As an EmblemHealth network provider, you may be responsible for providing and/or coordinating trauma-informed care for Medicaid Managed Care (MMC) children/youth in direct placement foster care and in the care of Voluntary Foster Care Agencies (VFCAs). See guidance documents, including:
- New York Medicaid Program 29-I Health Facility Billing Manual
- Transition of Children Placed in Foster Care and NYS Public Health Law Article 29-I Health Facility Services into Medicaid Managed Care
Effective April 1, 2023, MMC members, including children/youth placed in foster care, had their pharmacy benefits transitioned to NYRx, the Medicaid Pharmacy Program. However, physician-administered drugs, durable medical equipment, prosthetics, orthotics, and supplies are still covered by EmblemHealth when billed as a medical or institutional claim (refer to the pharmacy procedure code manual).
The pharmacy benefit requirements for children/youth placed in foster care include, but are not limited to:
- Rapid replacement of medically necessary prescriptions.
- Transitional fills for children/youth newly placed in foster care.
Fiscal Responsibility
When a community provider (dental, vision, primary care provider (PCP), etc.) accepts an MMC member as a patient, the community provider agrees to bill EmblemHealth for services provided. The community provider is prohibited from requesting any monetary compensation from the beneficiary, foster parent, foster care youth, the VFCA or Local Departments of Social Services (LDSS). The community provider will not require the child/youth’s responsible relative, foster parent, foster care youth, or VFCA to sign any documents that would indicate a financial responsibility for any services that are covered under Medicaid or EmblemHealth.
Consent
The foster parent is not permitted to consent to medical treatment on behalf of the child/youth in foster care. Community providers must contact the VFCA Managed Care Liaison before any community provider appointment to ensure any needed consents are signed by the medical consenter (i.e., birth parent, if parental rights are not terminated, or a designee from the agency, if parental rights are terminated).
Initial Medical Assessment
Upon placement into foster care, a child/youth is required to have an Initial Medical Assessment within the first 30 days of the child/youth’s placement. The child/youth may use any PCP or qualified practitioner in the EmblemHealth network for the purposes of this Initial Medical Assessment.
Primary Care
For ongoing primary care visits, if there is a discrepancy with the assigned PCP on the MMC member ID card, the child/youth should not be turned away; instead, please immediately call EmblemHealth at 855-283-2146 to rectify this matter.
Vision
Emergency, preventive, and routine eye care services are covered by EmblemHealth. Eye care coverage includes the replacement of lost, damaged, or destroyed eyeglasses. For children in foster care, replacement of eyeglasses and/or contact lenses must immediately be authorized as necessary upon placement into foster care, return from trial discharge, or return from home visit. Children/youth in foster care are not required to continuously use the same community vision provider and may access these services from any appropriate participating provider. Additional information can be found in the Medicaid Managed Care/Family Health Plus/ HIV Special Needs Plan Model Contract. If there are any questions or concerns, please immediately call EmblemHealth at 855-283-2146 to rectify this matter.
Orthodontic Treatment
For ongoing community orthodontic care for children/youth, it is desirable and recommended to continue and finish the active orthodontic treatment utilizing the existing functional orthodontic appliances. In a situation when the new orthodontist cannot continue the active orthodontic treatment with the existing orthodontic appliances due to multiple missing brackets and/or different treatment plans, then a detailed narrative substantiating the need for new orthodontic appliances must be submitted with a prior approval request. Additional information can be found in the New York State Medicaid Dental Policy and Procedure Manual.
If there are any questions or concerns regarding the information provided on this page, please immediately call EmblemHealth at 855-283-2146.
JP# 64624 09/2024