Part 45 - Cystic Fibrosis Health Care Program Adult Cystic Fibrosis Assistance Program

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Statutory Authority: 
Public Health Law, art. 27-G

Section 45.1 - Medical care and/or insurance premium reimbursement

Section 45.1 Medical care and/or insurance premium reimbursement.

Reimbursement for medical care for the treatment of cystic fibrosis patients and/or medical insurance premiums for cystic fibrosis patients will be made on behalf of patients enrolled in the Adult Cystic Fibrosis Assistance Program.
 

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Section 45.2 - Definitions

45.2 Definitions.

(a) Medical care for cystic fibrosis means such diagnostic, therapeutic and rehabilitative care by medical and paramedical personnel, including hospital and related care, drugs, prostheses, appliances, procedures, equipment and devices, as necessary for the treatment of cystic fibrosis and any conditions demonstrated to result from the progress or treatment of cystic fibrosis.

(b) Net annual income means gross income of the patient and/or patient's spouse, less State, local and Federal income taxes, and social security deductions.
 

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Section 45.3 - Eligibility criteria

45.3 Eligibility criteria.

(a) To be eligible for medical care reimbursement for cystic fibrosis and/or medical insurance premium payment through this program, such individual:

(1) shall be at least 21 years old;

(2) shall have been diagnosed as having cystic fibrosis;

(3) shall have resided in New York State for a minimum of 12 continuous months immediately prior to application for services from the Adult Cystic Fibrosis Assistance Program;

(4) shall not be eligible for medical benefits under any group or individual health insurance policy;

(5) shall not be eligible for medical assistance (Medicaid) pursuant to title 11 of article five of the Social Services Law solely due to earned income;

(6) shall submit an application and provide such other information, including documentation of net annual income, as required by the commissioner; and

(7) shall pay annually seven percent of his or her net annual income toward the cost of medical care related to cystic fibrosis and/or the cost of annual health insurance premiums at such intervals as are agreed upon by an authorized representative of the commissioner.

(b) To be a partially eligible individual for whom medical care reimbursement for cystic fibrosis and/or medical insurance premium payment will be provided through this program on a supplemental basis, such individual shall meet all criteria of a fully eligible individual except that a partially eligible individual shall have medical care reimbursement benefits available under a group or individual health insurance policy which does not provide full coverage for the care and treatment of cystic fibrosis.
 

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Section 45.4 - Qualified consultants

45.4 Qualified consultants.

Professional services rendered by medical specialists or consultants will be approved for reimbursement only if rendered by personnel listed in the department's file of clinical consultants and, when in-hospital care is required, if the hospital meets standards set forth in section 45.8 of this Part.
 

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Section 45.5 - Hospital and related medical care

45.5 Hospital and related medical care.

Reimbursement for inpatient and outpatient care rendered by hospitals and other facilities established pursuant to article 28 shall be made at rates not to exceed those established for patients eligible for medical assistance (Medicaid).
 

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Section 45.6 - Payment for outpatient and related medical care

45.6 Payment for outpatient and related medical care.

Fees for outpatient and related medical care may not exceed those established pursuant to title 11 of article five (Medicaid) of the Social Services Law.
 

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Section 45.7 - Out-of-state care

45.7 Out-of-state care.

Out-of-state care will not be approved for State aid reimbursement unless specific exception is made by an authorized representative of the commissioner for just cause.
 

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Section 45.8 - Accredited hospital

45.8 Accredited hospital.

Payment for care in hospitals will be made only if the hospital possesses a valid operating certificate from the commissioner if it is located within the State or appears on the Joint Commission on Accreditation of Hospitals list of approved hospitals if it is located out-of-state.
 

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Section 45.10 - Confidentiality

45.10 Confidentiality.

Medical, financial and personal information provided to the Adult Cystic Fibrosis Assistance Program to establish and maintain eligibility shall be kept confidential in accordance with Public Health Law, section 206(1)(j).

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Section 45.11 - Payor of last resort

45.11 Payor of last resort.

In all cases, the Adult Cystic Fibrosis Assistance Program shall be the payor of last resort.
 

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Section 45.9 - Foreign diplomatic personnel

45.9 Foreign diplomatic personnel.

No medical services shall be approved for State aid reimbursement under this program for any staff member of a foreign legation, consulate, embassy or mission, or for any child of such staff member who resides with such staff member. Provision of medical services shall be the responsibility of the foreign country through its appropriate representative in the United States.
 

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