SubPart 360-2 - APPLICATION PROCESS

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Effective Date: 
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Section 360-2.1 - Introduction.

Section 360-2.1 Introduction. This Subpart explains the application/recertification process for MA including:

 

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Section 360-2.2 - Applying for MA.

360-2.2 Applying for MA. (a) ADC and HR applicants. Persons applying for ADC or HR on the State-prescribed form are not required to make a separate application for MA.

(1) Persons determined to be eligible for ADC or HR are automatically eligible for MA if they meet the general conditions for MA eligibility in section 360-3.2 of this Part.

(2) Persons determined to be ineligible for ADC or HR will have their MA eligibility determined separately, unless they have stated in writing that they do not want their MA eligibility determined.

(b) SSI applicants. (1) Persons determined to be eligible for SSI from the Social Security Administration are automatically eligible for MA if they meet the general conditions for MA eligibility in section 360-3.2 of this Part. No separate application for MA is required.

(2) Persons determined to be ineligible for SSI must make a separate application if they wish to have MA eligibility determined, assuming they have not already done so.

(c) Title IV-E children. (1) A child receiving foster care maintenance payments pursuant to title IV-E of the Social Security Act or on whose behalf a title IV-E adoption assistance agreement is in effect is automatically eligible for MA. The child must be living in the state and meet the general conditions of MA eligibility in section 360-3.2 of this Part. No separate application for MA is required.

(2) If a child is determined ineligible under title IV-E, a separate application must be made in order to have MA eligibility determined, assuming this has not already been done.

(d) Application for MA only. (1) Persons may apply for MA without applying for ADC, HR, or SSI. Persons may also apply for MA separately from an application for SSI. Such applicants must complete and sign a State-prescribed form in ink. Spouses living together and applying for MA together must both sign the State-prescribed application form. The form may be completed and signed by anyone the applicant designates to represent him/her in the application process. The completed form must be returned to the social services district in the county in which the applicant lives.

(2) (i) HR eligibility will be determined for MA applicants who:

(a) are not eligible under the assistance programs listed in section 360-3.3(a) (2)-(6) of this Part; and

(b) do not meet the requirements, other than financial, for medically needy status in section 360-3.3(b) of this PART.

(ii) Generally, eligibility for MA on the basis of HR eligibility will be determined according to Parts 352 and 370 of this Title. Exceptions to this general rule are set forth below.

(a) A homestead, as defined in section 360-1.4(f) of this Part, is exempt from consideration in determining eligibility.

(b) Lump-sum and windfall payments will be counted as income in the month received. Any portion of such payments remaining in subsequent months will be counted as an available resource.

(c) A child's savings of under $500 accumulated from gifts from nonlegally responsible relatives or from the child's own wages will be disregarded in determining eligibility.

(d) The provisions of section 352.23(b)(6) of this Title regarding the sale of real property do not apply. If the value of the total resources of the applicant/recipient is over the maximum resource level, the applicant/recipient will be ineligible for MA.

(e) Recertification. Social Services districts must redetermine an MA recipient's eligibility at least once every 12 months and whenever there is a change in the recipient's circumstances that may affect eligibility. The district may redetermine eligibility more frequently.

(1) MA recipients who are not eligible for ADC, HR, SSI, title IV-E, or the adoption assistance benefits described in section 360-3.3(a)(6) of this Part must apply for recertification on a State-prescribed form each time MA eligibility is redetermined.

(2) MA recipients who are eligible for ADC, HR, SSI, Title IV-E, or the adoption assistance benefits described in section 360-3.3(a)(6) of this Part will continue to be eligible for MA as long as they are eligible under the other program. No application for recertification is required when MA eligibility is redetermined.

(f) Personal interview for applicants and recipients. (1) The social services district must conduct a personal interview with anyone applying for MA or for recertification of MA, except as provided in paragraphs (2) and (3) of this subdivision. If the applicant/recipient cannot be interviewed due to his/her physical or mental condition, the person who applied on his/her behalf must be interviewed. The district must conduct the interview before making any decision concerning an applicant's/recipient's eligibility for MA. The district does not have to conduct a personal interview when the application for MA is made on behalf of a child in the custody of the State Division for Youth or of a local commissioner of social services. At the interview, an applicant/recipient or his/her representative must be told about the following:

(i) the general eligibility requirements of the MA program;

(ii) the applicant's/recipient's responsibility to provide all information necessary to determine eligibility;

(iii) the applicant's/recipient's and the social services district's responsibility to explore all the facts concerning the applicant's/recipient's eligibility;

(iv) the kinds of information or documents the applicant/recipient must provide to show eligibility, the time when the information and documents must be submitted, and the applicant's/recipient's responsibility to obtain information or documents whenever possible;

(v) the social services district's responsibility to undertake necessary investigation to determine the applicant's/recipient's eligibility;

(vi) the applicant's/recipient's responsibility to inform the district immediately of all changes in circumstances; and

(vii) the availability of other assistance or services for which the applicant/recipient may be eligible.

(2) (i) Social services districts may request a waiver of the personal interview requirement for recertification for aged, certified blind or certified disabled recipients. The request must be sent in writing, by certified mail, to the State Commissioner of Social Services. The request must state the intended duration of the waiver and other conditions the local social services commissioner finds relevant. The local social services commissioner must sign the request. A waiver request may be granted if the social services district demonstrates that alternative procedures have been established to verify that recipients continue to meet all eligibility requirements for MA. The department may require follow-up reports from the social services district to insure that continuing eligibility is being accurately determined. The waiver may be withdrawn or modified, if, through the department's monitoring efforts, it is determined that the statewide medical assistance eligibility error rate may be adversely affected.

(ii) The local social services official will be notified in writing within 45 days of the approval, partial approval or denial of the waiver. If the waiver is denied, the department will inform the district of the reasons for the denial. The department's failure to act within the specified time period does not constitute an automatic approval of the waiver.

 

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Section 360-2.3 - Investigation of eligibility.

Section 360-2.3 Investigation of eligibility. (a) Generally. (1) The social services district has a continuing obligation to collect, verify, record and evaluate factual information concerning an MA applicant's/recipient's eligibility for MA.

(2) The MA applicant/recipient has a continuing obligation to provide accurate and complete information on his/her income, resources, and other factors that affect eligibility. The applicant/recipient must also provide information on the income and resources of a nonapplying legally responsible relative, even if the relative is not living with the applicant/recipient; if the applicant/recipient does not possess this information, he/she must cooperate with the social services district in obtaining it. An applicant/recipient will not have eligibility denied or discontinued solely because he/she does not possess and cannot obtain information about the income or resources of a nonapplying legally responsible relative who is not living with him/her.

(3) The applicant/recipient is the primary source of eligibility information. When an applicant/recipient is unable to document the information provided, the social services district must conduct an investigation to verify such information. The social services district must also conduct such an investigation if it believes that information provided by an applicant/recipient is inaccurate. The district may examine records, other than public records, only with the applicant's/recipient's permission. If the applicant/recipient refuses such permission and the social services district is unable to verify information through public records, the applicant/recipient will be informed that the district is unable to determine MA eligibility. The application then will be denied, or eligibility will be discontinued.

(4) Part 351 of this Title sets forth additional requirements which must be met in the investigation process.

(b) Nonfinancial eligibility requirements. The social services district must verify that applicants and recipients meet the nonfinancial eligibility requirements contained in Subpart 360-3 of this Part.

(c) Financial eligibility requirements. (1) Evaluation of financial circumstances. In determining whether an applicant/recipient is financially eligible for MA under section 360-3.3(b) or 360-3.3(c) of this Part, the social services district must review all sources of income and resources available or potentially available to the applicant/recipient. The district must consider the income and resources of all legally responsible relatives. The review will be based on information in the application and from a personal interview with the applicant/recipient or the person applying on his/her behalf. The district must consider only available income and resources, as defined in Subpart 360-4 of this Part. To be eligible for MA, the applicant must pursue any potential income and resources that may be available. As soon as income or resources become available, the applicant must report them to the district. The district must reevaluate the applicant's eligibility for MA based on the new financial information.

(2) Verification of income. The applicant must submit with his/her application documentation of wages received by all employed family members who are included in the application and by all legally responsible relatives living with the applicant. Acceptable forms of documentation are pay envelopes, wage stubs, or an employer's statement of wages. If the applicant's income varies, the documentation must show all wages earned in the past four weeks. If the applicant cannot supply such documentation, the social services district can accept other forms of information which it determines will verify the wages earned. All other income also must be documented and a determination made as to its availability. The social services district must record the type of information used to verify other available income.

(3) Verification of resources. (i) The applicant may attest to the amount of his or her resources, unless the applicant is seeking coverage for long-term care services. For purposes of this paragraph, long-term care services shall include those services defined in subparagraph (ii) of this paragraph, with the exception of short-term rehabilitation as defined in subparagraph (iii) of this paragraph. The applicant must provide documentation of all available or potentially available resources when applying for long-term care services. The social services district must record the documentation provided and determine the availability of such resources.

(ii) Long-term care services shall include, but not be limited to care, treatment, maintenance, and services: provided in a nursing facility licensed under article twenty-eight of the public health law; provided in an intermediate care facility certified under article sixteen of the mental hygiene law; provided in a residential treatment facility certified by the Commissioner of Mental Health pursuant to Section 31.02(a)(4) of mental hygiene law; provided in a developmental center operated by the Office of Mental Retardation and Developmental Disabilities; provided by a home care services agency, certified home health agency or long-term home health care program as defined in section thirty-six hundred two of the public health law; provided by an adult day health care program in accordance with regulations of the department of health; provided by a personal care provider licensed or regulated by any other state or local agency; provided in a hospital that is equivalent to the level of care provided in a nursing facility; and provided by an assisted living program in accordance with regulations of the department of health. Long-term care services also shall include: private duty nursing; limited licensed home care services; hospice services including services provided by the hospice residence program in accordance with the regulations of the department of health; services provided in accordance with the consumer directed personal assistance program; services provided by the managed long-term care program; personal emergency response services; and care, services or supplies provided by the Care at Home Waiver program, Traumatic Brain Injury Waiver program, or Office of Mental Retardation and Developmental Disabilities Home and Community-Based Waiver program.

(iii) Short-term rehabilitation means one period of certified home health care, up to a maximum of 29 consecutive days, and/or one period of nursing home care, up to a maximum of 29 consecutive days, commenced within a twelve-month period.

(4) If any income or resources are unavailable, the applicant/recipient must submit documentation establishing the unavailability.

(5) The applicant/recipient must satisfactorily explain and/or document how current living expenses are being met.

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Effective Date: 
Wednesday, December 20, 2006

Section 360-2.4 - Decision.

360-2.4 Decision. (a) Time frames.

(1) Except as provided in paragraphs (2) and (3) of this subdivision, the social services district must determine an applicant's eligibility for MA within 45 days of the date of the MA application.

(2) If an applicant's MA eligibility is dependent on disability status, the social services district will determine MA eligibility within 90 days of application. If a decision is not reached within 90 days, the applicant must be sent a statement explaining why.

(3) The district will determine eligibility within 30 days of the date of the MA application if an applicant is:

(i) a pregnant woman or an infant younger than one year of age whose household income does not exceed 200 percent of the applicable Federal poverty level; or

(ii) a child at least one year of age but younger than nineteen years of age whose household income does not exceed 133 percent of the applicable Federal poverty level.

(b) The social services district must determine MA eligibility within the time frames in subdivision (a) of this section except in unusual circumstances including:

(1) when the district cannot reach a decision because the applicant or an examining physician has delayed taking or has not taken a required action, or because medical records have not been received; or

(2) where there is an administrative or other emergency beyond the district's control.

(c) When a social services district determines that an applicant or recipient is eligible for MA, MA will be authorized. Such authorization will be effective back to the first day of the first month for which eligibility is established, except as otherwise provided in this Part. A retroactive authorization will be issued for medical expenses incurred during the three months prior to the month of application for MA, provided the applicant was eligible in the month in which the medical care and services were received. Direct payment to the recipient for paid medical bills will be limited to the MA rate or fee in effect at the time the services were rendered.

 

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Effective Date: 
Wednesday, April 24, 2013

Section 360-2.5 - Notification of acceptance/denial.

360-2.5 Notification of acceptance/denial. The social services district must notify applicants promptly on State-prescribed forms of MA eligibility decisions.

(a) Notice of acceptance. The social services district will provide eligible applicants with a notice on a State-prescribed form accepting the MA application. The notice will explain what MA care and services are authorized. It must also list any limitations. The notice must clearly indicate when only part of the cost of a particular service will be allowed, If an applicant is liable for part of the cost of care, the district will supply information on allowed costs to the applicant's service provided.

(b) Notice of denial. The social services district must provide ineligible applicants with a notice on a State-prescribed form denying the application. The notice of denial must be adequate, as defined in section 358-2.2 of this Title.

(c) If an applicant is denied MA on the basis of a denial of an application for ADC or HR, a single notice may be sent advising the applicant of both determinations. The notice must separately and adequately advise the applicant of the determination of MA ineligibility.

 

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Section 360-2.6 - Changes in circumstances affecting classification or eligibil

360-2.6 Changes in circumstances affecting classification or eligibility. (a) If an MA recipient's circumstances change, the social services district must take action within 30 days to:

(1) change the recipient's classification, when the change affects Federal financial participation;

(2) discontinue eligibility, when the change affects the recipient's eligibility; or

(3) provide the proper category of assistance, when the change affects the recipient's category of assistance.

(b) If a recipient's ADC, HR, SSI, or title IV-E case is discontinued, MA will be continued until the social services district determines the recipient to be ineligible for MA. The district must determine the recipient's continuing eligibility no later than the end of the calendar month following the month in which the recipient was determined ineligible for ADC, HR, SSI, or title IV-E.

(c) The social services district must provide an MA recipient with a notice on a State-prescribed form whenever a change in circumstances causes an increase or reduction in coverage and/or liability, or causes a change in the calculation of the recipient's excess income, even if the amount of the recipient's excess income is not affected. Such notice must meet the requirements of section 358-2.2 of this Title.

(d) Whenever the social services district is informed of a change in a recipient's circumstances, it must review the recipient's need for other assistance or services. The district must inform the recipient of available assistance and services, and help the recipient in obtaining them.

 

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Section 360-2.7 - Termination of MA; notification of discontinuance.

360-2.7 Termination of MA; notification of discontinuance. (a) When a social services district determines that a recipient is no longer eligible for MA, MA will be terminated. The effective date of discontinuance will be the date the recipient becomes ineligible, or a later date if necessary in order to provide the recipient with timely notice of the discontinuance, as required by section 358-3.3 of this Title. Except as limited by the provisions of this subdivision, the effective date of discontinuance may be any day during the month.

(b) The social services district must send a notice of discontinuance on a State-prescribed form to an MA recipient if it determines that the recipient has become ineligible for MA. The notice of discontinuance must be adequate, as defined in section 358-2.2 of this Title.

(c) If the recipient's MA benefits are being stopped for the same reason that his/her ADC or HR benefits are being stopped a single notice may be sent advising the recipient of both actions. The notice must separately and adequately advise the recipient of the proposed discontinuance of MA.

 

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Section 360-2.8 - Right to a conference.

360-2.8 Right to a conference. An MA applicant/recipient who disagrees with a decision of the social services district concerning his/her case may request a conference, as described in Part 358 of this Title. At the conference the applicant/recipient will meet with a district representative having the authority to change the district's decision. The district representative will review the district's decision, answer any questions the applicant/recipient has, and will consider any information the applicant/recipient presents. A request for a conference is not a request for a fair hearing and does not entitle the applicant/recipient to aid continuing pending the outcome of the conference. The applicant/recipient may still request a fair hearing, even if a conference has been requested. However, the deadline for requesting a fair hearing will remain the same whether or not a conference is requested.

 

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Section 360-2.9 - Right to a fair hearing.

360-2.9 Right to a fair hearing. An MA applicant or recipient may request a fair hearing if he/she disagrees with a social services official's decision, action or failure to act. A fair hearing is the procedure which an applicant or recipient can use to appeal certain decisions of a social services district to the State Commissioner of Social Services. A complete explanation of how to request a fair hearing, the grounds for requesting a fair hearing, and the fair hearing process is found in Part 358 of this Title.

 

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