Title: Section 43-1.9 - Extent of responsibility for payment

RESPONSIBILITY FOR PAYMENT FOR SERVICES

43-1.9 Extent of responsibility for payment.

(a) The local health official of the jurisdiction where a tuberculosis patient resides shall be responsible to pay providers for health care services rendered to a local charge tuberculosis patient when such services are authorized and provided in accordance with this Subpart, except:

(1) The maximum charges which the local health official shall be responsible for are the rates for the Medical Assistance Program established in accordance with the provisions of section 2807 of the Public Health Law and fees for services established in the State medical fee schedule for medical assistance.

(2) Amounts eligible for reimbursement or indemnification from any third-party payer shall not be paid by the local health official. Such amounts shall be deducted by the local health official from the charges billed by the provider or the established rates and/or fees in the State medical fee schedule for the health care services rendered, whichever are less.

(3) When a person has been admitted as an inpatient to a hospital for the treatment of a nontuberculous disease or condition and is subsequently found to have tuberculosis which requires inpatient care and treatment, a local health official has no responsibility to pay for care and treatment prior to the date of diagnosis of tuberculosis. If the person requires tuberculosis care and treatment, but hospitalization is not justified, the local health official shall not be responsible for hospitalization costs.

(4) If, upon review of a claim, the local health official determines that a tuberculosis patient had or was eligible for third-party coverage or indemnification and that the provider failed to make a good faith effort to determine whether there was such coverage or indemnification, the local health official may deny payment of claim.

(5) A person who volunteers to assume and pay for the cost of tuberculosis health care services hereunder shall be liable therefor.

(b) The State of New York shall be responsible to pay providers for health care services rendered to a State charge tuberculosis patient in accordance with the terms of this Subpart, with the same exceptions as described in subdivision (a) of this section.

(c) Subsequent to paying a provider for services, if a local health official or the State determines that a provider did not make a good faith effort to obtain third-party payer coverage or indemnification that was available, the local health official or the State shall require the provider to repay an amount equivalent to the amount of such third-party payer coverage or indemnification.