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