Medicaid Redesign Team Change Effective March/April 1, 2014

Date Issued: 4/4/2014


Smoking Cessation Counseling Benefit Increased

Effective March 1, 2014, the smoking cessation counseling benefit for Medicaid and Family Health Plus members increases from six to up to eight face-to-face sessions in a 12-month period.


Permanent Nursing Home Stays

SDOH has delayed the change in the Medicaid managed care benefit to cover long term nursing home placement for members 21 years of age and older who live in New York City, Nassau, Suffolk or Westchester county, pending receipt of CMS approval. We will inform you when a firm date is set.

HIV Laboratory Tests

Effective April 1, 2014, EmblemHealth covers the following laboratory tests for Medicaid and Family Health Plus members:

  • HIV phenotype testing for prediction using (regularly updated) genotype biochemical and biological analysis – CPT code: 87900
  • Infectious agent genotype analysis by nucleic acid (DNA or RNA); HIV-1, other region (e.g., integrase, fusion) – CPT code: 87906
  • HIV genotype testing (mutation analysis) for resistance - CPT code: 87901
  • HIV phenotype testing (resistance testing) - CPT codes:
    • 87903 for first 10 drugs
    • 87904 for each additional drug (list separately in addition to primary procedure)
  • Trofile Assay - CPT code: 87999

CTP code 87999 is “unlisted.” EmblemHealth requires providers to submit an unlisted procedure form to determine the service rendered. Once we receive the form, our medical directors will review the information and approve or deny the service.


  1. Trofile Assay is already a covered benefit for Family Health Plus members.
  2. EmblemHealth maintains a contract with Quest Diagnostics Inc. to provide outpatient clinical services to our members. In order to ensure that members receive the highest level of plan benefit, laboratory specimens should be referred to Quest Diagnostics.

Knee Surgery

Effective April 1, 2014 viscosupplementation is no longer covered for Medicaid and FHPlus enrollees with a diagnosis of osteoarthritis of the knee. All other diagnoses associated with viscosupplementation continue to be covered.