In This Issue:

HIP Service Area Expansion Affects GHI HMO Providers

New Prior Approval List

New Web Usage Requirements for GHI HMO Network Providers

New EmblemHealth Radiation Therapy Program and EmblemHealth Cardiology Imaging Program and HIP Radiology Programs Apply to More Members

Updated Fax Forms for: EmblemHealth Injectable Drug Utilization Management Program

EmblemHealth Consolidates Post Office Boxes for GHI HMO and EmblemHealth Medicare PPO

Claims Corner

Medicaid and Medicare Updates

Behind the Scenes

Case Management Programs

Stressing the Importance of Prenatal Visits

Well-Child Visits

High-Risk Medications for Elderly Patients

Healthful Aging Starts With Lifestyle Changes and Preventive Screenings

Talking With Patients About Urinary Incontinence

Treating Rheumatoid Arthritis

Assisting Patients Living With HIV

Treating Low Back Pain

Asthma Management

CPT Codes for Tobacco Cessation Counseling

Clinical Corner

News&Notes Archive

Medicaid and Medicare Updates

2012 Medicaid Redesign Team Changes

New York State Governor Andrew Cuomo has tasked the Medicaid Redesign Team (MRT) with lowering costs and increasing quality and efficiency for the state’s Medicaid program. In Phase 1, the MRT proposed significant structural reforms that would position the program within the target budget without requiring changes in eligibility. In March 2011, NYS passed many of these reforms.

Phase 2 MRT changes further support the state's goal to limit Medicaid program spending over multiple years, while retaining and improving quality. Phase 2 includes benefit changes, as well as population enrollment changes. Population enrollment changes were made in response to legislation requiring New York State to enroll additional populations into Medicaid managed care over the next three years.

Low Birth-Weight Babies

Infants weighing less than 1,200 grams at birth, or who are disabled and under 6 months of age, have begun receiving health benefit coverage through our Medicaid managed care plan as of April 1, 2012. Prior to this date, these infants were excluded from managed care and received their benefits from Medicaid Fee-for-Service.

We have a neonatal case management program to help low birth-weight babies and infants with disabilities at birth receive all necessary care and support and ensure that discharge treatment plans meet the needs of both the child and the family. For information about the program, please call 1-646-447-7302. If a newborn meets the criteria for disability, our nurse case managers will work with medical staff to complete required disability forms.

Additionally, our Healthy Beginnings PATH program helps plan members with high-risk pregnancies access effective prenatal care to prevent low birth-weight and infant disabilities. To enroll a pregnant member, please call 1-888-447-0337.

MRT Benefit Changes Summary

The following benefit changes now apply or are slated to apply to Medicaid and/or Family Health Plus (FHPlus) members as indicated. Please visit Policy Alerts on the provider page of our Web site for more information about the recent changes to our Medicaid and FHPlus plans.

Effective January 1, 2012

Personal Emergency Response Systems (PERS)
PERS was added to the Medicaid managed care benefit package. It's available only to members receiving home health or personal care services. Prior approval for PERS services is provided as part of the Personal Care Services (PCS) home assessment.

Effective January 1, 2012

Nonemergency Transportation Carve-Out Phase I

  • Medicaid: Emergency and nonemergency medical transportation are now covered by regular Medicaid via Medical Answering Services (MAS)
  • FHPlus: Nonemergency medical transportation are now covered by regular Medicaid via Medical Answering Services (MAS).

Effective October 1, 2012

This benefit is limited to Medicaid members under 21 years of age who exhibit a severe physically handicapping malocclusion and/or a qualifying congenital defect.

Effective November 1, 2012

Consumer Direct Personal Assistance Program (CDPAP)
CDPAP is a form of personal care services that permits self-directed members to select the home attendant who will provide their care. CDPAP is available only to Medicaid members authorized for Personal Care Services.

Effective October 1, 2012

Nonemergency Transportation Carve-Out Phase II
Nonemergency transportation will be carved out of the Medicaid managed care package in all five boroughs of New York City and will be covered by regular Medicaid.


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