Section 511.2 - Notification to applicants and recipients.

511.2 Notification to applicants and recipients. (a) Initial notification. (1) Social services districts must notify MA applicants about utilization thresholds when the districts accept MA applications or issue MA identification cards.

(2) The notification will describe the nature and extent of the utilization thresholds, how to calculate recipients' use of services, how to obtain an exemption from or increase in utilization thresholds, the recipients' fair hearing rights under section 511.9 of this Part, and the toll-free telephone number to call for additional information. The notification also will describe alternatives to the utilization threshold program such as enrollment in managed care programs and referral to preferred primary care providers designated pursuant to Section 2807(12) of the Public Health Law.

(b) Interim notification to recipients. (1) MA recipients will be sent written notices during their benefit year if they are using services of a specific provider service type at a rate which would cause them to reach the utilization threshold before the end of the benefit year. This notification will describe how to apply for an increase in or exemption from utilization thresholds, and how to contest the amount of service usage stated in the notice. This notification also will direct MA recipients to contact their social services district for information and assistance concerning: alternatives to the utilization threshold program such as enrollment in managed care programs and referral to preferred primary care providers designated pursuant to Section 2807(12) of the Public Health Law; and applying for federal disability benefits.

(2) MA providers who request an authorization for MA reimbursement for a service which is subject to a utilization threshold will also be informed, when they verify recipients' eligibility, if the recipients are using those services at a rate which would cause the recipients to reach the utilization thresholds before the end of the benefit year.

(c) Final notification to recipients. (1) Recipients will be sent written notification during the benefit year upon reaching utilization thresholds for each specific provider type. This notification will inform recipients that the threshold has been reached and that the MA program will not pay for further care, services, or supplies of this provider service type unless such care, services, or supplies is furnished to address an urgent medical need or medical emergency. This notification will describe how to apply for an increase in or exemption from the threshold, and how to contest the amount of service usage stated in the notification. This notification also will direct MA recipients to contact their social services district for information and assistance concerning: alternatives to the utilization threshold program such as enrollment in managed care programs and referral to preferred primary care providers designated pursuant to Section 2807(12) of the Public Health Law; and applying for federal disability benefits.

(2) Final notification will also include a statement describing recipients' fair hearing rights if a request for an increase in or exemption from a utilization threshold is denied.

(3) Providers who request authorization to render care, services, or supplies to recipients after the threshold has been reached will also be advised that the recipients have reached the threshold for that provider service type.

 

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