July 1, 2022

Below and attached please find final guidance for the inclusion of BH services into the Medicaid Advantage Plus Program documents.

Here’s the story:

Beginning in January 2021, the NYS Council identified a serious issue impacting payment to BH providers across the state.  MCOs, through a process called “default enrollment” were now able to enroll their Medicaid Managed Care members into their Medicare Advantage products when the client became Medicare-eligible.  In the absence of guidance from the state, MCOs were paying BH providers up to their Medicare rates with no opportunity to cross-over to the Medicaid Managed Care plan for payment up to their APG rates.  In effect, BH providers would lose money on every Medicaid Managed Care client that became Medicare-eligible.

Through our NYS Council advocacy alongside our Billing Geeks, we were able to compel the state to issue guidance that required MCOs to reimburse BH providers at the higher of Medicare OR  “APG government rates” for services provided to individuals concurrently enrolled in an MCOs’ Medicare Advantage product) AND its’ Medicaid managed care product.  That Guidance was issued last May and then again last November.

While this was a major win, at the point where the state confirmed our request, there was still an open issue because there was no specific guidance requiring MCOs to pay BH providers up to their Medicaid rates for individuals enrolled in a Medicaid Advantage Plus (MAP) product – one product that covers both Medicare and Medicaid benefits.  Due to our continued efforts, the state finally issued guidance to the plans requiring them to pay BH providers their Medicaid rates for ALL services.  See docs attached.

Notably, this section is from the Manual (attached):

Services Covered by Medicare and Medicaid –  Beginning January 1, 2023, MAP Plans will pay the “higher of” what Medicare or Medicaid would pay for BH ambulatory services that are reimbursable under both Medicare and Medicaid. With the principle of Medicaid being the payer of last resort, Medicaid is responsible for the remaining balance after the Medicare payment, up to the Medicaid rate if the Medicaid rate for the service is higher than Medicare. Medicaid reimburses 100 percent of the patient cost-sharing responsibility if the Medicare rate is higher than the Medicaid rate.

The “higher of” requirement applies to the following services:

• Mental Health Outpatient Treatment and Rehabilitative Services

• Personalized Recovery Oriented Services (PROS) (Clinic component)

• Outpatient Medically Supervised Stabilization and Withdrawal (Detox)

• Outpatient Chemical Dependence (CD) Clinic (aka Outpatient Addiction Rehab)

• Outpatient CD Rehabilitation (aka Outpatient Addiction Day Rehab)

• Opioid Treatment Program

Again, big shout out to Diane Novy at Jewish Board and all the other Billing Geeks who helped us achieve these reforms.  Also major thanks are due to Joe Katagiri.  Joe is the relatively new Director of Managed Care at the OMH.

From: OMH Managed Care Providers <PROVIDERS@LISTSERV.OMH.NY.GOV> On Behalf Of Roig, Annabella (OMH)
Sent: Friday, July 1, 2022 2:32 PM
To: PROVIDERS@LISTSERV.OMH.NY.GOV
Subject: NYS MAP Behavioral Health Billing and Coding Manual

Good Afternoon,

Attached please find the following billing documents for Medicaid Advantage Plus (MAP) Plans to support the carve-in of behavioral health services effective January 1, 2023. 

1. NYS MAP Behavioral Health Billing and Coding Manual 7.1.2022 – This guidance outlines the claiming requirements necessary to ensure proper BH claim submission with respect to MAP Plans.
2. Appendix- MAP Coding-taxonomy for BH services – This document provides the coding crosswalk from rate codes to procedure codes and modifiers for MAP Plan Behavioral Health Carve-in Services.
3. OMH Government Rate Table – MAP Plans should reference this document for provider-level rate information for OMH outpatient services.

A webinar will be scheduled with the Behavioral Health Providers on July 27, 2022 to review this and an announcement for registration will be sent shortly.

Please send any questions to the OMH-Managed-Care@omh.ny.gov  mailbox.