Title: Section 360-7.5 - Method of payment for medical care

Effective Date

08/30/2006

360-7.5 Method of payment for medical care.

(a)(1) Except as provided in paragraphs (2) through (4) of this subdivision, payment by the MA program for services covered under the program which are medically necessary in amount, duration, and scope, will be made to the enrolled MA provider which furnished the services, at the MA rate or fee in effect at the time the services were provided.

(2) Payment may be made to:

(i) a practitioner's employer if the practitioner would be required to do so as a condition of employment;

(ii) the facility in which such services were provided if the facility submits the claim under a contract between a practitioner and the facility; or

(iii) an organization, including a health maintenance organization, which furnishes health care through an organized health care delivery system, if there is a contract between the organization and the practitioner under which the organization bills or receives payment for the services.

(3)(i) Payment may be made to a recipient or the recipient's representative for paid medical bills if:

(a) an erroneous MA eligibility determination is reversed (whether the reversal is due to the social services district discovering its own error or is the result of a fair hearing decision or court order), or the social services district fails to determine MA eligibility within the time periods set forth in section 360-2.4 of this Part; and

(b) the erroneous eligibility determination or the delay in determining eligibility caused the recipient or the recipient's representative to pay for medically necessary services which otherwise would have been paid for by the MA program.

(ii) Payment under this paragraph is not limited to the MA rate or fee in effect at the time the services were provided, but may be made to reimburse the recipient's or the recipient's representative's reasonable out-of-pocket expenditures. In addition, payment under this paragraph may be made with respect to services furnished by a provider who is not enrolled in the MA program, if such provider is otherwise lawfully qualified to provide the services, and had not been excluded or otherwise sanctioned from the MA program under Part 515 of this Title.

(iii) For purposes of subparagraph (ii) of this paragraph, an out-of-pocket expenditure will be considered reasonable if it does not exceed 110 percent of the MA payment rate for the service. If an out-of-pocket expenditure exceeds 110 percent of the MA payment rate, the social services district will determine whether the expenditure is reasonable. In making this determination, the district may consider the prevailing private pay rate in the community at the time services were rendered, and any special circumstances demonstrated by the recipient.

(4) Payment may be made to a recipient or the recipient's representative for paid medical bills for services received during the recipient's retroactive eligibility period, provided that the recipient was eligible in the month in which the services were received, in accordance with the provisions of this paragraph.

(i) For services received during the period beginning on the first day of the third month prior to the month of the MA application and ending on the date the recipient applied for MA, payment can be made without regard to whether the provider of services was enrolled in the MA program. However, if the services were furnished by a provider not enrolled in the MA program, the provider must have been otherwise lawfully qualified to provide such services, and must not have been excluded or otherwise sanctioned from the MA program under Part 515 of this Title. If services were provided when the recipient was temporarily absent from the State, payment will be made if: MA recipients customarily use medical facilities in the other state; or the services were obtained to treat an emergency medical condition resulting from an accident or sudden illness.

(ii) For services received during the period beginning after the date the recipient applied for MA and ending on the date the recipient received his or her MA identification card, payment may be made only if the services were furnished by a provider enrolled in the MA program.

(b) The claim of any provider of medical care, services, or supplies assigned under a power of attorney or otherwise, is invalid and cannot be enforced against a social services district. However, an assignment from a supplier to a governmental agency or entity or an assignment established under a court order is valid.

(c) A provider of medical care, services, or supplies may employ a business agent, such as a billing service or an accounting firm. Such agent may prepare and send bills and receive MA payments in the name of the provider only if the compensation paid to the agent is:

(1) reasonably related to the cost of the services;

(2) unrelated, directly or indirectly, to the dollar amounts billed and collected; and

(3) not dependent on actual collection of payments.

(d) A social services district may use any appropriate organization as a fiscal intermediary to audit and pay for the district's share of the cost of medical care, services and supplies provided to recipients. An appropriate organization is any insurance carrier authorized to conduct audits and make payments to providers who furnish services under Medicare. A social services district must enter into an agreement with the organization that meets the requirements of this provision and other appropriate Federal authorities. The department must approve the agreement before the organization can be used as a fiscal intermediary.

(e) Payment for a recipient's transportation costs will be made to the vendor. If payment cannot be made directly to the vendor, it will be made to the recipient as an administrative expense. When the services of an attendant are essential, payment for the attendant's transportation costs will be made to the vendor. If payment cannot be made directly to the vendor, payment will be made to the attendant as an administrative expense.

(f) Payment for home health aide services will be made in the same manner as payment for any other medical care provided under the MA program.

(g) Payment or part-payment of the premium for personal health insurance covering care and other medical benefits which are authorized under the MA program may be made to the insurance carrier or to another appropriate third party:

(1) on behalf of MA households eligible for ADC, HR or extended MA coverage pursuant to paragraphs (1) and (2) of section 360-3.3(c) of this Part, for cost-effective, employer-sponsored group health insurance benefits. Such premiums will be paid for the benefit of the recipient's spouse and dependent children. Non-employer health insurance will be paid, in part or in
full, when it would reduce the expense of providing MA services;

(2) on behalf of a recipient if the recipient is receiving MA as a patient in a medical facility and all the recipient's nonexempt income
except that expended for the cost of such insurance, is applied to the cost of his/her care; or

(3) on behalf of a recipient or household which is eligible for MA if the full cost of such insurance premiums was not used in calculating financial eligibility and if full or partial payment would reduce the expense of providing MA services.

(h) Payment of the COBRA premiums for COBRA continuation coverage, as defined in paragraph (l) of this subdivision, will be made by the MA program on behalf of a person described in paragraph (2) of this subdivision.

(1) (i) COBRA continuation coverage means health insurance coverage required by Section 10002 of the consolidated omnibus Budget Reconciliation Act of 1985 (Pub. L. No. 99-272) and provided under a group health plan that meets the following requirements:

(a) the group health plan is provided by an employer of 75 or more employees; and

(b) the group health plan is provided pursuant to title XXII of the public Health service Act, section 4980B of the Internal Revenue code of 1986, or title VI of the Employee Retirement Income security Act of 1974.

(ii) COBRA premiums means the applicable premiums imposed with respect to COBRA continuation coverage.

(2) The MA program will pay the COBRA premiums for a person who meets the following requirements:

(i) he or she is entitled to elect COBRA continuation coverage;

(ii) his or her income does not exceed 100 percent of the poverty line, as defined in section 360-1.4(r) of this Part, applicable to a household of the same size as the person's household;

(iii) his or her resources do not exceed twice the maximum amount of resources that a person may have to be eligible for federal Supplemental Security Income (SSI) benefits; and

(iv) the social services district has determined that the savings in MA expenditures resulting from enrolling the person for COBRA continuation coverage are likely to exceed the amount of payments made for the COBRA premiums.

(3) When determining the eligibility of a person for payment of the COBRA premiums under this subdivisor, the social services district must:

(i) use the federal SSI eligibility requirements relating to income and resources; and

(ii) not consider costs that the person or the person's household has incurred for medical or remedial care.

(4) (i) The MA program will pay the COBRA premiums on behalf of a person who has applied to have the program pay for such premiums and who the social services district reasonably expects will meet the eligibility requirements of paragraph (2) of this subdivision but for whom the social services district has not yet received documentation verifying whether the person is eligible
for MA payment of his or her COBRA premiums.

(ii) When the social services district receives such documentation and determines that such person does not meet the eligibility requirements of paragraph (2) of this subdivision:

(a) the MA program's payment of the person's COBRA premiums will terminate;

(b) the person may request a fair hearing pursuant to part 358 of this Title to review the social services district's determination that he or she is ineligible for the MA program's payment of his or her COBRA premiums; however, the person will not be entitled to aid continuing; and

(c) the social services district may request that the person repay the amount of the MA program's payments for his or her COBRA premiums unless a fair hearing decision has held that the social services district's determination was incorrect.

(5) The social services district must notify the person, in writing and on forms required by the department of its determination whether the person is eligible, or continues to be eligible, to have the MA program pay for his or her COBRA premiums. The notice must advise the person of his or her right to request a fair hearing and of any aid continuing rights in accordance with part 358 of this Title.

(i) Payment of health insurance premiums will be made by the MA program on behalf of a person described in paragraph (1) of this subdivision.

(1) The MA program will pay the health insurance premiums for a person who:

(i) has Acquired Immune Deficiency Syndrome (AIDS) or an Human Immune Deficiency Virus (HIV) related illness, as defined by the AIDS Institute of the Department of Health;

(ii) resides in a household whose income does not exceed 185 percent of the poverty line, as defined in section 360-1.4(r) of this Part, applicable to a household of the same size as the person's household;

(iii) (a) is unemployed; participated in the health insurance plan his or her prior employer provided; and is eligible to continue his or her participation in such plan or convert his or her coverage to individual coverage;

(b) is employed; participated in the health insurance plan his or her prior employer provided; is eligible to continue his or her participation in such plan or convert his or her coverage to individual coverage; and is ineligible to participate in the health insurance plan that his or her current employer provides or such employer does not offer a health insurance plan; or

(c) is or was self-employed; maintained health insurance coverage while self-employed; and is eligible to continue his or her participation in such plan or convert his or her coverage to individual coverage; and

(iv) is ineligible for MA.

(2) When determining the eligibility of a person for the payment of his or her health insurance premiums under this subdivision, a social services district must:

(i) use the federal Supplemental Security Income eligibility requirements relating to income; and

(ii) not consider the following:

(a) costs that the person or the person's household has incurred for medical or remedial care; or

(b) resources available to the person or the person's household.

(3)(i) The MA program will pay the health insurance premiums on behalf of a person who has applied to have the program pay for such premiums and who the social services district reasonably expects will meet the eligibility requirements of paragraph (1) of this subdivision but for whom the social services district has not yet received documentation verifyin4 whether the
person is eligible for MA payment of his or her health insurance premiums.

(ii) When the social services district receives such documentation and determines that the person does not meet the eligibility requirements of paragraph (l) of this subdivision:

(a) the MA program's payment under this subdivision of the person's health insurance premiums will terminate;

(b) the person may request a fair hearing pursuant to Part 358 of this Title to review the social services district's determination that he or she is ineligible for the MA program's payment under this subdivision of his or her health insurance premiums; however, the person will not be entitled to aid continuing; and

(c) the social services district may request that the person repay the amount of the MA program's payments for his or her health insurance premiums unless a fair hearing decision has held that the social services district's determination was incorrect.

(4) The social services district must notify the person, in writing and on forms required by the department, of its determination whether the person is eligible, or continues to be eligible, to have the MA program pay for his or her health insurance premiums. The notice must advise the person of his or her right to request a fair hearing and of any aid continuing rights in accordance with Part 358 of this Title.

(j) Payments will be made to the facility, agency or person who provided medical services under the physically handicapped children's program when prior authorization was obtained from the social services district. Services under this program include inpatient hospital care, prosthetic appliance costing more than $40 and prescribed by someone other than a qualified specialist, multiple extractions and dental prosthesis, and other dental care and services. If, during a period for which such care and services have been authorized, the recipient or household becomes ineligible for MA, arrangements must be made with the recipient or household to pay the social services district for the cost of care and services provided during the period of MA ineligibility. In such instances, the social services district will limit accounting division authorization to the care and services for which prior authorization was obtained. If the recipient or household remains ineligible for MA when such care and services are completed, the
case will be closed.

Volume

VOLUME A-1 (Title 18)

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