New York State pharmacies participating in the Medicaid program face heightened scrutiny as the New York State Department of Health (DOH) and Office of the Medicaid Inspector General (OMIG) significantly ramp up enforcement of Medicare enrollment requirements necessary for participation in the Medicaid Program.
Recent enforcement activity signals a shift that impacts all New York State pharmacies, including those that do not furnish durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS). Pharmacies that fail to meet updated enrollment expectations may face delays, denials, or compliance risks related to Medicaid participation.
Medicare Enrollment Requirements for Pharmacy Participation in NYS Medicaid
Under current NYS Medicaid policy, pharmacies must be enrolled as Medicare providers via CMS-855B Pharmacy (Supplier) and CMS-855S as a prerequisite for Medicaid participation. CMS-855B Pharmacy (Supplier) enrollment is required for pharmacies to bill for Part B (e.g., vaccines), and CMS-855S is required for pharmacies providing DMEPOS.
DOH Enforcement Update: What Has Changed?
In recent weeks, the DOH has made it clear that for new applications and revalidation requests, providers will need to maintain enrollment under CMS-855B Pharmacy (Supplier) and CMS-855S as a prerequisite for Medicaid participation, regardless of whether the pharmacy sells any DMEPOS.
Importantly, enrollment solely under CMS-855B Mass Immunizer (Roster Biller) and/or CMS-855S will no longer be sufficient to satisfy this requirement.
The DOH instructed providers to stay up to date with pharmacy updates via the eMedNy website, underscoring the expectation that pharmacies remain proactive and compliant.
Immediate Action Steps for NYS Pharmacies
To avoid disruptions to Medicaid participation, pharmacies should take the following steps immediately:
- Verify Provider Enrollment, Chain, and Ownership System (PECOS) Status: Pharmacies should confirm their PECOS status with both CMS-855B and CMS-855S enrollments are active and consistent with Medicaid files.
- Regularly Check eMedNY: Pharmacies should stay current on policy changes by checking eMedNY frequently.
- Initiate Missing Application: If you are currently enrolled in CMS-855B but not CMS-855S, start the missing application immediately as processing takes time.
If your pharmacy is currently enrolled in CMS-855B Mass Immunizer (Roster Biller) but not CMS-855B Pharmacy (Supplier), contact Barclay Damon for assistance with completing the enrollment application.
How Barclay Damon Supports Pharmacies in New York State and Nationwide
Barclay Damon’s national Pharmacy Team advises pharmacies across the United States on legal and contractual compliance requirements, including Medicare and Medicaid enrollment and revalidation, PECOS compliance and troubleshooting, DOH and OMIG enforcement matters, and pharmacy audits and investigation defense. Our team works with pharmacies at every stage of the process to ensure continued compliance and uninterrupted participation in government programs.
If you have any questions regarding the content of this alert, please contact Brad Gallagher, co-leader of the Health Care Controversies and Pharmacy Teams, at bgallagher@barclaydamon.com; Alix Hirsh, associate, at ahirsh@barclaydamon.com; Michelle Ciliberto, paralegal, at mciliberto@barclaydamon.com; or another member of the firm’s Health Care Controversies or Pharmacy Teams.