175.000 MEDICAID

175.953           Medicaid Fee Parity with Medicare for all E&M Services

MSSNY works with NY State Dept. of Health to extend 80% of Medicare fee schedule reimbursement for all E&M services across all places of service provided to NYS Fee for Service all Medicaid and all Medicaid HMO patients. (HOD 2024 – 262)

175.954           Medicaid to pay Medicare coinsurance for dual eligible patients MSSNY HOD-2024

MSSNY will work with NY State Dept. of Health for NYS Medicaid to resume paying 20% Medicare coinsurance for all dual eligible patients. (HOD 2024 – 109)

175.959           NYS Medicaid Coverage of Treatments for Severe Obesity

The Medical Society of the State of New York supports legislation that would require NYS Medicaid to pay for FDA-approved anti-obesity medications in adults with class 3 obesity when prescribed by practitioners. (HOD 2023-251)

175.960           Fair Reimbursement for Obstetrical Surveillance and Care

MSSNY will advocate for a significant increase in the Medicaid physician payment for patient care for labor and delivery, which accounts for the significant increase in office overhead costs since the last time such fees were established. (HOD 2023 – Late E)

175.961           Funding Primary Care

The Medical Society of the State of New York supports legislation to require investment in primary and preventative care by New York State commercial insurers, including managed Medicaid insurers, to be no less than 12% of total health care spending. (HOD 2023-51)

175.962           New York State Medicaid Fee Adequacy

MSSNY will seek legislative and regulatory changes to establish that New York State Medicaid Physician Fees shall not be less than 100% of Medicare Fee for Service physician fee schedule to ensure adequate and equitable access for New York Medicaid patients. (HOD 2023-50)

(See also Drugs and Medications, 75.000; Health Insurance Coverage, 120.000, Medicare, 195.000; Professional Medical Conduct, 250.000; Reimbursement, 265.000)

175.963           Medicaid Spousal Refusal

The Medical Society of the State of New York opposes elimination of Medicaid Spousal Refusal.  (HOD 2020-110) 

175.964           Expand New York State Medicaid Benefit Coverage for Implantable Infusion Pumps for Non-Cancer Pain

MSSNY will advocate to expand coverage of Medicaid Benefits for proven comprehensive pain management programs such as motivational counseling, physical and/or occupational therapy and if that fails, to include coverage for implantable infusion pumps for non-cancer pain.  (HOD 2019-270)

175.965           Oppose Medicaid Eligibility Lockout

The Medical Society of the State of New York opposes ‘lock-out’ provisions which exclude for long periods those eligible for Medicaid merely for failing to meet paperwork burdens.  MSSNY supports provisions that permit those eligible to reapply.  A resolution to this effect will be submitted to the AMA.  (HOD 2018-112)

175.966           Opposition to Medicaid Work Requirements

The Medical Society of the State of New York opposes instituting work requirements for those eligible for Medicaid.  MSSNY will urge the AMA to reaffirm AMA Policy H-290.961.  (HOD 2018-111)

175.967                Percentage Based Billing Services Arrangement

The Medical Society of the State of New York will work for repeal of the New York State law barring percentage-based payment arrangements between physicians and their billing agents. MSSNY will also continue to work with hospital associations and other allied organizations to oppose efforts by state government officials to demand refunds from physicians based upon allegations that claims were submitted to Medicaid using percentage-based arrangements between physicians and their billing agents and MSSNY will continue to educate physicians regarding the laws applicable to payments for billing services. (HOD 2017-57)

175.968                 Medicaid Payment of 20% Residual Medicare Fee

MSSNY will pursue state regulatory and/or legislative action seeking to restore funding for “crossover” payments, cut in previous years, for care provided by physicians to patients who are dually eligible for Medicare and Medicaid. (HOD 2017-106)

175.969            Medicaid and Child Health-Plus Renewals

The Medical Society of the State of New York (MSSNY) will work with the New York State Department of Health Office of Health Insurance Programs to establish policy that the insureds in Medicaid and Child Health Plus programs be contacted about the status of their insurance renewals and initial applications via their preferred method of communication, including but not limited to mail, e-mail, text and telephone. (HOD 2016-257)

175.970              Reinstate Partial Medicare Part B Coinsurance Payments

The Medical Society of the State of New York will continue to advocate for legislation which would restore New York State Medicaid coinsurance payments for patients insured by both Medicare and Medicaid and work with physicians and patient advocacy groups across the State to identify and bring to the attention of policymakers access issues affecting patients as a result of the elimination of Medicaid coinsurance payments for these dually eligible patients. The MSSNY delegation to the AMA House of Delegates will introduce a resolution calling upon the AMA to support federal legislation which would require coverage of the coinsurance payments for patients insured by both Medicare and Medicaid. (HOD 2016-64 & 65)

175.971                  Acne Medication Coverage

The Medical Society of the State of New York (MSSNY) will support a change by New York State Medicaid to cover Retin A and similar topical acne medication sfor the treatment of acne. (HOD 2015-250)

175.972              OPMC Inform Physicians of Untended Consequences

Utilizing legislative, regulatory or other relief against the Office of Medicaid Inspector General, the Medical Society of the State of New York will seek a prohibition from removing a physician from the State Medicaid program solely on the basis that the physician entered into a consent order with the Board of Professional Medical Conduct. (HOD 2014-100; Reaffirmed HOD 2024)

175.973              Equal Pay for Equal Medical Tasks

MSSNY reaffirms Policy 175.992 and will advocate for equal pay for equal medical tasks performed by equally qualified physicians regardless of the setting in which said task is performed. (HOD 2013-262; Reaffirmed HOD 2023)

175.974:             Short Acting Opioid Preauthorization

MSSNY will seek immediate action by New York State Medicaid to cease and desist from requiring a prior authorization on all short acting opioid pain medications for persons who have been on them for 120 days or longer, and to require at least 90 days’ notice of the enforcement of any such change in prior authorization requirements to allow for public comment and discussion. (HOD 2013-71; Reaffirmed HOD 2023)

175.975:              Medicaid Participation

MSSNY will continue to communicate with legislators, regulators and the media that efforts to expand health insurance coverage will not enhance timely quality care for patients unless steps are taken to assure the viability of physician practices to provide this needed care, and will continue to advocate for increased fees for providing care to Medicaid patients.

(HOD 2013-65; Reaffirmed HOD 2023)

175.976               Mandated Medicaid Managed Care Programs

The Medical Society of the State of New York will encourage the State Assembly, Senate and Governor to:
(a) maintain current funding levels for providers, and assure that the cost of high quality nursing home care is adequately reflected in managed care rates and
(b) assure that Managed Long Term Care plan rates are established to meet wage parity or living wage requirements, and the increased risk that managed care plans are being asked to assume;
(c) assure that Long Term Home Health Care Programs are allowed to contract with a Managed Long Term Care Plan, to continue providing cost effective services that help chronically ill older adults and the disabled; and
(d) assure that the legislative bodies and executive herein mentioned vote for and sign into law the Independent Senior Housing Freedom of Choice Act (A.7309/S,4319), assuring that seniors living in congregate housing have the right to receive health care services that they would be able to obtain living in their own homes. (HOD 2012-107; Reaffirmed HOD 2022)

175.977             Mandate Single Formulary for All Medicaid Managed Care Programs and Participating Carriers: SUNSET HOD 2022

175.978                Changes to Medicaid Patients Formulary: SUNSET HOD 2022

175.979           Consequences of Involuntary Termination of Medicaid Participation:

MSSNY will work with the New York State Office of Professional Medical Conduct (OPMC), the New York State Office of Medicaid Inspector General (OMIG), The Joint Commission, the Healthcare Association of New York State (HANYS) and the Greater New York Hospital Association (GNYHA) to remedy the situation where disciplined physicians are allowed by OPMC to retain their medical licenses but are effectively relieved of any ability to treat their patients because of the regulatory cascade imposed by OMIG, hospitals and third party payers.  (HOD 2010-69; Reaffirmed HOD 2020)

175.980           Physicians as Medicaid Providers While in Supervised Recovery:

MSSNY will:

1. request that the New York State Office of Professional Conduct (OPMC) and the New York State Office of the Medicaid Inspector General (OMIG) should work together cooperatively to permit physicians who are participating in a program of rehabilitation that includes practicing only in a monitored setting to maintain enrollment as a participating provider in the New York State Medicaid Program; and

2. urge the New York State OMIG to recognize the plan of rehabilitation developed by the OPMC and Committee for Physician Health to permit physicians to return to the practice of medicine in a monitored setting and reinstate such physicians in the New York State Medicaid Program. (HOD 2009-111; Reaffirmed HOD 2019)

175.981           Promotion of Cost Savings for New York State:

MSSNY will study and explore ways that physicians can contribute ideas to our elected officials on ways to reduce the cost of health care to Medicaid without negatively impacting the quality of care or the physician-patient relationship, and communicate these ideas to its membership and the State of New York in an effort to help the state reduce its budget deficit.  (HOD 2009-99; Reaffirmed HOD 2019)

175.982           Medicaid Utilization Thresholds:  SUNSET HOD 2019

175.983           CPT Coding:

MSSNY will (a) draft legislation to require that the Medicaid program limit itself to standard Current Procedural Terminology (CPT) coding and standard billing forms and will attempt to secure sponsors for this legislation in the majority party of each house of the New York State Legislature; and (b) actively lobby to get this legislation introduced and passed in this legislative session.  (HOD 2009-97; Reaffirmed HOD 2019)

175.984                  Reconsideration of the Current Medicaid Process:

MSSNY will contact the newly-elected New York State Governor to: (1) reconsider the hassles associated with the current process which are impediments to physician participation; and (2) work with MSSNY in an effort to alleviate these impediments. (Council 1/25/07; Reaffirmed HOD 2017)

175.985                 Cost Effective Support for Medicaid Prenatal and Perinatal Services in Economically Distressed Communities and Hospitals:

The Medical Society of the State of New York will advocate for increased Medicaid rates, including prenatal and perinatal services that will allow for a sustainable infrastructure in underserved economically distressed areas. (HOD 2006-155; Reaffirmed HOD 2016)

175.986                Identification of Medicaid Applicants: Sunset HOD 2011

175.987                Medicaid as a Secondary Payer:   SUNSET HOD 2019

175.988                New York State Department of Health Office of Medicaid Management Medicaid Fee Increase: SUNSET HOD 2024

175.989        Expanding Scope of Commission on Medicaid: SUNSET HOD 2014

175.990       Standing Orders:

Since (a) the Medicaid Program does not currently recognize a standing orders protocol which is widely accepted by other insurers and (b) it becomes inefficient and burdensome for physicians to provide original signatures on all laboratory test requisitions, MSSNY will urge the Office of Medicaid Management of the NYS Department of Health to:

• Eliminate the requirement for original physician signatures, except the first signature, on each laboratory test requisition and allow standing orders for such tests involving chronic patient conditions (which may include, but not be limited to, diabetes (Glucose, Hemoglobin A1C/Glycohemoglobin), chemotherapy (CBC, Platelets), heart conditions (Prothrombin Time, Digoxin) substance abuse monitoring by a licensed treatment facility, any other condition deemed chronic in the reasonable judgment of a physician, etc.);
• Allow the initial standing order containing an original physician signature to be valid for up to six months, after which time it must be renewed;
• Enable physicians to designate staff members to sign the laboratory test requisitions on their behalf so long as the physicians formally acknowledge ultimate responsibility for the ordered tests;
• Develop a similar protocol for electronically ordered laboratory tests
• Interact the MSSNY, the Advisor on Practice Parameters Partnership and the NYS Clinical Laboratory Association (NYSCLA) to develop a listing of acceptable chronic conditions for the application of standing orders;
• Interact with MSSNY and NYSCLA to develop an appropriate mechanism for the implementation of a standing orders protocol for laboratory test requisitions. (Council 2/4/98; Reaffirmed HOD 2014; Reaffirmed HOD 2024)

175.991            Public Health Mandate Funding:

Fee schedules for immunizations under public funding mechanisms such as Medicaid should be modified to include additional reimbursement to help defray physicians’ expenditures for compliance with State and City mandates which increase physicians’ operating costs. (HOD 1997-268; Reaffirmed HOD 2014; Reaffirmed HOD 2024)

175.992            Site of Service Differential Payment Policy:

MSSNY reaffirms its position calling for the elimination of the highly objectionable Medicaid site of service differential payment policy for similar services provided in physicians’ offices as compared to hospital settings; particularly as the state-proposed Medicaid Managed Care Demonstration unfolds. (Council 12/19/96; Reaffirmed HOD 2013; Reaffirmed HOD 2014; Reaffirmed HOD 2024)

175.993            Nine-Tier Reimbursement Structure for HIV Care: SUNSET HOD 2014 (Reaffirmed HOD 2024)

175.994            Emergency Care Exemption Under a Regionalized System: SUNSET HOD 2014 (Reaffirmed HOD 2024)

175.995            Funding for Medicaid Services:

MSSNY has urged the Governor of the State of New York not to impose co-payments on Medicaid services, including nursing and therapy visits, paraprofessional services, prescriptions, and clinic visits. In addition, MSSNY has urged the Governor to: (1) Retain the existing Medicaid personal care program; (2) Retain Medicaid payments to hospitals for patients receiving alternative level of care services; and (3) Not to freeze Medicaid reimbursement rates for home health care providers. (HOD 1993-106; Reaffirmed HOD 2014; Reaffirmed HOD 2024)

175.996              “Pill Mill” Centers:

MSSNY is seeking regulatory or statutory reform mandating that physicians affiliated with Medicaid “Pill Mill” Centers where there is undisputed evidence of Medicaid abuse be subject to an expedited license review and suspension as may be required by the appropriate agencies. MSSNY is seeking to ensure that suspension of any physician’s license be based on direct and verifiable identification of the clinic(s) in question by the appropriate enforcement and investigative agencies and established community organizations, and not solely upon indirect and tangential criteria. Such unacceptable criteria would include, but not be limited to, Medical Management Information Services (MIS) computerized billing records or superficial and unreliable “spot check” site visits productive of only anecdotal and ultimately inadmissible evidence as gathered by the funding agency of the Medical Assistance Program. (Council 1/19/92; Reaffirmed HOD 2014; Reaffirmed HOD 2024)

175.997               Utilization and Audits:

MSSNY is working with the New York State Department of Social Services and the New York State Department of Health to establish protocols against inappropriate utilization of Medicaid services and commensurate expenditures and to address the needs for: (1) Clear utilization of services parameters for dissemination to the physician community to guide physicians in the provision of health care under the Medical Assistance Program; (2) Development of more palatable and equitable methodologies to ensure appropriateness in audit investigations through mutually agreeable physician peer review activities and any disputes arising from such a peer review process. (Council 12/19/92; Reaffirmed HOD 2014; Reaffirmed HOD 2024)

175.998                  Fraud and Abuse Audit Control Activities:

MSSNY is cognizant of the realities surrounding health insurance audit and utilization review activities to ensure justifiable expenditures of private or public funds for claimed medical services. The Society is, nevertheless, deeply concerned by reports of inappropriate and inequitable Medicaid fraud and abuse investigations in New York State.

MSSNY asserts that any such fraud and abuse investigations motivated by established recoupment targets and bonus incentives by investigating state and federal entities is highly unethical, immoral, and contrary to the principles of fairness that are inherent in the American administrative and judicial system, and that have come to be rightfully expected by the medical community and the public at large. In acknowledging that not all individuals seek to fulfill the highest aspirations of their particular professions, MSSNY believes that any such individuals in medical practice who subscribe to substandard principles of medicine and ethics in interacting with health insurance programs should be treated accordingly. However, since MSSNY is confident that such practitioners comprise a decided minority of the state’s medical community, the Society logically expects the New York State Department of Social Services (NYSDSS) Fraud and Abuse/Audit Control Divisions, the New York State Attorney General’s Office, and the Office of the Inspector General to conduct legitimate Medicaid fraud and abuse investigation in an ethical and moral manner that ensures: (1) Equitable and meaningful due process for those medical professionals whose services are under review or investigation; (2) Appropriate classification of Medicaid audits so that cases basically involving the following are not unduly labeled as fraudulent activities and, thus, pursued accordingly: (a) Lack of adequate documentation of services; (b) Simple billing irregularities; or (c) Other billing errors (3) Physician safeguards against occurrences of unwarranted prosecutions by investigating agencies through: (a) Utilization of medical experts to corroborate substandard medical practices and justify Medicaid investigations; (b) Provision of pertinent guidelines to physicians for proper conformance with Medicaid requirements; (4) Retention of sufficient physician participation in the Medicaid program to guarantee access to quality health care for medically needy recipient (5) Physician immunity against harassment and victimization by overzealous reviewers to the detriment of their well-being, community standing, and professional careers; with such reviewers being answerable for their unwarranted actions; (6) Physician immunity against undue harassment and pursuit by reviewers on the basis of state budgetary constraints or bureaucratically devised recoupment targets and bonus plan incentives; (7) Physician entitlement to reasonable compensation by the investigating state or federal agencies for legal costs incurred by exonerated practitioners for compelled involvement in arbitrary fraud and abuse or audit control activities. In summary, it is the position of the Medical Society of the State of New York that no medical practitioner in the State of New York be subjected to the traumatic, intimidating and career-threatening activities of state and federal agencies, or any other health insurance entities, unless there is absolute and unimpeachable evidence of serious wrongdoing to warrant such focused pursuit. (Council 1/31/91; Reaffirmed HOD 2014; Reaffirmed HOD 2024)

175.999                     Medicaid – Title XIX Recipients:

The position of the Medical Society of the State of New York is that all Title XIX (Medicaid) recipients must have equal access to high-quality health care along with freedom of choice as to the source from which they receive such care. This quality care should be delivered in an efficient manner by appropriately recognized and varying alternative mechanisms of medical care delivery. Reimbursement for medical service rendered to Title XIX (Medicaid) patients must be based on a realistic fee pattern, in keeping with current economic realities and with the physician mode of practice. Such fee patterns must be subject to periodic adjustments in the same manner as are all other recognized alternative mechanisms of medical care delivery. Further, there should be a: (1) Return of Medicaid patients to the offices of practicing physicians by revising the New York State Medicaid fee schedule to provide usual and customary fees, or to implement a realistically higher fixed fee schedule. (2) Well developed peer review system, administered by physicians at the local level and providing for an adequate appeals mechanism through physician ombudsmen. (3) Development of a program that would provide incentives to physicians for locating in undeserved areas. (4) Unification of administrative and fiscal Medicaid responsibilities within a single Department at the State level. (Council 4/22/82; Reaffirmed Council 6/3/04; Reaffirmed HOD 2014; Reaffirmed HOD 2024)