Part 527 - STATE REIMBURSEMENT FOR PAYMENT TO OUT-OF-STATE PROVIDERS OF MEDICAL CARE AND SERVICES

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Statutory Authority: 
Social Services Law, Sections 20(3)(d), 34(3)(f), 363-a(2), 365, 365-a, 367-a, 368-a

Section 527.1 - Maximum reimbursable fee schedule.

Section 527.1 Maximum reimbursable fee schedule. (a) Maximum reimbursable rates for payments made to out-of-state providers of medical care and services shall be as follows:

(1) Effective January 1, 1984, for inpatient hospital care, the lowest of the following charges:

(i) the title XIX payment established for the hospital under the Medical Assistance Program in that state;

(ii) the title XVIII Medicare payment established for the hospital;

(iii) the hospital's customary charge for public beneficiaries; or

(iv) the maximum New York State title XIX payment for similar inpatient care.

(2) For care in a nursing facility, charges in accordance with rates negotiated by the Commissioner which will not, with the exception of ancillary services not included in that state's medical assistance rate, exceed the rate established for the facility under that State's medical assistance program. A nursing facility may arrange for the provision of ancillary services through contractual agreements or may use providers who are enrolled in the State's medical assistance program and bill the State directly on a fee for service basis. Ancillary services are those services which are required to be provided to medical assistance recipients receiving nursing facility care but which the nursing facility is not required to provide directly.

(3) For all other medical care and services:

(i) rates applicable to New York State providers for similar services when the care was rendered by an out-of-state provider of services who is located within the usual medical marketing area of the community where the patient resides; or

(ii) charges as billed by the out-of-state provider of services when such provider of service is located outside the usual medical marketing area of the community where the patient resides.

 

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