Outpatient Clotting Factor Products Transition from Medicaid Fee-For-Service to Medicaid Managed Care

Date Issued: 7/24/2017

As of July 1, 2017, outpatient clotting factor products for the treatment of hemophilia and other blood-related diseases are a part of Medicaid Managed Care benefits. The products are given to those members at:

  • Medicaid-enrolled pharmacies.
  • Hemophilia clinics.
  • In non-inpatient settings, including in the home.

EmblemHealth still requires approval for the services, but will reimburse these providers for authorized, medically necessary clotting factor products and services given to plan members.

Current members

  • Members who currently get clotting factor may keep using the same service provider for two years after July 1, 2017.
  • If the clotting factor is medically necessary (as stated in their service plan), and is received as non-inpatient services, it will get immediate approval until at least September 29, 2017 (90 days after July 1).

New enrollees

  • Members that enrolled after July 1, 2017 may keep using the same service provider for two years from the date of their enrollment.
  • If the clotting factor is medically necessary (as stated in their service plan), it will get immediate approval until at least 90 days after the date of their enrollment, or until the EmblemHealth plan of care is in place, whichever is later.

For more information about active clotting factor J-Codes, go to the New York State Department of Health website.