Medicaid and Medicaid HARP

The following updates have been made to your CDPHP Medicaid plan:

Pharmacy Benefit Change

Starting April 1, 2023, your prescriptions will not be covered by Capital District Physicians’ Health Plan, Inc. (CDPHP®). They will be covered by Medicaid NYRx, the Medicaid pharmacy program. Most pharmacies in New York State take the Medicaid NYRx pharmacy program. If your pharmacy does not take Medicaid, you may:

• Ask your doctor to send a new prescription to a pharmacy that takes Medicaid NYRx pharmacy program, or

• Ask your pharmacist to transfer a refill to a pharmacy that takes Medicaid NYRx pharmacy program, or

• Locate a pharmacy that takes Medicaid NYRx at:https://member.emedny.org.

You will need to show the pharmacist either your Medicaid Card or your Health Plan Card. This will tell them your Client Identification Number (CIN).

Medicaid NYRx has a list of covered drugs. Over-the-counter drugs and most drugs are on the list. This list of covered drugs can be found at: https://www.emedny.org/info/formfile.aspx

• Some drugs need prior approval before they can be filled. This list will tell you if a drug needs prior approval. Your doctor will call to get prior approval.

• If your drug is not on this list:

• Your doctor can ask Medicaid for approval to let you get the drug, or

• Your pharmacist can talk to your doctor about changing to a drug that is on the list.

Medicaid NYRx pharmacy plan also has a preferred drug list. This list can be found at: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PDL.pdf.

• If you need a drug that is listed as a non-preferred drug, you will be able to get a one-time only fill of this drug from April 1, 2023, through June 30, 2023.

• If you need a non-preferred drug, please contact your pharmacist or doctor so that they can get approval for you to get this drug.

The Medicaid copayment structure is not changing. Your copayment might change depending on if the drug is preferred or non-preferred.

Your pharmacy benefit also covers certain supplies:

• A list of covered supplies can be found at: https://member.emedny.org/.

• A list of preferred diabetic meters and test strips can be found at: https://newyork.fhsc.com/downloads/providers/NYRx_PDSP_preferred_supply_list.pdf.

• Medicaid will allow a one-time only fill from April 1, 2023, through June 30, 2023, for non-preferred test strips.

• You will need to change to a preferred diabetic meter and test strip.

Do you have questions or need help? The Medicaid Helpline can assist you. They can talk to you in your preferred language. They can be reached at 1-855-648-1909 TTY 1-800-662-1220.

They can answer your call:

• Monday - Friday, 8 am – 8pm

• Saturday, 9am – 1 pm

Applied Behavior Analysis (ABA) Services

Starting January 1, 2023, Capital District Physicians' Health Plan, Inc. (CDPHP) will cover Applied Behavior Analysis (ABA) therapy provided by:

• Licensed Behavioral Analyst (LBA)

• Certified Behavioral Analyst Assistant (CBAA) under the supervision of an LBA

Who can get ABA?

Children/youth under the age of 21 with a diagnosis of autism spectrum disorder and/or Rett Syndrome. If you think you are eligible to get ABA services, talk to your doctor about this service. CDPHP will work with you and your provider to make sure you get the service you need.

The ABA services include:

• assessment and treatment by a physician, licensed behavioral analyst, or certified behavior analyst assistant

• individual treatments delivered in the home or other setting

• group adaptive behavior treatment

• training and support to family and caregivers

To learn more about these services, call member services at 1-888-320-9584.

Gambling Disorder Treatment Provided by Office of Addiction Services and Supports (OASAS) Certified Programs.

Starting January 1, 2023, Capital District Physicians' Health Plan, Inc. will cover Gambling Disorder Treatment provided by Office of Addiction Services and Supports (OASAS) certified programs.

This benefit covers both in-person and telehealth treatment options. It also includes coverage for outpatient and if necessary, inpatient or residential programs administered by OASAS.

You do not need a referral from your primary care doctor to get these services. If you need help finding a doctor, please call CDPHP member services at the number listed below.

To learn more about these services, call member services at 1-888-320-9584.

Home-Delivered Medically Tailored Meals (MTM)

As a CDPHP member, you have access to benefits and services that help you live your healthiest life. Starting July 1, 2022, you can receive healthy meals delivered straight to your home at no cost through our Medically Tailored Meals program.

Medically Tailored Meals are created to improve your health and well-being, based on your medical needs. The meals are approved by a Registered Dietitian Nutritionist (RDN) after a nutritional assessment and a referral from your doctor. This benefit is voluntary. If you are interested in having meals delivered to your home, continue reading to see if you’re eligible.

Eligibility

This program is offered to Capital District Physicians' Health Plan, Inc. (CDPHP^®) Medicaid members ages 18 years or older. Members must have a secure place to store and heat meals, and:

• Receive personal care services. Member must choose to replace some of their meal preparation and food shopping hours while getting a medically tailored meal. The hours reduced will depend on the number of meals you receive.

  OR

• Have cancer, diabetes, heart failure, or HIV/AIDS, and a certain number of inpatient hospital stays and/or emergency room (ER) visits within the last 12 months related to these conditions.

A CDPHP Care Team representative will call you to see if you want to enroll in the program. On the call, you’ll learn more about the program and get help enrolling, if you’re interested. You may also receive a recommendation for Medically Tailored Meals from your doctor.

We have updated your member handbook to add these benefits. This update is available on our website at: https://www.cdphp.com/members/health-plan/government-plans/medicaid-harp/updates

If you have questions, we’re here to help.

• CDPHP Care Manager at (518) 641-3460

• Member Services at 1-800-388-2994. TDD/TTY:711

Behavioral Health Community Oriented Recovery and Empowerment (CORE) Services

Starting February 1, 2022, four Adult Behavioral Health Home and Community Based Services (BH HCBS) will be changing to Community Oriented Recovery and Empowerment (CORE) Services. Capital District Physicians' Health Plan, Inc. (CDPHP®) will cover CORE Services. You can use your CDPHP® plan card to get these CORE Services.

New York State is making this change because CORE Services are easier to get than BH HCBS. Eligible members can get CORE Services through a recommendation from a qualified provider.

The services moving from BH HCBS to CORE Services are:

• Psychosocial Rehabilitation (PSR)
  This service helps with life skills, like making social connections; finding or keeping a job; starting or returning to school; and using community resources.

• Community Psychiatric Supports and Treatment (CPST)
  This service helps you manage symptoms through counseling and clinical treatment.

• Empowerment Services – Peer Supports
  This service connects you to peer specialists who have gone through recovery. You will get support and assistance with learning how to:

  • live with health challenges and be independent

  • help you make decisions about your own recovery

  • find natural supports and resources

• Family Support and Training (FST)
  This service gives your family and friends the information and skills to help and support you.

What are the changes from BH HCBS to CORE Services?

These CORE Services are almost the same as they were in BH HCBS. There are two changes:

1. You now have more options for services to support goals related to work and school. You can work with a CORE PSR provider to help you:

   • get a job or go to school while managing mental health or addiction struggles

   • live independently and manage your household

   • build or strengthen healthy relationships

2. Short-term Crisis Respite and Intensive Crisis Respite are now called Crisis Residential Services and are still available.

These seven services are still available under BH HCBS:

• Habilitation

• Education Support Services

• Pre-Vocational Services

• Transitional Employment

• Intensive Supported Employment

• Ongoing Supported Employment

• Non-Medical Transportation

Will I have to change my BH HCBS provider to get CORE Services?

If you were getting CPST, PSR, FST or Peer Support as BH HCBS before February 1, 2022, you can keep getting the same services from your provider under CORE. Your provider will talk to you about any changes that affect you. You can also ask your care manager for help.

Do I need an assessment for BH HCBS?

Yes, you need to do the New York State Eligibility Assessment with your health home care manager or recovery coordinator to get a BH HCBS.

Do I need an assessment for CORE Services?

No, you do not need the New York State Eligibility Assessment to get CORE Services. You can get a CORE service if it is recommended for you by a qualified provider, like a doctor or social worker. The qualified provider may want to discuss your diagnosis and needs before making a recommendation for a CORE service.

How do I find a qualified provider to recommend me for CORE Services?

Your primary care provider or therapist may be able to make a recommendation for CORE Services. If you need help finding a qualified provider, contact member services at the number below. You can also ask your care manager for help.

To learn more about these services, call Member Services at 1-888-320-9584.

Applied Behavior Analysis (ABA) Services

Starting October 1, 2021, New York State Medicaid will cover Applied Behavior Analysis (ABA) therapy provided by:

• Licensed Behavioral Analyst (LBA),

• Certified Behavioral Analyst Assistant (CBAA) under the supervision of an LBA, or

• Other individuals specified under Article 167 of NYS education law.

Who can get ABA?

Children/youth under the age of 21 with a diagnosis of autism spectrum disorder and/or Rett Syndrome as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). If you think you are eligible to get ABA services, talk to your provider about this service.

Note: You will need to use your Medicaid card when you receive these services.

The ABA services include:

• assessment and treatment by a physician, licensed behavioral analysts, or certified behavior analyst assistants, or other qualified health professionals,

• individual treatments delivered in the home or other setting, and

• training and support to family and caregivers.

To learn more about these services, call Member Services at 1-888-320-9584.

Medication-Assisted Treatment (MAT) Formulary Change

The New York State Department of Health (NYSDOH) has created a new list of covered prescription drugs (also known as a formulary). This formulary will be used for the treatment of opioid dependence, and agents used to reverse an opioid overdose. The change will begin on October 1, 2021. Under the formulary, Medicaid Fee-For-Service and Medicaid Managed Care Members will follow a single formulary, where coverage parameters are consistent across the Medicaid Program. Certain preferred prescription drugs will also be available without a prior authorization.

What does this mean for CDPHP members?

• Starting October 1, 2021, CDPHP® will cover buprenorphine/naloxone sublingual tablets, brand-name Suboxone films (buprenorphine/naloxone films), and buprenorphine sublingual tablets (to be used for induction only) without a prior authorization. Members currently on generic buprenorphine/naloxone film can continue to go to the pharmacy and the pharmacist is able to make the change to the brand drug.

• Members who are currently on Zubsolv (buprenorphine/naloxone tablets) or buprenorphine sublingual tablets (as maintenance therapy) will need to get a new prescription from their provider. Letters will be sent to all impacted members and providers by September 3, 2021.

• If a member or a provider determines that a change cannot be made at this time, a prior authorization request will be required to continue on non-preferred products. Prior authorization requests must include clinical documentation to support the use of the non-preferred product.

This table shows which drugs are preferred and non-preferred:

For more details, please review the CDPHP Medicaid or HARP handbooks.