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Title: Section 505.1 - Scope of medical assistance.

Effective Date

03/28/2012

Section 505.1 Scope of medical assistance. (a) Services available. (1) Medical care, services and supplies available to eligible persons must, except to the extent that such medical care, services and supplies are either furnished solely to promote fertility or certified as inappropriate, unnecessary or otherwise not authorized by the Commissioner of Health or his or her designee and except as provided in subdivision (b) of this section, include the following:

(i) services of qualified physicians, dentists, nurses, optometrists and other related professional personnel;

(ii) care, treatment, maintenance and nursing services in hospitals, skilled nursing facilities that qualify as, or have applications pending to become, providers in the Medicare program pursuant to title XVIII of the Federal Social Security Act, or other eligible institutions, and health-related care and services in intermediate care facilities, while such institutions and facilities are operated in compliance with applicable provisions of law and to the extent authorized by this Subchapter. However, no medical assistance payment will be authorized for care provided after December 31, 1977 in skilled nursing facilities which have participated in title XIX since September 1, 1976, but for whom title XVIII certification is still lacking, except for those skilled nursing facilities providing solely pediatric care.

(2) Medical care, services and supplies available 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, except to the extent that such medical care, services and supplies are certified as inappropriate, unnecessary or otherwise not authorized by the Commissioner of Health or his or her designee, include the following only if such recipient is enrolled in a health maintenance organization or other entity which provides comprehensive health services, a managed care program or other primary provider program as specified by the Department, 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.

(b) Authorization for medical services and supplies. The identification card issued to a person eligible for medical assistance shall constitute full authorization for providing any medical services and supplies for which the person is eligible under title 11 of article 5 of the Social Services Law except when:

(1) medical services and supplies, in accordance with the regulations of the department, routinely require:

(i) prior approval of a local professional director; or

(ii) prior authorization of the social services official; or

(iii) certification by the Commissioner of Health or his designee;

(2) the identification card on its face:

(i) restricts an individual recipient to a single provider; or

(ii) requires prior authorization for all ambulatory medical services and supplies except emergency care; or (3) the service exceeds benefit limitations as established by the department.

Volume

VOLUME C (Title 18)

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