Perinatal Care Manual 4th Edition 2020
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Managed care is a system where the overall care of a patient is overseen by a single provider or organization as a way to improve quality and control costs. The manual below defines procedures that Managed Care Organizations (MCOs) must follow in order to meet certain requirements in the HHSC managed care contracts, and to provide interpretation on contractual provisions that need clarification.
A joint project by ACOG and The American Academy of Pediatrics, this edition maintains the focus on reproductive awareness and regionally based perinatal care services with an added focus on patient safety and quality improvement. This edition provides updated information on maternal transport, definitions of levels of neonatal care, immunizations, nutrition, and planned home birth.
The New York State (NYS) Department of Health (DOH) has issued new NYS Medicaid Perinatal Care Standards, which incorporate and replace the previously published NYS Prenatal Care Standards, in full. The official NYS Medicaid Perinatal Care Standards policy document is available on the NYS DOH "Medicaid Perinatal Care Standards" web page.
The updated standards are effective August 1, 2022, for NYS Medicaid fee-for-service (FFS), and effective October 1, 2022, for NYS Medicaid Managed Care (MMC) Plans [inclusive of Mainstream MMC Plans, Human Immunodeficiency Virus (HIV) Special Needs Plans (HIV-SNPs), as well as Health and Recovery Plans (HARPs)]. This policy is applicable to all Medicaid perinatal care providers who provide prenatal/antepartum care, intrapartum care, and/or postpartum care. This includes medical care facilities, public or private not-for-profit agencies or organizations, physicians, licensed nurse practitioners, licensed midwives practicing on an individual or group basis, and MMC Plans that contract with these providers.
The New York State (NYS) Department of Health (DOH) Office of Health Insurance Programs (OHIP) has recently identified hospital inpatient billings for an acute level of care when the Medicaid member was in an alternate level of care (ALC) status, which has resulted in overpayments to inpatient facilities. Hospitals must accurately report the ALC status of a patient when billing Medicaid to ensure appropriate payment. Hospitals should adjust claims for overpayments and should also self-disclose overpayments to the Office of the Medicaid Inspector General (OMIG). Information regarding self-disclosure can be found on the OMIG "Self-Disclosure" web page.
New York State Codes, Rules, and Regulations (NYCRR) Title 10, 86-1.15(h) defines ALC services as "those services provided by a hospital to a patient for whom it has been determined that inpatient hospital services are not medically necessary, but that post-hospital extended care services are medically necessary, consistent with utilization review standards, and are being provided by the hospital and are not otherwise available." In addition, ALC claims for Medicaid members who have Coverage Code 20 (Community Coverage without Long Term Care) assigned, will be denied. If an individual assigned Coverage Code 20 no longer requires acute care and is being moved to ALC status, the inpatient facility must contact the local social services district of fiscal responsibility to determine the patient's eligibility for ALC care. Providers can refer to the NYCRR Title 18, 505.20 for more information regarding inpatient hospital responsibilities when a Medicaid member is in an ALC status.
New York State (NYS) Medicaid has been providing payment for lactation counseling services since 2013. Effective July 1, 2022, for NYS Medicaid fee-for-service (FFS), and effective September 1, 2022, for NYS Medicaid Managed Care (MMC) Plans [including mainstream MMC Plans, Human Immunodeficiency Virus (HIV) Special Needs Plans (HIV-SNPs) and Health and Recovery Plans (HARPs)], the list of allowable lactation certifications provided below, will be expanded to include those from nationally recognized accrediting agencies. NYS Medicaid payment is available for separate and distinct breastfeeding services provided by licensed medical professionals, who are also specially trained lactation counselors with the allowable certifications. Providers must be licensed as a physician, midwife (MW), nurse practitioner (NP), physician assistant (PA), or registered nurse (RN) and certified by a nationally recognized accrediting agency, as listed below, to be eligible for NYS Medicaid reimbursement for lactation counseling. Unlicensed providers and licensed professionals who are not listed below, even with certification in lactation counseling, are not eligible for NYS Medicaid reimbursement for lactation counseling.
Breastfeeding education and lactation counseling services must be ordered by a physician, NP, MW, or PA. Lactation consultants in this program are expected to practice within the scope of practice appropriate to their respective discipline, as defined by the Office of the Professions, New York State Education Department (NYSED).
As previously stated in the April 2022 Medicaid Update article titled Medicaid Enrollment Requirements and Compliance Deadlines for Managed Care Providers, all Medicaid Managed Care (MMC) network furnishing, ordering, prescribing, referring and attending (OPRA) providers must be enrolled with New York State (NYS) Medicaid program. Effective September 1, 2022, MMC Plans will deny payment to unenrolled pharmacies, other unenrolled practitioners, and providers for services provided and/or prescribed. Providers servicing MMC members should, without delay, begin the enrollment process and complete all required forms, including certifications.
Please note: The enrollment requirement is applicable only to enrollable provider types including pharmacies and most licensed practitioners. Non-enrollable provider types must not be terminated from MMC networks for failure to enroll in NYS Medicaid. Providers can refer to the NYS Enrollable Providers list, which is available through Excel.
Not all practitioner and pharmacy providers will meet criteria to qualify for enrollment. Providers can refer to the provider manuals available on the eMedNY "Provider Manuals" web page and on the eMedNY "Provider Enrollment and Maintenance" web page by selecting the appropriate provider type from the right-hand box titled "Provider List Filter".
Providers can check their enrollment status by utilizing the tools available on the NYS DOH "Medicaid Enrolled Provider Lookup" web page. Providers can search by entering their NYS Medicaid Provider ID or their National Provider Identifier (NPI). Providers are encouraged to use the table below to determine their current enrollment status and the corresponding action necessary, as required from the "Medicaid Type" provided in the result.
Providers who have submitted enrollment applications may check the status of their application in the Medicaid Pending Provider Listing file, which is updated weekly on the eMedNY "Medicaid Managed Care Network Provider Enrollment" web page.
Effective July 1, 2021, children in foster care placement were no longer excluded from New York State (NYS) Medicaid Managed Care (MMC) enrollment. Children who enter foster care placement receive a dental screening during their initial medical assessment. It is required that children in foster care are up to three years of age have their mouths examined at such medical examination and, where appropriate, referred for dental care. Children in foster care over the age of three are required to see a dentist at minimum, once a year, and must be provided dental care when needed.
Children may enter foster care having never seen a dentist. It is critical that these children receive expedited access to care. Providers must consider making an extra effort to accommodate these children into their dental practice by ensuring availability of appointments. As a reminder, the cost of analgesic and anesthetic agents, including nitrous oxide, is included in the reimbursement for dental services under the NYS Medicaid dental policy, which is available in the eMedNY New York State Medicaid Program Dental Policy and Procedure Code Manual. By enrolling in the NYS Medicaid program, providers have agreed to provide this service when medically necessary as part of the dental procedure. MMC Plans are also required to cover nitrous oxide when medically necessary; reimbursement for nitrous oxide is determined by the terms of the contract between the provider and the plan and may be included in rates for service or separate. Providers should check the terms of their contracts with the MMC Plans they participate with on appropriate billing for analgesic and anesthetic agents.
Foster parents should never be charged for services that are already covered. For additional information, providers can refer to the Medicaid Beneficiaries Cannot be Billed article, published in the February 2014 issue of the Medicaid Update.
In order to better understand patient perspectives on telehealth, the New York State (NYS) Department of Health (DOH) Office of Health Insurance Programs (OHIP) has partnered with the Office of Addiction Services and Support (OASAS), Office of Mental Health (OMH), Office of Children and Family Services (OCFS), and the Office for People with Developmental Disabilities (OPWDD) to conduct the Telehealth Consumer Survey. All NYS residents, whether they have used telehealth services or not, are encouraged to complete the survey, which will close on August 1, 2022. Survey results will be used to inform future telehealth policy development within NYS. Providers are asked to encourage their patients to complete the survey before August 1, 2022.
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