Part 43 - State Aid For Tuberculosis and Uninsured Care Programs

Effective Date: 
Wednesday, April 24, 2019
Doc Status: 
Complete
Statutory Authority: 
Public Health Law, Sections 2201, 2202(1), (2), (3), (4); Laws of 1981, ch. 623, Sec. 4

SubPart 43-1 - STATE AID FOR TUBERCULOSIS

Effective Date: 
Wednesday, December 31, 2014
Doc Status: 
Complete
Statutory Authority: 
Public Health Law, sections 2201, 2202(1),(2), (3) and (4), section 4 of Chapter 623 of the Laws of 1981

STATE AID FOR TUBERCULOSIS

Section 43-1.1 - Definitions

Section 43-1.1 Definitions.

(a) A tuberculosis case shall mean a person diagnosed as having disease caused by M. tuberculosis determined by bacteriological evidence of tuberculous disease or a significant reaction to a mantoux tuberculin test and clinical or roentgenographic evidence of current disease.

(b) A person with tuberculosis infection shall mean a person diagnosed as having a significant reaction to the mantoux tuberculin test in the absence of clinical, roentgenographic or bacteriological evidence of tuberculous disease.

(c) A suspect shall mean a person suspected of having either tuberculosis infection or disease, (including a person who has been in close contact with a tuberculosis case) for whom diagnostic procedures have not been completed and who may or may not be receiving treatment. A person shall not be classified as a tuberculosis suspect for longer than 60 days.

(d) A tuberculosis contact shall mean a person who has been in close association with a suspect or tuberculosis case for a length of time sufficient to become infected with M. tuberculosis by breathing contaminated droplets.

(e) A provider shall mean any facility, agency or organization authorized to furnish tuberculosis health care services under Article 3, 28, 36 or 44 of the Public Health Law, or a licensed and registered physician.

(f) A tuberculosis patient shall mean a person who is a tuberculosis case; a tuberculosis suspect; or has a tuberculosis infection; and who has been accepted or admitted into care by a provider.

(g) Tuberculosis health care services shall mean diagnostic procedures, care, and treatment for tuberculosis patients furnished by a provider.

(h) Local health official shall mean the Commissioner of Health or public health administrator of a county or part county health district, the Commissioner of Health of the City of New York, the county health director or other appropriate health officer designated by the legislative body of each county or the corresponding authority of the City of New York to be responsible for providing or securing tuberculosis care and treatment, pursuant to section 2202 (1) of the Public Health Law.

(i) A state or local charge shall mean those persons defined as such in section 2200 (4) and (5) of the Public Health Law.

(j) Third-party payer shall mean Medicare, workers' compensation, medical assistance in accordance with the Social Services Law, the Veterans Administration, health and other insurers and indemnitors or other third parties by whom diagnosis, care and treatment hereunder is payable.
 

Effective Date: 
Wednesday, February 8, 1989
Doc Status: 
Complete

Section 43-1.2 - Responsibility for tuberculosis care and treatment

43-1.2 Responsibility for tuberculosis care and treatment. The local health official, where a tuberculosis patient or contact resides or is found, shall provide or secure tuberculosis health care services needed by such person. Upon notification of a tuberculosis case or suspect, the appropriate local health official shall be responsible for immediately determining if other persons may have become infected with tuberculosis by the case or suspect, and shall perform those duties and responsibilities identified in Part 2 of the State Sanitary Code. The local health official shall provide or secure health care services needed for all cases or suspects found.

The local health official shall initiate preventive measures, to prevent the spread of infection or development of disease.

If a case or contact resides outside of the geographic jurisdiction of the local health official to which he or she has been reported, the local health official shall transfer copies of all materials concerning that case or contact to the local health official with jurisdiction.
 

Effective Date: 
Wednesday, February 8, 1989
Doc Status: 
Complete

Section 43-1.3 - Nonresidents, aliens, refugees and staff members of legations

43-1.3 Nonresidents, aliens, refugees and staff members of legations.

(a) There shall be no discrimination against tuberculosis patients or contacts because of lack of United States citizenship or lack of New York State or local residence.

(b) Tuberculosis health care services for the following aliens are not eligible for payment by local health officials or the State or for payment of State aid reimbursement:

(1) officials, representatives or employees of foreign governments;

(2) officers and employees of international organizations;

(3) attendants, servants, personal employees of those listed in paragraphs (1) and (2) of this subdivision; or

(4) members of immediate families of those listed in paragraphs (1) through (3) of this subdivision.

Payment for tuberculosis health care services for these persons is the responsibility of the individual or foreign country through its appropriate representative in the United States.

(c) Refugees eligible for medical assistance in accordance with the Social Services Law and the rules and regulations thereunder shall also be eligible for tuberculosis health care services hereunder.
 

Effective Date: 
Wednesday, February 8, 1989
Doc Status: 
Complete

REQUIREMENTS APPLYING TO PROVIDERS AS A CONDITION TO BEING ENTITLED TO PAYMENT FOR TUBERCULOSIS HEALTH CARE SERVICES

Section 43-1.4 - Standards for tuberculosis care and services

REQUIREMENTS APPLYING TO PROVIDERS AS A CONDITION TO BEING ENTITLED TO PAYMENT FOR TUBERCULOSIS HEALTH CARE SERVICES

43-1.4 Standards for tuberculosis care and services.

The care and treatment by providers of tuberculosis patients shall include health care services which meet prevailing standards of professional practice, including the following:

(a) a licensed and currently registered physician shall be responsible for the tuberculosis health care services furnished to a patient;

(b) tuberculosis suspects shall be confirmed as being or not being tuberculosis cases within 60 days from the date accepted into care by a provider. On or before the 60th day, the provider shall report findings in writing to the local health officials where the patient resides and where the provider is located;

(c) providers shall comply with applicable utilization review requirements.
 

Effective Date: 
Wednesday, February 8, 1989
Doc Status: 
Complete

Section 43-1.5 - Hospital inpatient admissions

43-1.5 Hospital inpatient admissions.

(a) Tuberculosis health care services provided in a hospital shall be based on prevailing standards of professional practice for the care of tuberculosis.

(b) An inpatient admission of a tuberculosis patient to a hospital for treatment of tuberculosis may be made when a person has severe symptoms attributed to tuberculosis, presents diagnostic problems or presents difficulties in drug treatment selection.
 

Effective Date: 
Wednesday, February 8, 1989
Doc Status: 
Complete

Section 43-1.6 - Reporting by providers

43-1.6 Reporting by providers.

(a) When a tuberculosis case or suspect is accepted for care by a provider, the provider shall notify by telephone within 24 hours the local health official where the provider is located, and also the local health official where the person resides. The provider shall then submit a written case report within 5 working days to the same local health official or officials. The written report shall include the person's name, date accepted for care, age, address, telephone number, name and address of employer, county of residence, diagnosis, clinical evidence of disease and diagnostic procedures completed. If the person has been admitted as an inpatient, a written statement shall also be submitted by the hospital indicating the reasons for inpatient admission, rather than ambulatory care.

(b) When a tuberculosis case or suspect accepted into care by a provider is or may be a local charge, as defined by Article 22, Section 2200 of the Public Health Law, the provider shall, within 5 working days, notify the local health official where the person resides of the person's name, address, potential status as a local charge, and the names and addresses of any third-party payers, along with all other information stated in part (a) of this section.

(c) When a tuberculosis case or suspect accepted for care by a provider is or may be a State charge, as defined by Article 22, Section 2200 of the Public Health Law, the provider shall, within 5 working days, notify the local health official where the provider is located of the person's name, address, potential status as a State charge, and the names and addresses of any third-party payers, along with all information stated in part (a) of this section. The health official will immediately inform the person designated by the State Health Commissioner for such purpose.

(d) A monthly patient status report on each person with tuberculosis disease shall be submitted by each provider to the local health officials where the person resides and where the provider is located, which shall include a medical and social history and, if applicable, a discharge summary. Reports shall be submitted within two weeks of the end of each month.

(e) Providers shall submit to such health official additional reports as the State Commissioner of Health may provide.
 

Effective Date: 
Wednesday, February 8, 1989
Doc Status: 
Complete

AUTHORIZATION

Section 43-1.7 - Authorization of reimbursement for tuberculosis health care and services

AUTHORIZATION

43-1.7 Authorization of reimbursement for tuberculosis health care and services.

(a) Tuberculosis health care services shall be paid by the local health official with jurisdiction or the State only as authorized. Authorization for local charges shall be made by the local health official where the patient resides. Authorization for State charges shall be made by the designee of the State Health Commissioner.

(b) Providers shall be deemed authorized to collect reimbursement for tuberculosis health care services when they are so notified by the local health official or designee of the State Health Commissioner, if they comply with the requirements of this Subpart.

(c) Reimbursement for inpatient hospital services for a patient hospitalized for a period in excess of six weeks during a calendar year are not authorized unless approved in writing before expiration of the six weeks. Authorization for local charges may only be made by the local health official where the patient resides. If the patient is a potential State charge, the provider shall request authorization for care beyond six weeks by writing to the local health official where the patient resides. Such health official shall recommend whether such care is justified or not to the designee of the State Health Commissioner. Authorization for State charges may only be made by the designee of the State Health Commissioner.

(d) In determining which tuberculosis health care services to authorize for a tuberculosis patient, the local health official or designee of the State Health Commissioner shall consider available alternative tuberculosis health care services and determine the most appropriate source to meet the patient's needs.
 

Effective Date: 
Wednesday, February 8, 1989
Doc Status: 
Complete

PROVIDER CLAIM FOR PAYMENT AND EFFORTS TO DETERMINE AVAILABILITY OF THIRD-PARTY PAYERS

Section 43-1.8 - Provider claim

PROVIDER CLAIM FOR PAYMENT AND EFFORTS TO DETERMINE AVAILABILITY OF THIRD-PARTY PAYERS

43-1.8 Provider claim.

(a) Providers of tuberculosis health care services may not claim payment from local health officials or the State for amounts which are eligible for payment from any other third-party payer or payers.

(b) For a tuberculosis patient who is a local charge, a provider shall submit to the local health official where the patient resides an itemized claim form for payment for tuberculosis health care services furnished to the patient who does not have full third-party coverage of the claim.

(c) For a State charge who does not have full third-party coverage, a provider shall submit an itemized claim form to the local health official where the patient resides. The health official shall verify the information on the claim form and shall forward the claim to the designee of the State Health Commissioner.

(d) The claim form shall show the charges for each of the services provided and shall deduct all amounts eligible for reimbursement or indemnification by the third-party payers.

(e) The claim form shall include the names of third-party payers or indemnitors who have paid, or are or may be responsible for making payments for part or all of the claim, and the amounts each has paid or is or may be responsible for paying.

(f) A form shall be submitted with a copy maintained by the provider, together with the claim form stating in detail the efforts made to determine whether there is third-party coverage or indemnification available for the claim. The form shall also state the efforts made to claim such reimbursements. If the provider's efforts to determine or obtain third-party reimbursement, as reported in the form are found unsatisfactory by the local health official, the provider shall make additional efforts and shall submit a supplemental form.
 

Effective Date: 
Wednesday, February 8, 1989
Doc Status: 
Complete

RESPONSIBILITY FOR PAYMENT FOR SERVICES

Section 43-1.10 - No patient obligation to pay

43-1.10 No patient obligation to pay.

(a) No tuberculosis patient or his legally responsible relatives shall be requested or required by a provider, local health official, the State, or any other party to pay personally for any portion of tuberculosis health care services received, as provided in section 2202 of the Public Health Law.

(b) No provider, local health official, the State or any other person shall inquire into the financial ability of a tuberculosis patient or his legally responsible relatives to pay for tuberculosis health care services except to determine third-party coverage.
 

Effective Date: 
Wednesday, February 8, 1989
Doc Status: 
Complete

Section 43-1.9 - Extent of responsibility for payment

RESPONSIBILITY FOR PAYMENT FOR SERVICES

43-1.9 Extent of responsibility for payment.

(a) The local health official of the jurisdiction where a tuberculosis patient resides shall be responsible to pay providers for health care services rendered to a local charge tuberculosis patient when such services are authorized and provided in accordance with this Subpart, except:

(1) The maximum charges which the local health official shall be responsible for are the rates for the Medical Assistance Program established in accordance with the provisions of section 2807 of the Public Health Law and fees for services established in the State medical fee schedule for medical assistance.

(2) Amounts eligible for reimbursement or indemnification from any third-party payer shall not be paid by the local health official. Such amounts shall be deducted by the local health official from the charges billed by the provider or the established rates and/or fees in the State medical fee schedule for the health care services rendered, whichever are less.

(3) When a person has been admitted as an inpatient to a hospital for the treatment of a nontuberculous disease or condition and is subsequently found to have tuberculosis which requires inpatient care and treatment, a local health official has no responsibility to pay for care and treatment prior to the date of diagnosis of tuberculosis. If the person requires tuberculosis care and treatment, but hospitalization is not justified, the local health official shall not be responsible for hospitalization costs.

(4) If, upon review of a claim, the local health official determines that a tuberculosis patient had or was eligible for third-party coverage or indemnification and that the provider failed to make a good faith effort to determine whether there was such coverage or indemnification, the local health official may deny payment of claim.

(5) A person who volunteers to assume and pay for the cost of tuberculosis health care services hereunder shall be liable therefor.

(b) The State of New York shall be responsible to pay providers for health care services rendered to a State charge tuberculosis patient in accordance with the terms of this Subpart, with the same exceptions as described in subdivision (a) of this section.

(c) Subsequent to paying a provider for services, if a local health official or the State determines that a provider did not make a good faith effort to obtain third-party payer coverage or indemnification that was available, the local health official or the State shall require the provider to repay an amount equivalent to the amount of such third-party payer coverage or indemnification.
 

Effective Date: 
Wednesday, February 8, 1989
Doc Status: 
Complete

REQUIREMENTS APPLYING TO LOCAL HEALTH OFFICIALS FOR RECEIVING STATE AID FOR TUBERCULOSIS HEALTH CARE SERVICES

Section 43-1.11 - State aid for tuberculosis

REQUIREMENTS APPLYING TO LOCAL HEALTH OFFICIALS FOR RECEIVING STATE AID FOR TUBERCULOSIS HEALTH CARE SERVICES

43-1.11 State aid for tuberculosis.

(a) Expenses incurred by a local health official for health care services rendered to tuberculosis patients in accordance with the terms of this Subpart shall be eligible for State aid reimbursement.

(b) Such aid shall be provided to local health officials through the same procedures and at the same rate as State aid for general public health work, pursuant to Part 40 of this Subchapter.
 

Effective Date: 
Wednesday, December 31, 2014
Doc Status: 
Complete

Section 43-1.12 - Limitations on State aid

43-1.12 Limitations on State aid.

(a) No State aid is available to local health officials or providers for tuberculosis health care services which do not meet the terms of this Subpart or:

(1) if payment of a claim is available from any other third-party payer which equals or exceeds the per diem rate or fee for services;

(2) for tuberculosis health care services for persons listed in subdivision (b) of section 43-1.3 of this Subpart; or

(3) for services for which payment by a local health official is not required under this Subpart.

(b) If a local health official pays a provider more than it was responsible to pay under section 43-1.9 of this Subpart, State aid shall not exceed the amount that would have been due if the local health official had so limited payment in accordance with said section.
 

Effective Date: 
Wednesday, February 8, 1989
Doc Status: 
Complete

Section 43-1.13 - Audits by local health officials

43-1.13 Audits by local health officials.

Local health officials shall audit a sufficient number of provider reports, medical records, and if necessary, interview physicians and other personnel to determine whether a provider has furnished or is furnishing tuberculosis health care services in accordance with the requirements of this Subpart.
 

Effective Date: 
Wednesday, February 8, 1989
Doc Status: 
Complete

Section 43-1.14 - Recovery

43-1.14 Recovery.

Local health officials shall oversee all provider efforts to identify third-party coverage and to be able to demonstrate on audit that such third-party coverage was identified and fully utilized and that the providers adhered to the terms of this Subpart. Upon receipt of audit information by the State Health Department showing State aid overpayment, the Commissioner shall deduct from the next State aid voucher the amount previously overpaid.
 

Effective Date: 
Wednesday, February 8, 1989
Doc Status: 
Complete

LOCAL HEALTH UNIT RECORDS AND REPORTS TO STATE HEALTH DEPARTMENT

Section 43-1.15 - Records and reports

LOCAL HEALTH OFFICIAL RECORDS AND REPORTS TO STATE HEALTH DEPARTMENT

43-1.15 Records and reports.

The local health officials shall submit all reports as required by the Department.
 

Effective Date: 
Wednesday, February 8, 1989
Doc Status: 
Complete

Section 43-1.16 - Return of a tuberculosis patient to location of residence

43-1.16 Return of a tuberculosis patient to location of residence.

(a) A New York State resident who is receiving tuberculosis health care services in another state and desires to return to New York State shall be referred to the local health official where the patient resides. The information requested of the other state by the local health official regarding the patient, shall include at least the following:

(1) medical history including sufficient clinical data to indicate need for further care and treatment of tuberculosis;

(2) a statement that the patient is physically able to travel without harm to himself or others, and arrangements have been made for his transfer to New York State;

(3) information for residence verification;

(4) a statement indicating the patient's willingness to return to New York State for further care and treatment of tuberculosis; and

(5) names and addresses of individuals who will assume responsibility for the patient.

(b) Once residence is established and the patient is able and willing to return, final arrangements for transfer shall be made by the local health official directly with the authorities of the other state.

(c) When a non-resident tuberculosis patient is willing and able to return to the political subdivision in which the patient resides in another state or country, the local health official where the patient's provider is located, or the Commissioner's designee, shall make arrangements with the health official of the political subdivision in which the patient resides so that the patient can be met on return and be provided the health care services needed. Copies of provider reports shall also be forwarded to said health official.
 

Effective Date: 
Wednesday, February 8, 1989
Doc Status: 
Complete

Section 43-1.17 - Commissioner's orders

43-1.17 Commissioner's orders.

If a local health official fails to provide or secure tuberculosis health care services or to pay providers for such services rendered under the terms of this Subpart, the State Health Commissioner upon notice and opportunity to be heard may order the local health official to provide or secure the services or to make such payment.
 

Effective Date: 
Wednesday, February 8, 1989
Doc Status: 
Complete

Section 43-1.18 - Violations by a provider

43-1.18 Violations by a provider.

A violation of any provision of this Subpart as applied to a specific patient, shall be punishable by a denial of payment of State aid reimbursement to a local health official or a provider or the repayment thereof for tuberculosis health care services for such patient.
 

Effective Date: 
Wednesday, February 8, 1989
Doc Status: 
Complete

SubPart 43-2 - Uninsured Care Programs

Effective Date: 
Wednesday, April 24, 2019
Doc Status: 
Complete
Statutory Authority: 
Public Health Law, Sections 201(1)(j), (q), 2776(1)(e)

Section 43-2.1 - Scope

Section 43-2.1 Scope.

These regulations govern the application and eligibility determination process for the Uninsured Care Programs and establish the rights and responsibilities of applicants, participants, providers, and contractors in that process.
 

Effective Date: 
Wednesday, April 24, 2019
Doc Status: 
Complete
Statutory Authority: 
Public Health Law, Sections 201(1)(o), 201(1)(p) and 2776(1)(e)

Section 43-2.2 - Definitions

43-2.2 Definitions.

(a) An applicant is a person who has directly or by a representative, applied in writing to the New York State Department of Health.

(b) An application is the process by which a person indicates, in writing on a Department of Health-approved form, his/her desire to receive assistance.

(c) Resident means a person domiciled within the State.

(d) Authorized representative means any person authorized by an applicant or participant to act on his/her behalf.

(e) Period of coverage. Coverage for assistance for each individual program component is effective as specified in the individual's notification of eligibility. Coverage will terminate under the following circumstances:

(1) the applicant indicates in writing that they no longer need or desire assistance;

(2) the department determines that a change in the participant's circumstances or residence has affected their eligibility.

(3) the participant has died or cannot be located; and

(4) funding for the Uninsured Care Programs is exhausted.

(f) Program means the Uninsured Care Programs, as defined by the AIDS Institute, including the following service components:

(1) AIDS Drug Assistance Program, which provides coverage of medications;

(2) ADAP Plus, which provides coverage for ambulatory care services;

(3) ADAP Plus Insurance Continuation, which pays for insurance premiums for eligible individuals who have cost effective insurance policies; and

(4) the HIV Home Care Program, which provides coverage for home care services.

(g) Household. The applicant, persons legally responsible for the applicant, and persons for whom the applicant is legally responsible, shall be considered part of the household.

(h) Income means total gross income of the household. Income shall include: monetary compensation for services, including wages, salary, commissions or fees; net income from self-employment; unemployment insurance compensation; government civilian employee or military retirement or pension, including veterans' payments; pensions or annuities; alimony or child support payments; regular contributions from persons not living in the household; net royalties; social security benefits; dividends or interest on savings or bonds; income from estates or trusts; net rental income; public assistance or welfare payments; cash or any other income resource.

(i) Available household income means the applicant's household income after deducting the amount paid by the applicant under the Federal Insurance Contributions Act for Social Security and Medicare and the cost of health care coverage paid by the applicant.

(j) Provider means a medical provider, including a pharmacy, hospital, clinic, clinical practitioner, laboratory or home health care agency.

 

Effective Date: 
Wednesday, April 24, 2019
Doc Status: 
Complete

Section 43-2.3 - Confidentiality

43-2.3 Confidentiality.

All information which may identify an applicant which is received by the program will be confidential and can only be used when necessary for supervision, monitoring or administration of the program. Information received by any contractor, his agents, employees, or by any other person or agency concerning applicants or participants in the program is confidential and may not be disclosed without the written approval of the Uninsured Care Program director, who shall approve disclosure only in conformance with Article 27-F of the Public Health Law and the federal standards with respect to the privacy and security of individually identifiable health information contained in Part 164 of Title 45 of the Code of Federal Regulations.
 

Effective Date: 
Wednesday, April 24, 2019
Doc Status: 
Complete

Section 43-2.4 - Use of the application form

43-2.4 Use of the application form.

(a) The State-approved application form must be completed:

(1) for each applicant upon initial application and recertification, if required; and

(2) documentation may be required when there is a change in status affecting eligibility.

(b) The signature of the individual applying for assistance is required on the State-approved application form. In any case where the applicant is incapable of signing the application because of physical incapability, or mental incompetency, application shall be signed on behalf of such a person by his/her authorized representative.

(c) The State-approved form shall contain the following information, in addition to any other information which the Department of Health may require for the proper administration of the program:

(1) name, gender, date of birth, social security number, marital status, address and telephone number of the applicant;

(2) name and relationship to applicant for applicant's household members;

(3) income information for the applicant and members of the applicant's household; and

(4) information regarding any other health benefits or insurance coverage that is available to the applicant.
 

Effective Date: 
Wednesday, April 24, 2019
Doc Status: 
Complete
Statutory Authority: 
Public Health Law, Sections 201(1)(o), 201(1)(p) and 2776(1)(e)

Section 43-2.5 - Eligibility for coverage

43-2.5 Eligibility for coverage.

(a) An applicant must be confirmed as medically eligible to participate in the program. The Department of Health will confirm medical eligibility based upon information received from the applicant and the applicant's clinical practitioner or their designee. The applicant's clinical practitioner or their designee will be required to submit information regarding an applicant's medical condition on a State-approved form consistent with their scope of practice.

(b) Financial eligibility will be based upon the available household income.

(1) In order to be eligible, an applicant's available household income must be equal to or less than 500% of the amount under the annual United States Department of Health and Human Services poverty guidelines for the applicant's family size. Federal poverty guidelines are published annually by the Department of Health and Human Services in the Federal Register.

(2) Applicants must provide income information for a reasonable period prior to application. Applicants who are self-employed must provide business records for the three months prior to application indicating type of business, gross income and net income.

(c) Full and proper use shall be made of existing public and private medical and health services and facilities for obtaining therapeutic drugs, medical services, and related supplies and equipment for the treatment or prevention of HIV or AIDS.

(d) An applicant or recipient of assistance may be required as a condition of eligibility or continued eligibility to assign any rights they may have for coverage benefits under any health insurance policy or group health plan to the department.

(e) In order to be eligible for ADAP Plus Insurance Continuation, an applicant must have:

(1) a health insurance policy that is determined to be cost effective by the department, based on the cost of premiums, limitations of coverage (i.e., deductible, caps, co-payments) and estimates of the monetary value of projected utilization and reimbursement under the insurance policy; and

(2) a premium cost that is more than 4% of the applicant's available household income, if the applicant's available household income is greater than 200% of the amount under the annual United States Department of Health and Human Services poverty guidelines for the applicant's family size. 

 

Effective Date: 
Wednesday, April 24, 2019
Doc Status: 
Complete
Statutory Authority: 
Public Health Law, Sections 201(1)(o), 201(1)(p) and 2776(1)(e)

Section 43-2.6 - Decision on eligibility

43-2.6 Decision on eligibility.

(a) The department shall make one of the following decisions, based upon the application information:

(1) Accepted for coverage. This means that eligibility has been established through review and verification to the satisfaction of the department.

(2) Not accepted for coverage. Applications are denied when the information given by the applicant establishes that the applicant is ineligible, or when the applicant refuses to comply with any requirement essential to the determination of eligibility.

(b) No decision is required when:

(1) an application is withdrawn by the applicant; or

(2) the department documents that the applicant has died, cannot be located, or has left the State prior to the completion of the review and verification.
 

Effective Date: 
Friday, September 9, 1988
Doc Status: 
Complete

Section 43-2.7 - Responsibility for prompt determination of eligibility

43-2.7 Responsibility for prompt determination of eligibility.

The decision to accept or deny the application shall be made as soon as sufficient information to make a determination about eligibility is obtained.
 

Effective Date: 
Friday, September 9, 1988
Doc Status: 
Complete

Section 43-2.8 - Notification

43-2.8 Notification.

Written notification shall be given of the decision to accept or deny an application. Notification of denial shall clearly set forth the specific reason why the application was denied.
 

Effective Date: 
Friday, September 9, 1988
Doc Status: 
Complete

Section 43-2.9 - RESERVED

43-2.9 RESERVED

Effective Date: 
Wednesday, June 2, 2010
Doc Status: 
Complete

Section 43-2.10 - Investigation

43-2.10 Investigation.

The department official shall review and verify information received on applications, as required. Documents, personal observation, personal and collateral interviews and contacts, reports, correspondence and conferences are means of verification of information supplied. When information is sought from collateral sources, other than public records or sources designated by the applicant on the application form, the department will inform the applicant/participant or his/her representative of what information is desired, why it is needed and how it will be used.
 

Effective Date: 
Wednesday, June 2, 2010
Doc Status: 
Complete

Section 43-2.11 - Fraud and abuse

43-2.11 Fraud and abuse.

(a) The commissioner, his agents or designees, shall investigate and refer for prosecution any violations of State laws pertaining to fraud or abuse in the program.

(b) Where review indicates substantial evidence of abuse of the program, the participant may be removed from the program or restricted to a single provider.

(c) If the recipient did not provide accurate information regarding his income and expenses, the commissioner may summarily suspend an enrollee's participation in the program, and the department can recover the amount of assistance granted, to which the recipient is not entitled.
 

Effective Date: 
Wednesday, September 18, 1991
Doc Status: 
Complete

Section 43-2.12 - Appeals

43-2.12 Appeals.

(a) An applicant may request a reconsideration of an adverse decision within 60 days of a decision.

(b) The department shall review any additional submissions and issue a written decision within 30 days of an applicant's request and submission of additional documents.
 

Effective Date: 
Friday, September 9, 1988
Doc Status: 
Complete

Section 43-2.13 - Continuing eligibility

43-2.13 Continuing eligibility.

(a) Participants may be required to establish periodically that they remain eligible for the program.

(b) The applicant/participant must notify the department immediately of any changes in circumstances that may affect eligibility.
 

Effective Date: 
Friday, September 9, 1988
Doc Status: 
Complete

Section 43-2.14 - Enrollment of providers.

43-2.14 Enrollment of providers.

The department will contract with or enter into provider agreements with providers, including providers of related laboratory and ancillary services, which demonstrate that they are qualified to provide program services.
 

Effective Date: 
Wednesday, June 2, 2010
Doc Status: 
Complete

Section 43-2.15 - Audit and claim review

43-2.15 Audit and review.

(a) Providers shall be subject to audit and reviews for quality assurance and proper utilization by the commissioner, his agents or designees. With respect to such audits and reviews, the provider may be required:

(1) to reimburse the department for overpayments discovered by audits; and

(2) to pay restitution for any direct or indirect monetary damage to the program resulting from their improperly or inappropriately furnishing covered drugs, services, supplies or equipment.

(b) The commissioner, his agents or designees, may conduct audits and reviews, and investigate potential fraud or abuse in a provider's conduct.

(c) The commissioner, his agents or designees, may pay or deny claims, or delay claims for audit review.

(d) When audit findings indicate that a provider has provided covered drugs, services, supplies or equipment in a manner which may be inconsistent with regulations governing the program, or with established standards for quality, or in an otherwise unauthorized manner, the commissioner may summarily suspend a provider's participation in the program and/or payment of all claims submitted and of all future claims may be delayed or suspended. When claims are delayed or suspended, a notice of the withholding payment or recoupment shall be sent to the provider by the department. This notice shall inform the provider that within 30 days he/she may request in writing an administrative review of the audit determination before a designee of the commissioner. The review must occur and a decision rendered within a reasonable time after a request for review. If the designee of the commissioner decides withholding or recoupment is warranted, or if no request for review is made by the provider within the 30 days provided, the department shall continue to recoup or withhold funds pursuant to the audit determination.

(e) Where investigation indicates evidence of abuse by a provider, the provider may be fined, suspended, restricted or terminated from the program.
 

Effective Date: 
Wednesday, June 2, 2010
Doc Status: 
Complete

Section 43-2.16 - Audits and recovery of overpayments

43-2.16 Audits and recovery of overpayments.

(a) Recovery of overpayments shall be made only upon a determination by the commissioner, his agents or designees, that such overpayments have been made, and recovery shall be made of all money paid to the provider to which it has no lawful right or entitlement.

(b) Recovery of overpayments pursuant to this subject shall not preclude the commissioner or any other authorized governmental body or agency from taking any other action with respect to the provider, including auditing or reviewing other payments or claims for payment for the same or similar periods, imposing program sanctions, or taking any other action authorized by law.

(c) The commissioner may utilize any lawful means to recover overpayments, including civil lawsuit, participation in a proceeding in bankruptcy, common law set-off, or such other actions or proceedings authorized or recognized by law.

(d) All fiscal and statistical records and reports of providers and prescriptions filled or refilled which are used for the purpose of establishing the provider's right to payment under the program, and any underlying books, records and documentation which formed the basis for such fiscal and statistical records and reports, shall be subject to audit. All underlying books, records and documentation, including all prescriptions filled or refilled, shall be kept and maintained by the provider for a period of not less than three years from the date of completion of such reports, or the date upon which the fiscal and statistical records were required to be filed, whichever is later, or the date the prescription was filled or refilled.

(e) All claims made under the program shall be subject to audit by the commissioner, his agents or designees, for a period of six years from the date of their filing, or as required by state law, regulation or funding source. This limitation shall not apply to situations in which fraud may be involved or where the provider or an agent thereof prevents or obstructs the performance of an audit pursuant to this Part.
 

Effective Date: 
Wednesday, June 2, 2010
Doc Status: 
Complete

Section 43-2.17 - Recoupment of overpayments

43-2.17 Recoupment of overpayments.

Overpayments determined to have been made pursuant to this section and section 43-2.16 of this Subpart shall be recovered by billing the provider for reimbursement, withholding the provider's current or withholding future payments on claims submitted or a percentage of payments otherwise payable on such claims, or such other remedies as may be available through a court of law.
 

Effective Date: 
Wednesday, June 2, 2010
Doc Status: 
Complete

Section 43-2.18 - Claims submission

43-2.18 Claims submission.

(a) Providers shall submit claims for drugs or services within ninety days of the date of service in the manner and form proscribed by the program in order to receive reimbursement.

(b) The department will not be obligated to pay claims submitted more than ninety days after the date of service. Claims submitted later than 90 days with written justification may be considered for payment if funds are available.

Effective Date: 
Wednesday, June 2, 2010
Doc Status: 
Complete