, or affiliates who provide care, services, or supplies under the Medicaid program, or who submit claims for care, services, or supplies for or on behalf of another person for which Medicaid is, or should be reasonably expected by the provider to be, a substantial portion of their business operations as follows:
- A person, provider, or affiliate who claims, orders, has claimed or ordered, or should be reasonably expected to claim or order at least $500,000 in any consecutive 12-month period from Medicaid;
- A person, provider, or affiliate who receives, has received, or should be reasonably expected to receive at least $500,000 in any consecutive 12-month period directly or indirectly from Medicaid or a Medicaid Managed Care Plan; or
- A person, provider, or affiliate who submits or has submitted claims for care, services, or supplies to the Medicaid program on behalf of another person or persons in the aggregate of at least $500,000 in any consecutive 12-month period.
The law and regulations contain a set of eight minimum core elements applicable to all providers, regardless of size. However, the law also recognizes compliance programs should reflect the provider’s size, complexity, resources, and culture as long as the compliance program meets the requirements. The second annual compliance attestation, referred to as the Deficit Reduction Act (DRA) certification, must be completed by health care entities that receive or make $5 million or more in Medicaid payments. Providers required to meet both provisions usually include the DRA requirements in their (typically more comprehensive) mandatory compliance programs. OMIG suggests Medicaid providers review OMIG’s published Compliance Guidance, Medicaid Updates, and Compliance Alerts, among other OMIG publications and outreach methods, for information on how to meet NYS mandatory compliance program requirements. There is a Compliance Library on OMIG’s website to guide providers in developing and implementing an effective compliance program. Medicaid providers are encouraged to subscribe to OMIG’s listserv. The listserv provides an email notification of any changes to OMIG’s website, including changes to published compliance program-related materials. To see more detail on the compliance program requirements, see: OMIG's ssl certification and OMIG's dra certification.
