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.

 

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