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DOH Issues Provider Enrollment Guidance for MAP Plans

The Department of Health (DOH) Office of Health Insurance Programs (OHIP) issued Managed Long Term Care (MLTC) Policy 19.02 to clarify the responsibilities of Medicare/Medicaid plans regarding terminating network providers for failing to enroll in Medicaid. Pursuant to the 21st Century Cures Act, Medicaid Advantage and Medicaid Advantage Plus (MAP) plan network providers must enroll in the New York State Medicaid program in order to remain in the Integrated Plan’s Medicaid provider network.

However, providers subject to this requirement may remain in an Integrated Plan’s Medicare provider network (regardless of whether they enroll as a Medicaid provider) as long as the plan establishes adequate mechanisms to ensure that Medicare-only network providers that are not enrolled Medicaid providers cannot bill the Integrated Plan for benefit package services, other than Medicare cost-sharing, where Medicaid is or could become primary payor. These services are identified in Appendix K-2 of each Integrated Plan’s model contract.

The policy document is posted here, and questions should be addressed to mltc.compliance.reporting@health.ny.gov.

LeadingAge NY Contact: Darius Kirstein, dkirstein@leadingageny.org, 518-867-8841