Section 360-7.6 - Payment for services or supplies.

360-7.6 Payment for services or supplies. (a) For most services, rates of payment are established pursuant to section 367-a of the Social Services Law. They are contained in Subchapter E of this Title. Where rates of payment are not otherwise established, each social services district must set a schedule of rates of payment for services and supplies provided under the MA program. These rates of payment must be set to assure that adequate services and supplies will be provided. Each social services district must require that payment of rates made according to established schedules, including any portion to be paid by the recipient, will constitute full payment for the services or supplies provided to the MA recipient.

(b)(1) Payment for the following medical care, services and supplies provided to a recipient who is eligible for medical assistance (MA) solely as a result of being eligible for or in receipt of Home Relief (HR) and who is at least 21 years of age but under the age of 65 is available only if the recipient is enrolled in a health maintenance organization or other entity which provides comprehensive health services, a managed care program, a primary provider program, or a voluntary medical care coordinator program (MCCP):

(i) home health services;

(ii) personal care;

(iii) physical, speech and occupational therapy;

(iv) transportation;

(v) private duty nursing;

(vi) optometric care;

(vii) audiology services;

(viii) clinical psychology;

(ix) orthotic devices;

(x) sick room supplies; and

(xi) nursing home in-patient care unless the recipient was an in-patient nursing home resident on July 1, 1992.

(2) Payment for in-patient hospital services provided to a recipient who is eligible for MA solely as a result of being eligible for or in receipt of HR and who is at least 21 years of age but under the age of 65 will be limited to 32 days in any consecutive 12-month period unless such services are provided through a program which receives full capitation payments.

 

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