SubPart 360-7 - PAYMENT FOR MA SERVICES

Doc Status: 
Complete

Section 360-7.1 - Introduction.

Section 360-7.1 Introduction. This Subpart specifies:

(a) when MA will pay for covered medical care and services;

(b) who may receive MA payment for providing covered medical care and services;

(c) that recipients must cooperate in obtaining payments from third parties; and

(d) that MA may pay for certain insurance premiums, coinsurance and deductibles, and for reserved beds in medical institutions.

 

Doc Status: 
Complete

Section 360-7.2 - MA program as payment source of last resort.

360-7.2 MA program as payment source of last resort. Where a third party, such as a health insurer or responsible person, has a legal liability to pay for MA-covered services on behalf of a recipient, the department or social services district will pay only the amount by which the MA reimbursement rate for the services exceeds the amount of the third party liability. The department or social services district will also pay if the third party payment will not be made within a reasonable time. The department or social services district will seek reimbursement for any payments for care and services it makes for which a third party is legally responsible. They will seek reimbursement to the extent of the third party's legal liability unless the amount reasonably expected to be recovered is less than the cost of making the recovery.

 

Doc Status: 
Complete

Section 360-7.3 - Use of health, hospital or accident insurance.

360-7.3 Use of health, hospital or accident insurance. (a) Definitions used in this section.

(1) Insurance providing full coverage. A recipient's insurance is providing full coverage when the recipient's care is paid for under the insurance contract without the payment of any coinsurance amount, deductible, or Medicare.

(2) Insurance providing partial coverage. A recipient's insurance is providing partial coverage when payment for his/her care under the insurance contract is subject to payment of a coinsurance amount, deductible, or Medicare.

(3) Indemnity insurance coverage is any insurance benefit a recipient receives because of accident or injury. Examples of this type of insurance are automobile and liability insurance and workers' compensation benefits.

(4) Coinsurance amount or deductible are amounts an insurance beneficiary must pay when he/she receives care or services.

(b) A recipient must use health, hospital or accident insurance benefits to the fullest extent in meeting his/her medical needs.

(1) Using insurance benefits to pay for care provided to a recipient by a medical institution:

(i) Blue Cross, Government Health Insurance and other types of insurance (other than indemnity insurance).

(a) When a recipient's care in a medical institution is covered in full by insurance, the social services district will only make payments for items of care not covered by the insurance contract that are the recipient's responsibility to pay. Payments which the social services district makes for a recipient in this way will be at rates set by the appropriate official. The total payment by the social services district for any item of service must be limited to the amount by which the rate of payment approved by the State Director of the Budget, according to section 2807 of the Public Health Law, exceeds the amount paid by the insurance carrier.

(b) When a recipient's care in a medical institution is partially covered by insurance, the payment by the social services district must be no more than the amount by which the rate of payment for the institution approved by the State Director of the Budget, in accordance with section 2807 of the Public Health Law, exceeds the amount paid by the insurance carrier. The term "partially covered" for the purpose of this clause includes specific and fixed benefits for maternity care.

(ii) Assignment of a recipient's indemnity insurance coverage. The social services district must establish procedures for the proper use of a recipient's indemnity insurance benefits. These procedures must provide for an MA applicant or recipient to assign these benefits to the medical institution providing his/her care or to the social services district. If the procedures provide for assignment of benefits to the social services district, they must include a method for obtaining payment of the benefits to the social services district.

(iii) Situations where the social services district pays the difference between the amount of assigned benefits and the established rate. If a recipient assigns his/her indemnity insurance benefits to the medical institution, the social services district must pay the medical institution the amount by which the rate of payment for the institution approved by the State Director of the Budget, in accordance with section 2807 of the Public Health Law, exceeds the amount paid by the insurance carrier.

(2) Using insurance benefits to pay for care provided to recipients by persons and agencies other than medical institutions.

(i) Blue Shield, Government Health Insurance and other insurance (except indemnity coverage). The social services district must pay the provider of a recipient's medical services the amount by which the fee for the care and services that is set by the social services district exceeds the amount paid by the insurance carrier.

(ii) Assignment of indemnity insurance coverage. The social services district must establish procedures for the proper use of indemnity insurance benefits. These procedures must provide for an applicant or recipient to assign his/her indemnity insurance benefits to the provider of medical services, if the provider will accept such assignment, or to the social services district. If the social services district's procedures provide for assignment of these benefits to the district, they must include the methods for obtaining payment by the social services district.

(iii) If a recipient assigns indemnity insurance benefits to the provider of medical services, the social services district must pay the provider the amount by which the fee established by the district for the service rendered exceeds the amount paid by the insurance carrier. If the indemnity insurance benefit is assigned to the social services district, the provider must be paid the district's established fee for the services the recipient receives.

(3) The social services district staff must obtain from applicants/recipients information about their private health coverage. This information includes insurance coverage which may be available to the applicant/recipient through an absent parent or spouse. If the applicant/recipient is unaware of what coverage is available through an absent parent or spouse, the social services district is responsible for getting the information from either the absent parent or spouse or their employers. The applicant/ recipient must provide the social services district with the name of the insurance carrier, type of coverage, policy number, and amount of the premium payment.

(c) Applicants/recipients must make full use of available medical resources which will provide or pay for medical care, services and supplies.

(1) Children under 21 years of age may be eligible for medical services under the children with physical disabilities program (formerly the physically handicapped children's program), provided for under Title V of Article 25 of the Public Health Law. The social services district must promptly refer the case of a child who may be eligible for this program to the local program medical director. If the local program medical director determines that the child is medically eligible, MA-covered services must be provided in accordance with the plan of care approved by the local program medical director. Once the social services district official has been notified that the child is medically eligible, the child's financial eligibility for MA must be determined, in accordance with the agreement between the State Department of Health and the State Department of Social Services. If the child is eligible for MA with no parental liability, the medical services must be authorized by the social services district and paid for from MA funds. If the child's parents are required to contribute toward the cost of his/her care under MA eligibility standards, the child's case must be referred to the children with physical disabilities program for payment of the cost of medical services up to the amount of the child's excess income.

(2) The social services district must review any existing support order which has been entered for a recipient's benefit against a spouse or parent. The social services district must petition to amend orders of support to provide that the parent or spouse participate in a family medical insurance plan if one is available through the parent's or spouse's employer.

 

Doc Status: 
Complete

Section 360-7.4 - Liability of third parties.

360-7.4 Liability of third parties.

(a) (1) When care and services are or may be provided to an applicant/recipient for treatment of injury, disease or disability, the State or social services district will take all reasonable measures to ascertain the legal liability of third parties (including health insurers) to pay for such care and services.

(2) The social services district, when determining or redetermining eligibility , must collect sufficient information to enable the State to pursue claims against such third parties, including all information specifically required by the department.

(3) As a condition of eligibility, an applicant/recipient must cooperate with the State or social services district in identifying third parties who may be liable to pay for care. The applicant/recipient must provide information to assist the State in pursuing such third parties. An applicant/recipient may refuse to cooperate only for good cause.

(4) As a condition of eligibility, an applicant/recipient with the legal capacity to execute an assignment, must assign to the State and social services district any rights against any third party for support (specified as support for medical care by a court or administrative order) and for payment of medical care. The requirement extends to any person with the legal authority to execute an assignment on behalf of an applicant/recipient.

(5) The State or social services district will seek reimbursement for MA when there is a third party legal liability and the expected amount of reimbursement is more than the costs of making the recovery.

(6) Upon furnishing MA to a recipient, the social services district or the department will be subrogated, to the extent of the expenditures by such district or the department, to any rights the recipient may have to medical support or third party reimbursement. For purposes of this section, the term medical support means the right to support for purposes of medical care as specified by court or administrative order. The social services district or the department will issue a written notice of the exercise of subrogation rights to the appropriate party or parties.

(b) A recipient is eligible to receive MA even if he/she has a right of action, suit, claim, counterclaim or demand against a third party for personal injuries suffered, if all other eligibility requirements are met. If the social services district finds that the third party has paid or will pay within a reasonable time, the district will pay only the amount by which the allowable MA claim exceeds the third party liability. If payment will not be made within a reasonable time, the social services district must file a lien covering the cost of such assistance in accordance with section 104-b of the Social Services Law. The recipient will be required to assign to the district the proceeds of such right or demand.

(c) Whenever a social services district authorizes hospital care for the treatment of recipient's personal injuries, it must obtain a satisfaction or discharge of any hospital lien covering such care before or at the time payment to the hospital is made. The district must file the satisfaction or discharge in accordance with the Lien Law.

 

Doc Status: 
Complete

Section 360-7.5 - Method of payment for medical care

360-7.5 Method of payment for medical care.

(a)(1) Except as provided in paragraphs (2) through (4) of this subdivision, payment by the MA program for services covered under the program which are medically necessary in amount, duration, and scope, will be made to the enrolled MA provider which furnished the services, at the MA rate or fee in effect at the time the services were provided.

(2) Payment may be made to:

(i) a practitioner's employer if the practitioner would be required to do so as a condition of employment;

(ii) the facility in which such services were provided if the facility submits the claim under a contract between a practitioner and the facility; or

(iii) an organization, including a health maintenance organization, which furnishes health care through an organized health care delivery system, if there is a contract between the organization and the practitioner under which the organization bills or receives payment for the services.

(3)(i) Payment may be made to a recipient or the recipient's representative for paid medical bills if:

(a) an erroneous MA eligibility determination is reversed (whether the reversal is due to the social services district discovering its own error or is the result of a fair hearing decision or court order), or the social services district fails to determine MA eligibility within the time periods set forth in section 360-2.4 of this Part; and

(b) the erroneous eligibility determination or the delay in determining eligibility caused the recipient or the recipient's representative to pay for medically necessary services which otherwise would have been paid for by the MA program.

(ii) Payment under this paragraph is not limited to the MA rate or fee in effect at the time the services were provided, but may be made to reimburse the recipient's or the recipient's representative's reasonable out-of-pocket expenditures. In addition, payment under this paragraph may be made with respect to services furnished by a provider who is not enrolled in the MA program, if such provider is otherwise lawfully qualified to provide the services, and had not been excluded or otherwise sanctioned from the MA program under Part 515 of this Title.

(iii) For purposes of subparagraph (ii) of this paragraph, an out-of-pocket expenditure will be considered reasonable if it does not exceed 110 percent of the MA payment rate for the service. If an out-of-pocket expenditure exceeds 110 percent of the MA payment rate, the social services district will determine whether the expenditure is reasonable. In making this determination, the district may consider the prevailing private pay rate in the community at the time services were rendered, and any special circumstances demonstrated by the recipient.

(4) Payment may be made to a recipient or the recipient's representative for paid medical bills for services received during the recipient's retroactive eligibility period, provided that the recipient was eligible in the month in which the services were received, in accordance with the provisions of this paragraph.

(i) For services received during the period beginning on the first day of the third month prior to the month of the MA application and ending on the date the recipient applied for MA, payment can be made without regard to whether the provider of services was enrolled in the MA program. However, if the services were furnished by a provider not enrolled in the MA program, the provider must have been otherwise lawfully qualified to provide such services, and must not have been excluded or otherwise sanctioned from the MA program under Part 515 of this Title. If services were provided when the recipient was temporarily absent from the State, payment will be made if: MA recipients customarily use medical facilities in the other state; or the services were obtained to treat an emergency medical condition resulting from an accident or sudden illness.

(ii) For services received during the period beginning after the date the recipient applied for MA and ending on the date the recipient received his or her MA identification card, payment may be made only if the services were furnished by a provider enrolled in the MA program.

(b) The claim of any provider of medical care, services, or supplies assigned under a power of attorney or otherwise, is invalid and cannot be enforced against a social services district. However, an assignment from a supplier to a governmental agency or entity or an assignment established under a court order is valid.

(c) A provider of medical care, services, or supplies may employ a business agent, such as a billing service or an accounting firm. Such agent may prepare and send bills and receive MA payments in the name of the provider only if the compensation paid to the agent is:

(1) reasonably related to the cost of the services;

(2) unrelated, directly or indirectly, to the dollar amounts billed and collected; and

(3) not dependent on actual collection of payments.

(d) A social services district may use any appropriate organization as a fiscal intermediary to audit and pay for the district's share of the cost of medical care, services and supplies provided to recipients. An appropriate organization is any insurance carrier authorized to conduct audits and make payments to providers who furnish services under Medicare. A social services district must enter into an agreement with the organization that meets the requirements of this provision and other appropriate Federal authorities. The department must approve the agreement before the organization can be used as a fiscal intermediary.

(e) Payment for a recipient's transportation costs will be made to the vendor. If payment cannot be made directly to the vendor, it will be made to the recipient as an administrative expense. When the services of an attendant are essential, payment for the attendant's transportation costs will be made to the vendor. If payment cannot be made directly to the vendor, payment will be made to the attendant as an administrative expense.

(f) Payment for home health aide services will be made in the same manner as payment for any other medical care provided under the MA program.

(g) Payment or part-payment of the premium for personal health insurance covering care and other medical benefits which are authorized under the MA program may be made to the insurance carrier or to another appropriate third party:

(1) on behalf of MA households eligible for ADC, HR or extended MA coverage pursuant to paragraphs (1) and (2) of section 360-3.3(c) of this Part, for cost-effective, employer-sponsored group health insurance benefits. Such premiums will be paid for the benefit of the recipient's spouse and dependent children. Non-employer health insurance will be paid, in part or in
full, when it would reduce the expense of providing MA services;

(2) on behalf of a recipient if the recipient is receiving MA as a patient in a medical facility and all the recipient's nonexempt income
except that expended for the cost of such insurance, is applied to the cost of his/her care; or

(3) on behalf of a recipient or household which is eligible for MA if the full cost of such insurance premiums was not used in calculating financial eligibility and if full or partial payment would reduce the expense of providing MA services.

(h) Payment of the COBRA premiums for COBRA continuation coverage, as defined in paragraph (l) of this subdivision, will be made by the MA program on behalf of a person described in paragraph (2) of this subdivision.

(1) (i) COBRA continuation coverage means health insurance coverage required by Section 10002 of the consolidated omnibus Budget Reconciliation Act of 1985 (Pub. L. No. 99-272) and provided under a group health plan that meets the following requirements:

(a) the group health plan is provided by an employer of 75 or more employees; and

(b) the group health plan is provided pursuant to title XXII of the public Health service Act, section 4980B of the Internal Revenue code of 1986, or title VI of the Employee Retirement Income security Act of 1974.

(ii) COBRA premiums means the applicable premiums imposed with respect to COBRA continuation coverage.

(2) The MA program will pay the COBRA premiums for a person who meets the following requirements:

(i) he or she is entitled to elect COBRA continuation coverage;

(ii) his or her income does not exceed 100 percent of the poverty line, as defined in section 360-1.4(r) of this Part, applicable to a household of the same size as the person's household;

(iii) his or her resources do not exceed twice the maximum amount of resources that a person may have to be eligible for federal Supplemental Security Income (SSI) benefits; and

(iv) the social services district has determined that the savings in MA expenditures resulting from enrolling the person for COBRA continuation coverage are likely to exceed the amount of payments made for the COBRA premiums.

(3) When determining the eligibility of a person for payment of the COBRA premiums under this subdivisor, the social services district must:

(i) use the federal SSI eligibility requirements relating to income and resources; and

(ii) not consider costs that the person or the person's household has incurred for medical or remedial care.

(4) (i) The MA program will pay the COBRA premiums on behalf of a person who has applied to have the program pay for such premiums and who the social services district reasonably expects will meet the eligibility requirements of paragraph (2) of this subdivision but for whom the social services district has not yet received documentation verifying whether the person is eligible
for MA payment of his or her COBRA premiums.

(ii) When the social services district receives such documentation and determines that such person does not meet the eligibility requirements of paragraph (2) of this subdivision:

(a) the MA program's payment of the person's COBRA premiums will terminate;

(b) the person may request a fair hearing pursuant to part 358 of this Title to review the social services district's determination that he or she is ineligible for the MA program's payment of his or her COBRA premiums; however, the person will not be entitled to aid continuing; and

(c) the social services district may request that the person repay the amount of the MA program's payments for his or her COBRA premiums unless a fair hearing decision has held that the social services district's determination was incorrect.

(5) The social services district must notify the person, in writing and on forms required by the department of its determination whether the person is eligible, or continues to be eligible, to have the MA program pay for his or her COBRA premiums. The notice must advise the person of his or her right to request a fair hearing and of any aid continuing rights in accordance with part 358 of this Title.

(i) Payment of health insurance premiums will be made by the MA program on behalf of a person described in paragraph (1) of this subdivision.

(1) The MA program will pay the health insurance premiums for a person who:

(i) has Acquired Immune Deficiency Syndrome (AIDS) or an Human Immune Deficiency Virus (HIV) related illness, as defined by the AIDS Institute of the Department of Health;

(ii) resides in a household whose income does not exceed 185 percent of the poverty line, as defined in section 360-1.4(r) of this Part, applicable to a household of the same size as the person's household;

(iii) (a) is unemployed; participated in the health insurance plan his or her prior employer provided; and is eligible to continue his or her participation in such plan or convert his or her coverage to individual coverage;

(b) is employed; participated in the health insurance plan his or her prior employer provided; is eligible to continue his or her participation in such plan or convert his or her coverage to individual coverage; and is ineligible to participate in the health insurance plan that his or her current employer provides or such employer does not offer a health insurance plan; or

(c) is or was self-employed; maintained health insurance coverage while self-employed; and is eligible to continue his or her participation in such plan or convert his or her coverage to individual coverage; and

(iv) is ineligible for MA.

(2) When determining the eligibility of a person for the payment of his or her health insurance premiums under this subdivision, a social services district must:

(i) use the federal Supplemental Security Income eligibility requirements relating to income; and

(ii) not consider the following:

(a) costs that the person or the person's household has incurred for medical or remedial care; or

(b) resources available to the person or the person's household.

(3)(i) The MA program will pay the health insurance premiums on behalf of a person who has applied to have the program pay for such premiums and who the social services district reasonably expects will meet the eligibility requirements of paragraph (1) of this subdivision but for whom the social services district has not yet received documentation verifyin4 whether the
person is eligible for MA payment of his or her health insurance premiums.

(ii) When the social services district receives such documentation and determines that the person does not meet the eligibility requirements of paragraph (l) of this subdivision:

(a) the MA program's payment under this subdivision of the person's health insurance premiums will terminate;

(b) the person may request a fair hearing pursuant to Part 358 of this Title to review the social services district's determination that he or she is ineligible for the MA program's payment under this subdivision of his or her health insurance premiums; however, the person will not be entitled to aid continuing; and

(c) the social services district may request that the person repay the amount of the MA program's payments for his or her health insurance premiums unless a fair hearing decision has held that the social services district's determination was incorrect.

(4) The social services district must notify the person, in writing and on forms required by the department, of its determination whether the person is eligible, or continues to be eligible, to have the MA program pay for his or her health insurance premiums. The notice must advise the person of his or her right to request a fair hearing and of any aid continuing rights in accordance with Part 358 of this Title.

(j) Payments will be made to the facility, agency or person who provided medical services under the physically handicapped children's program when prior authorization was obtained from the social services district. Services under this program include inpatient hospital care, prosthetic appliance costing more than $40 and prescribed by someone other than a qualified specialist, multiple extractions and dental prosthesis, and other dental care and services. If, during a period for which such care and services have been authorized, the recipient or household becomes ineligible for MA, arrangements must be made with the recipient or household to pay the social services district for the cost of care and services provided during the period of MA ineligibility. In such instances, the social services district will limit accounting division authorization to the care and services for which prior authorization was obtained. If the recipient or household remains ineligible for MA when such care and services are completed, the
case will be closed.

Doc Status: 
Complete
Effective Date: 
Wednesday, August 30, 2006

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.

 

Doc Status: 
Complete

Section 360-7.7 - Payments of deductibles and coinsurance under title XVIII of

360-7.7 Payments of deductibles and coinsurance under title XVIII of the Social Security Act (Medicare). (a) The MA program will pay on behalf of qualified Medicare beneficiaries, as defined in subdivision (g) of this section, the full amount of any deductible and coinsurance costs incurred under Part A or B of Title XVIII of the Social Security Act (Medicare).

(1) The MA program will pay the full amount of such deductible and coinsurance costs for care, services or supplies included in the MA program and for care, services or supplies that are included in the MA program.

(2) The MA program will pay the full amount of such deductible and coinsurance costs for qualified Medicare beneficiaries who are otherwise eligible for MA and for qualified Medicare beneficiaries who are not otherwise eligible for MA.

(b) The MA program will pay on behalf of MA recipients who are also eligible for benefits under Part A or B of Title XVIII (Medicare), but who are not qualified Medicare beneficiaries, the full amount of any deductible or coinsurance costs incurred under such part provided that the costs were incurred for care, services and supplies included in the MA program.

(c) Before the MA program will pay any Medicare Part B deductible or coinsurance liability, the MA recipient or qualified Medicare beneficiary must assign to the provider any Part B benefit payment to which he or she is entitled. A provider of a Medicare Part B benefit must accept assignment from such recipient or beneficiary of his or her right to receive the Medicare Part B payment.

(d) A provider of a Medicare Part B benefit must not seek to recover any Medicare Part B deductible or coinsurance amounts from an MA recipient or qualified Medicare beneficiary.

(e) To be paid for transportation services that are not paid through the Medicaid Management Information System, a provider must submit to the social services district bills for deductible and coinsurance amounts and the explanations of benefits form issued by the Medicare carrier. A provider does not have to submit the explanation of benefits form to a district which can obtain this information from the Medicare Part B fiscal agent's computer files. A district must apply Medicare Part B benefits before making MA payments for claims.

(f) Reimbursement is not available under the MA program for services or supplies furnished pursuant to Title XVIII of the Social Security Act (Medicare) if:

(1) the provisions of such title or the regulations promulgated to implement such title preclude a provider of such services or supplies from charging a Medicare beneficiary for the cost of the supplies or services provided; or

(2) the provider agrees, under the terms of a Medicare provider agreement, not to charge an individual for the cost of services or supplies.

(g) Qualified Medicare beneficiaries. (1) As used in this section and section 360-7.8 of this Subpart, the term qualified Medicare beneficiary means a person:

(i) who is entitled to hospital insurance benefits under Medicare Part A;

(ii) whose income does not exceed 100 percent of the poverty line, as defined in section 360-1.4 of this Part, applicable to a family of the size involved;

(iii) whose resources do not exceed twice the maximum amount of resources that the person may have to be eligible for Supplemental Security Income benefits; and

(iv) who meets the non-financial eligibility requirements contained in Subpart 360-3 of this Part.

(h) Qualified disabled and working individuals. As used in this section and section 360-7.8 of this Subpart, the term qualified disabled and working individual means a person who is not otherwise eligible for medical assistance and:

(1) who is entitled to hospital insurance benefits under section 1818A of Part A of Title XVIII of the Social Security Act;

(2) whose income does not exceed 200 percent of the official Federal poverty line applicable to the person's family size; and

(3) whose resources do not exceed twice the maximum amount of resources that an individual or a couple, in the case of a married individual, may have and obtain Federal supplemental security income benefits under Title XVI of the Federal Social Security Act, as determined for purposes of that program.

(i) Specified low income Medicare beneficiaries. As used in this section and section 360-7.8 of this Subpart, the term specified low income Medicare beneficiary means a person:

(1) who would be a qualified Medicare beneficiary as defined in 360-7.7(g) of this Subpart except that the person's income exceeds the regulatory income requirements; and

(2) whose income is greater than 100 percent of the official federal poverty line applicable to the person's family size but, in calendar years 1993 and 1994, is less than 110 percent of such poverty line and, in calendar years beginning in 1995, is less than 120 percent of such poverty line.

 

Doc Status: 
Complete

Section 360-7.8 - Payments of premiums under Title XVIII of the Social Security

360-7.8 Payments of premiums under Title XVIII of the Social Security Act (Medicare). (a) Payment of Medicare part A monthly premiums will be made by the MA program for qualified Medicare beneficiaries and qualified disabled and working individuals, as defined in section 360-7.7 of this Subpart. Payment of Medicare Part A monthly premiums for a qualified Medicare beneficiary will begin with the month following the month he or she applies of MA payment of these amounts.

(b) Payment of Medicare part B premiums will be made by the MA program if a recipient is:

(1) enrolled in a voluntary insurance program under Medicare part B;

(2) receiving cash grants as an eligible recipient of public assistance;

(3) receiving chronic care in a medical institution;

(4) receiving care in a public home; or

(5) a qualified Medicare beneficiary, as defined in section 360-7.7(g) of this Subpart. The MA program will pay the Medicare part B monthly premiums for a qualified Medicare beneficiary beginning with the month following the month he or she applies for MA payment of these amounts.

(6) a specified low income Medicare beneficiary as defined in section 360-7.7(i) of this Subpart. The MA program will pay the Medicare Part B monthly premiums for a specified low income Medicare beneficiary.

(c) Method of payment. (1) The State will pay Medicare part B premiums initially for recipients of cash grants. The social services district will be charged periodically for its proportionate share of the premiums. The charge to a social services district cannot exceed 50 percent of the cost of such premium after crediting any available Federal reimbursement.

(2) The social services district will pay the premiums for recipients in chronic care in a medical institution or care in a public home. Each social services district must claim State reimbursement for the cost of the premiums that it paid initially.

Doc Status: 
Complete

Section 360-7.9 - Special needs of MA recipients subject to chronic care budget

360-7.9 Special needs of MA recipients subject to chronic care budgeting. A recipient subject to chronic care budgeting in a medical facility or an intermediate care facility will receive a grant to satisfy unmet needs and expenses if his/her monthly income is less than the amount allowed by the department for incidental needs and expenses. The grant will be from the category of assistance for which he/she is eligible.

 

Doc Status: 
Complete

Section 360-7.10 - Reserved

Reserved

Section 360-7.11 - Medical assistance liens and recoveries.

360-7.11 Medical assistance liens and recoveries.

(a) Liens. The social services district may not impose any lien against a person's property prior to his or her death for MA paid or to be paid on his
or her behalf except:

(1) based upon a court judgment for benefits incorrectly paid; or

(2) against claims and suits for personal injuries, to recover the amount of MA furnished to a person on and after the date the person incurred the
injuries; or

(3) with respect to the real property of a person who is an in-patient in a nursing facility, intermediate care facility for the mentally retarded, or
other medical institution, and who is not reasonably expected to be discharged from the medical institution and return home, provided that:

(i) any such lien will dissolve upon the person's discharge and return home; and

(ii) no lien may be imposed on the person's home if the person's spouse, child under twenty-one years of age, certified blind or certified disabled child of any age, or sibling who has an equity interest in the home and who resided in the home for at least one year immediately before the date of the person's admission to the medical institution, is lawfully residing in the home.

(b) Adjustments and recoveries.

(1) A social services district may make no adjustment or recovery for MA correctly paid except from:

(i) the estate of a person who was 65 years of age or older when he or she received MA; or

(ii) the sale of real property subject to a lien imposed pursuant to paragraph (a)(3) of this section, or from the estate of such person; or

(iii) a legally responsible relative of an MA recipient, and then only the amount of MA granted, provided the relative has sufficient income and
resources which he or she fails or refuses to make available. The amount of income and resources required to be contributed by a legally responsible
relative is determined under Subpart 360-4 of this Part.

(2) An adjustment or recovery under subparagraph (i) or (ii) of paragraph (1) of this subdivision may be made from a person's estate only after the
death of the person's surviving spouse, and only when the person has no surviving child who is under twenty-one years of age or who is certified blind
or certified disabled.

(3) In addition to the limitations set forth in paragraph (2) of this subdivision, in the case of a lien on a person's home, no adjustment or recovery may be made when:

(i) a sibling of the person resided in the home for at least one year immediately before the date of the person's admission to the medical institution, and has lawfully resided in the home on a continuous basis since the date of admission; or

(ii) a child of the person resided in the home for a period of at least two years immediately before the date of the person's admission to a medical
institution, provided care to such person which permitted the person to reside at home rather than in an institution, and has lawfully resided in the home on a continuous basis since the date of admission.

(4) A social services district may maintain an action pursuant to sections 101 and 104 of the Social Services Law to collect from a trustee, grantor, or grantor's spouse any beneficial interest of the grantor or grantor's spouse in any trust established other than by will, to reimburse such district for the amount of MA granted to, or on behalf of, a grantor or grantor's spouse. The beneficial interest of the grantor or grantor's spouse includes any income and principal amounts to which the grantor or grantor's spouse would be entitled under the terms of the trust, by right or in the discretion of the trustee, assuming the full exercise of discretion by the trustee.

(5) If an MA recipient receives an insurance settlement for personal injuries which includes an amount for medical bills, the social services district may recover from such amount the cost of MA provided for the treatment of the injuries.

(6) A social services district may maintain an action under the Debtor and Creditor Law to set aside any transaction which appears to have been made for the purpose of qualifying a person for MA or for avoiding a lien or recovery of MA paid on behalf of an MA recipient.

Doc Status: 
Complete

Section 360-7.12 - Co-payments by recipients.

360-7.12 Co-payments by recipients. (a) In accordance with section 367-a(6) of the Social Services Law, nominal co-payments must be imposed upon recipients for certain care, services and supplies furnished under the medical assistance program. Payments for claims for services specified in subdivision (d) of this section will be reduced by the amounts determined in subdivision (f) of this section. The providers of such services may charge recipients the co-payments. However, providers may not deny services to recipients because of their inability to pay the co-payments.

(b) Definitions.

(1) For purposes of this section, drugs with FDA-approved indications for the treatment of tuberculosis means aminosalicylate sodium (para-aminoslaicylate sodium), capremycin sulfate, cycloserine, ethambutol, ethionamide, isoniazid, pyrazinamide, rifampin, and streptomycin.

(2) Medical facility means residential health care facility or an intermediate care facility for the developmentally disabled.

(3) For purposes of this section, psychotropic drugs means acetazolamide, acetophenazine, alprazolam, amantadine, amitriptyline, amoxapine, benztropine, biperiden, bupropion, buspirone, butabarbital, cabamazepine, chloral hydrate, chlordiazepoxide, chlormezanone, chlorpromazine, chlorprothixene, clomipramine, clonazepam, clorazepate dipotassium, clozapine, desipramine, diazepam, diphenhydramine, doxepin, estazolam, ethorpropazine HC1, ethosuximide, ethotoin, fluoxetine, fluphenazine, flurazepam, halazpam, halorperidol, hydroxyzine HC1, hydroxyzine pamoate, imipramine, isocarboxazid, lithium, lorazepan, loxapine, maprotiline, mephenytoin, mephobarbital, meprobamate, methsuximide, mesoridazine, molindone, nortriptyline, oxazepam, paraldehyde, paramethadione, pentobarbital, perphenazine, phenacemide, phenelzine, phenobarbital, phensuximide, phenytoin, pimozide, prazepam, primidone, prochlorperazine, procyclidine, promazine, protriptyline, quazepam, secobarbital, sertraline, temazepam, thioridazine, thiothizene, tranylcypromine, trazodone, triazolam, trifluoperazine, triflupromazine, trihexyphenidyl HC1, trimethadione, trimipramine, and valproic acid and its derivatives.

(4) X-ray services means diagnostic radiology, diagnostic ultrasound, nuclear medicine or radiation oncology.

(c) Co-payments apply to all recipients except:

(l) individuals under 21 years of age;

(2) pregnant women;

(3) individuals who are in-patients in medical facilities or residents of community based residential facilities licensed by the Office of Mental Health or the Office of Mental Retardation and Developmental Disabilities who have been required to spend all of their incomes for medical care, except their personal needs allowances;

(4) individuals enrolled in health maintenance organizations or other entities which provide comprehensive health services, or other managed care programs; and

(5) any other individuals required to be excluded by federal law or regulations.

(d) Co-payments only apply to the following services:

(1) in-patient care in a general hospital, as defined in subdivision 10 of section 2801 of the Public Health Law;

(2) out-patient hospital and clinic services, except for mental health services, mental retardation and developmental disability services, alcohol and substance abuse services and methadone maintenance services;

(3) sickroom supplies;

(4) drugs, except psychotropic drugs and drugs with FDA-approved indications for the treatment of tuberculosis as defined in subdivision (b) of this section;

(5) clinical laboratory services, except those provided by and payable to a physician or podiatrist;

(6) x-ray services, except those provided by and payable to physicians, podiatrists or dentists; and

(7) emergency room services provided for non-urgent or non-emergency medical care.

(e) Co-payments do not apply to emergency services or family planning services and supplies or tuberculosis directly observed therapy services provided by programs approved by the Department of Health.

(f) The amount of the co-payment for each service specified in subdivision (d) of this section, except for paragraph (1) relating to in-patient care, must not exceed the amount specified in paragraph (l) of this subdivision. The amount of the co-payment for each service specified in subdivision (d) is a standard co-payment amount based upon the average or typical payment for the service by the MA program, as set forth in paragraph (2) of this subdivision. The co-payment for each service specified in paragraph (l) of subdivision (d) of this section is $25.00 for each discharge.

(1) Schedule of co-payments:

 

Average or typical MA payment

Co-payment

$10 or less

$.50

$10.01 to $25

$1.00

$25.01 to $50

$2.00

$50.01 or more

$3.00

 

(2) Standard co-payment amounts:
 

Service

Co-payment

In-patient care

$25.00 per discharge

Out-patient hospital and clinic services

$3.00 per visit

Sickroom supplies

$1.00 per order

Enteral and parenteral formulae/supplies

$1.00 per claim

Brand name prescription drugs

$2.00 for each prescription dispensed

Generic prescription drugs

$ .50 for each prescription dispensed

Non-prescription drugs

$ .50 for each order dispensed

Clinical laboratory procedures

$ .50 for each procedure billed

Radiology procedures              

$1.00 for each procedure code billed

Emergency room services provided for non-urgent or non-emergency care

$3.00 per visit

 

Doc Status: 
Complete