December 14, 2021

In May 2021 after many months of NYS Council advocacy to include amazing support from our mighty Billing Geeks group, the state notified us that plans are required to pay providers at an amount equivalent to the payments established for such services under New York State’s Medicaid ambulatory patient group (APG) rate-setting methodology for services provided to dual eligible clients.

While we were pleased with the ruling by the state, we were not satisfied with the transmittal the state sent to the plans notifying them of the requirement. Recently we requested an update to the initial letter that was transmitted to the plans on this matter to include the use of state letterhead, etc.  The updated Memorandum is linked below.  Feel free to use the Memo if/when a health plan representative gives you a hard time about payment for services in full and as required.

Here’s a link to the Memorandum.  Note the effective date:

https://health.ny.gov/health_care/managed_care/plans/docs/2021-12-01_duals_reimbursement_mmc.pdf

Many thanks to all for your advocacy resulting in this outcome.  Please let us know if you continue to have trouble with timely and full payment for services rendered.