Part 500 - GENERAL PROVISIONS

Doc Status: 
Complete
Statutory Authority: 
Social Services Law, Sections 20, 34 L. 1971, ch. 110, Section 83

Section 500.1 - Introduction.

Section 500.1 Introduction. (a) Medical care which may be provided under the medical assistance program, as authorized by title 11 of article five of the Social Services Law, consists of the care, services and supplies enumerated therein, together with any other care, services or supplies authorized to be provided by these regulations and furnished in accordance with these regulations, sound medical practice and the rules and regulations of the state board or body supervising the respective professions.

(b) The department will limit the amount, duration and scope of medical assistance authorized to be provided under the Social Services Law and this Title to medical care, services and supplies which are medically necessary and appropriate, consistent with quality care and generally accepted professional standards.

(c) The department will employ methods and procedures to deter unnecessary utilization of medical care, services and supplies reimbursed under the medical assistance program including, but not limited to, requiring prior authorization or prior approval of medical care, services and supplies and the use of utilization controls, recipient restrictions, utilization thresholds, and service limits.

(d) The department will employ such methods and procedures as are necessary to ensure the proper and efficient operation and administration of the medical assistance program and the delivery of medically necessary and appropriate care, services and supplies to medical assistance recipients.

Doc Status: 
Complete

Section 500.2 - How provided.

500.2 How provided. (Additional statutory authority: N.Y. Const., art. XVII, 2; Social Security Law, Section 17)

(a) Medical care as herein defined shall be provided by social services officials in accordance with regulations of the department, which shall require full and proper use of existing public and private medical and health services.

(b) Such medical care may be secured through the use of medical personnel who provide services:

(1) as individual independent medical practitioners;

(2) through medical professional service corporations organized under article 15 of the Business Corporation Law;

(3) as members of a medical facility;

(4) through the auspices of insurance or indemnity plans, provided the organization employing such methods of group medical protection or treatment are, when required by law, appropriately licensed by the New York State Department of Insurance; or

(5) through the auspices of comprehensive health care organizations or plans using the prepayment capitation principle, provided the organizations employing such methods of group medical care are, when required by law, appropriately qualified, licensed, or certified by the New York State Departments of Insurance or Health, or other designated regulatory agency.

(c) However, the use of such group-based resources is not to be effectuated in any local social services district until approval is secured from the State Department of Social Services. Such State approval will be dependent on a review of data submitted by the local social services district covering such factors as quality, standards, adequacy of protection, extent and duration of coverage, and cost analyses which demonstrate that the plan will assure prompt, adequate medical care to individuals at reasonable cost.

 

Doc Status: 
Complete

Section 500.3 - Reimbursement for expenditures.

500.3 Reimbursement for expenditures. Except as otherwise provided by the Social Services Law, expenditures for medical care shall be eligible for reimbursement, provided such expenditures are made and reimbursement therefor claimed in accordance with the rules of the board and such regulations as have been established, or may hereafter be established, by the department.

 

Doc Status: 
Complete

Section 500.5 - Reimbursement and payment for appointments not kept.

500.5 Reimbursement and payment for appointments not kept. Reimbursement shall not be available to the local districts nor shall payment be made through the Medicaid Management Information System under the Medical Assistance Program for appointments for medical care which are not kept.

 

Doc Status: 
Complete