Title: Section 360-3.7 - Presumptive eligibility.

Effective Date

04/23/2014

360-3.7 Presumptive eligibility. (a) Any person applying for MA will be presumed eligible for such assistance for a period of up to 60 days from the date of transfer from a general hospital to a certified home health agency or long term home health care program if:

(1) the applicant is receiving acute care in such hospital;

(2) a physician certifies that the applicant no longer requires acute hospital care, but still requires medical care which can be provided by a certified home health agency or a long term home health care program;

(3) the applicant or his/her representative states that the applicant does not have insurance coverage for the required medical care and that such care cannot be afforded;

(4) it reasonably appears that the applicant is eligible for MA; and

(5) it reasonably appears that the amount expended by the department and the social services district for care and services provided by a certified home health agency or long term home health care program during the period of presumed eligibility would be less than the amount which would be expended for continued acute hospital care.

(b) An applicant determined to be presumptively eligible for MA under subdivision (a) of this section will not be eligible, during the period of presumptive eligibility, for MA coverage of inpatient care in a hospital or residential health care facility, hospital emergency room treatment, and hospital-based clinic care. If the applicant is subsequently determined to be eligible for MA, he/she will be eligible for all care and services available under the MA program retroactively to the effective date of presumptive eligibility. If a presumptively eligible applicant is subsequently determined to be ineligible for MA, any sums expended for such assistance during the period of presumptive eligibility will be recouped from the applicant. The social services district will have the authority to recoup such sums on behalf of the department.

(c) A period of presumptive eligibility pursuant to subdivision (a) of this section will end automatically after 60 days from the date of transfer from the general hospital or upon a determination by the social services district as to the applicant's eligibility for MA, whichever occurs first. If a presumptively eligible applicant is subsequently determined to be ineligible for MA, the applicant may request a fair hearing pursuant to Part 358 of this Title to dispute the denial of MA but the period of presumptive eligibility will not be extended by such request.

(d) Presumptive eligibility for pregnant women.

(1) A pregnant woman will be presumed eligible to receive the MA care, services and supplies listed in paragraph (9) of this subdivision when a qualified provider determines, on the basis of preliminary information, that the pregnant woman's family income does not exceed 185 percent of the applicable poverty line listed in section 360-4.7 (b) of this Part.

(2) For purposes of this subdivision, the pregnant woman's family income will be determined according to section 360-4.6 of this Part relating to financial eligibility for MA. The resources of the pregnant woman's family will not be considered in determining the pregnant woman's presumptive eligibility for MA.

(3) For purposes of this subdivision, a pregnant woman's family includes the pregnant woman, any legally responsible relatives and any legally dependent relatives with whom she resides.

(4) As used in this subdivision, the term "qualified provider" means a provider who:

(i) is eligible to receive payment under the MA program;

(ii) provides one or more of the following types of services:

(a) outpatient hospital services;

(b) rural health clinic services; or

(c) clinic services furnished by or under the direction of a physician, without regard to whether the clinic itself is administered by a physician;

(iii) has been found by the department to be capable of making presumptive eligibility determinations based on family income; and

(iv) meets at least one of the following additional criteria:

(a) receives funds under the federal Migrant Health Centers or Community Health Centers programs pursuant to the federal Public Health Service Act;

(b) receives funds under the federal Maternal and Child Health Services Block Grant programs pursuant to Title V of the federal Social Security Act;

(c) participates in the program established under the federal Special Supplemental Food Program for Women, Infants, and Children pursuant to the federal Child Nutrition Act of 1966;

(d) participates in the program established under the federal Commodity Supplemental Food Program pursuant to the federal Agriculture and Consumer Protection Act of 1973; or

(e) participates in the New York State Department of Health's Prenatal Care Assistance Program (PCAP), established pursuant to Article 25 of the Public Health Law (PHL).

(5) A pregnant woman who has been determined presumptively eligible for MA must submit an MA application to the social services district in which she resides by the lase day of the month following the month in which a qualified provider determined her to be presumptively eligible.

(6) A qualified provider that has determined a pregnant woman to be presumptively eligible for MA must:

(i) on the day the qualified provider determines the pregnant woman to be presumptively eligible, inform her that she must submit an MA application to the social services district in which she resides by the last day of the following month in order to continue her presumptive eligibility until the day the social services district determines her eligibility;

(ii) assist her to complete the MA application and submit the application on her behalf;

(iii) within five business days after the day the qualified provider determines the pregnant woman to be presumptively eligible, notify the social services district in which the pregnant woman resides of its presumptive eligibility determination on forms the department develops or approves; and

(iv) if the qualified provider participates in PCAP, offer to represent the presumptively eligible pregnant woman during the remainder of the MA eligibility process, including acting as her representative at the personal interview the social services district conducts pursuant to section 360-2.2 of this Part.

(7) The period of presumptive eligibility for MA begins on the day a qualified provider determines the pregnant woman to be presumptively eligible. If the pregnant woman submits an MA application to the social services district in which she resides by the last day of the following month, the period of presumptive eligibility continues through the day the social services district determines whether the pregnant woman is eligible for MA; if the pregnant woman fails to submit such an application, the period of presumptive eligibility continues through the last day of the following month.

(8) A pregnant woman is eligible for only one period of presumptive eligibility during each pregnancy.

(9) A presumptively eligible pregnant woman is eligible for medical care, services and supplies as follows:

(i) a presumptively eligible pregnant woman whose family income does not exceed 100 percent of the applicable poverty line, as listed in section 360-4.7 (b) of this Part, is eligible for all medical care, services and supplies available under the MA program, excluding inpatient and institutional long-term care; and

(ii) a presumptively eligible pregnant woman whose family income exceeds 100 percent of the applicable poverty line but does not exceed 185 percent of such line, as listed in section 360-4.7 (b) of this Part, is eligible for comprehensive prenatal care services available under PCAP, as described in section 2522 of the Public Health Law, excluding inpatient care.

(10) If a presumptively eligible pregnant woman is subsequently determined to be ineligible for MA, she may request a fair hearing pursuant to Part 358 of this Title to dispute the denial of MA, but her presumptive eligibility period will not be extended by such request.

(e) Presumptive eligibility for coverage of family planning benefit program (FPBP) services.

(1) An individual will be presumed eligible to receive the MA care, services and supplies listed in paragraph (8) of this subdivision when a qualified provider determines, on the basis of preliminary information, that the individual's family income does not exceed 200 percent of the Federal poverty line applicable to a family of the same size.

(2) For purposes of this subdivision, the individual's family income will be determined according to section 360-4.6 of this Part relating to financial eligibility for MA. The resources of the individual's family will not be considered in determining the individual's presumptive eligibility for coverage of FPBP services.

(3) For purposes of this subdivision, an individual's family includes the individual, any legally responsible relatives and any legally dependent relatives with whom he or she resides. In determining eligibility for children under 21, parental income is disregarded when the child requests confidentiality, has good cause not to provide or is otherwise unable to obtain parental income information.

(4) As used in this subdivision, the term qualified provider means a provider who:

(i) is eligible to receive payment under the MA program;

(ii) provides family planning services, treatment and supplies; and

(iii) has been found by the department to be capable of making presumptive eligibility determinations based on family income.

(5) An individual who has been determined presumptively eligible for coverage of FPBP services must submit a FPBP application to the social services district in which he or she resides, or to the department or its agent, by the last day of the month following the month in which a qualified provider determined him or her to be presumptively eligible.

(6) A qualified provider that has determined an individual to be presumptively eligible for coverage of FPBP services must:

(i) on the day the qualified provider determines the individual to be presumptively eligible, inform the individual that a FPBP application must be submitted to the social services district in which he or she resides, or to the department or its agent, by the last day of the following month in order to continue presumptive eligibility until the day his or her FPBP eligibility is determined;

(ii) assist the individual to complete the FPBP application and submit the application on his or her behalf; and

(iii) within five business days after the day the qualified provider determines the individual to be presumptively eligible, notify the social services district in which the individual resides, or the department or its agent, of its presumptive eligibility determination on forms the department develops or approves.

(7) The period of presumptive eligibility for coverage of FPBP services begins on the day a qualified provider determines the individual to be presumptively eligible. If the individual submits a FPBP application to the social services district in which he or she resides, or to the department or its agent, by the last day of the following month, the period of presumptive eligibility continues through the day the individual's eligibility for FPBP is determined; if the individual fails to submit such an application, the period of presumptive eligibility continues through the last day of the following month.

(8) An individual found presumptively eligible pursuant to this subdivision is eligible for coverage of the following medically necessary FPBP services and appropriate transportation to obtain such services:

(i) hospital based and free standing clinics;

(ii) county health department clinics;

(iii) federally qualified health centers or rural health centers;

(iv) obstetricians and gynecologists;

(v) family practice physicians,

(vi) licensed midwives, nurse practitioners; and

(vii) family planning related services from pharmacies and laboratories.

(9) If a presumptively eligible individual is subsequently determined to be ineligible for FPBP, he or she may request a fair hearing pursuant to Part 358 of this Title to dispute the denial of FPBP, but the presumptive eligibility period will not be extended by such request.

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VOLUME A-1 (Title 18)

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