SubPart 360-9 - Catastrophic Health Care Expense Program

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Section 360-9.1 - Scope.

Section 360-9.1 Scope. As part of a comprehensive response to the difficulties individuals and families face in obtaining access to medical care and the extraordinary costs of such care, the Legislature enacted Title 11-A of Article 5 of the Social Services Law. That Title established the Catastrophic Health Care Expense Program (CHCEP) to test ways to expand the availability of health insurance coverage on a demonstration basis in no more than three social services districts. These regulations implement the provisions of the CHCEP.

 

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Section 360-9.2 - Demonstration applications.

360-9.2 Demonstration applications. A social services district may apply to participate in the CHCEP by submitting a proposal which describes how the program would be implemented in the district if the department approved the proposal. All proposals must be submitted by February 28, 1989, or such later date specified by the department.

 

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Section 360-9.3 - Definitions.

360-9.3 Definitions. For the purposes of this Subpart:

(a) Adjusted family income means the family income during a calendar year reduced by documented alimony payments, support payments, FICA contributions and federal, State and local income tax payments.

(b) Eligible catastrophic health care expenses means those health care expenses which can be paid for under the Medical Assistance (MA) program excluding expenses incurred for services provided to in-patients or residents of health care facilities, other than expenses incurred for acute care services that are provided by general hospitals. Eligible catastrophic health care expenses must be incurred in a calendar year after the time when a family's total health care expenses exceed fifty percent of the difference between the annual adjusted family income and the maximum amount of public assistance (PA) the family would receive if it were eligible for PA.

(c) Hardship. Hardship means an applicant's adjusted annual family income does not exceed 200 percent of the comparable federal income official property line (as defined and annually revised by the federal Office of Management and Budget) for a family of the same size and the family's total countable resources, computed according to Subpart 360-4 of this Title, do not exceed $10,000.

 

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Section 360-9.4 - Eligibility for the CHCEP Services.

360-9.4 Eligibility for the CHCEP Services.

(a) The CHCEP is available to a family which: is ineligible for MA and PA; meets the residency requirements of Section 369-c of the Social Services Law; and has eligible catastrophic health care expenses.

(b) (1) The CHCEP assistance with cost sharing of eligible catastrophic health care expenses is available to a family if its health care expenses, after deducting health insurance benefits, are in excess of 50 percent, but are no more than 75 percent, of the difference between the adjusted or projected annual family income and the maximum PA grant it would receive if it were eligible for PA.

(2) For a family which is eligible for the CHCEP assistance with cost sharing under paragraph (1) of this subdivision, the CHCEP will pay a percentage of the expenses for covered services and the family must pay the remainder. The Commissioner of Health has established a schedule setting forth the cost sharing percentages which will be used to allocate costs between families and the CHCEP for the various CHCEP services (l0 NYCRR 85.42). The CHCEP share of the expenses will be determined by multiplying the cost sharing percentage by the MA rate for the service or the rate charged by the provider of the service, whichever is less.

(3) A family in receipt of the CHCEP assistance with cost sharing may be reimbursed only for paid bills for health care services incurred during the previous calendar year, unless the family demonstrates hardship as defined in Section 360-9.3 of this Subpart. If hardship is demonstrated, the family in receipt of the CHCEP may be reimbursed up to the MA rate for the current year's expenses. When the social services district determines that hardship exists, payments may be made directly to the provider of the health care services. The social services district may determine that hardship exists at the time a family applies for an interim authorization or assistance with or without cost sharing under this Subpart.

(c) (1) The CHCEP assistance without cost sharing of eligible catastrophic health care expenses is available to a family if its health care expenses, after deducting health insurance benefits and the benefits available pursuant to Section 360-9.4(b) of this Subpart, are in excess of 75 percent of the difference between the adjusted or projected annual family income and the maximum PA grant it would receive if it were eligible for PA.

(2) For a family which is eligible for the CHCEP assistance without cost sharing under paragraph (l) of this subdivision, the CHCEP will reimburse a family for the bills it has paid for covered services and directly pay the provider of service for unpaid bills. The CHCEP will reimburse or pay for such bills at the MA rate for the service or the rate charged by the provider of the service, whichever is less.

(d) A family may apply to the social services district for an interim authorization which would enable the family, on a prospective basis, to have any medical expenses covered under the MA program reduced to the MA rate or fee. To be eligible for an interim authorization, a family must be eligible for the CHCEP pursuant to subdivision (b) or (c) of this section. The social services district must use projected income and allowable deductions to compute the current year's adjusted income for purposes of determining eligibility for interim authorization. The interim authorization may not extend beyond the final day of the calendar year in which the services were rendered and in which eligibility for the CHCEP assistance was based.

 

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Section 360-9.5 - Responsibilities of the CHCEP applicant and recipient.

360-9.5 Responsibilities of the CHCEP applicant and recipient.

(a) An applicant for the CHCEP assistance must submit to the social services district an application for such assistance together with documentation of any third-party health insurance benefits which are available to family members.

(b) A family which has received an interim authorization for CHCEP assistance must notify the appropriate social services official of any change in family size, income or estimated income upon which the eligibility determination was based within 30 days of the change.

 

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Section 360-9.6 - Powers and responsibilities of the social services district.

360-9.6 Powers and responsibilities of the social services district. Each social services district that participates in the CHCEP must:

(a) determine eligibility of a family to participate in the CHCEP within 90 days from receipt of an application;

(b) not require that a new application be submitted by an applicant who re-applies within 30 days of a notice of denial;

(c) ensure that the application date is the date of original application for any applicant who re-applies within 30 days of the notice of denial;

(d) provide written notice to the department if a problem arises which threatens the continuation or completion of the project. Such notice must be provided within three days after the problem arises or is discovered, including recommendations for resolving the problem;

(e) submit claims for payment to the department on a monthly basis;

(f) transfer to the department any funds received from sources other than the CHCEP for medical expenses which would be paid under the CHCEP;

(g) prepare quarterly progress and financial reports and submit the reports to the department no later than 30 days after the close of each calendar quarter;

(h) provide notice of the termination of the project to the department not less than 30 days prior to the effective date of termination if the district determines that continuing the CHCEP in the district is not feasible;

(i) use interim authorization and vendor billing forms approved by the department; and

(j) give applicants for or families in receipt of CHCEP assistance notices which comply with sections 358-2.2 and 358-3.3 of this Title.

 

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Section 360-9.7 - Powers and responsibilities of the department.

360-9.7 Powers and responsibilities of the department. The department may:

(a) withhold up to 10 percent of any CHCEP grant money owed to the district if the district does not comply with the provisions of section 360-9.6(h) of this Subpart; the department may pay the district the withheld amount only when the district complies with such provisions; and

(b) terminate the demonstration project in a social services district when it determines that termination would be in the State's best interest. Written notice of the termination must be provided to the district not less than 30 days prior to the effective date of the notice.

 

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