2023 New York Laws › SOS - Social Services › Article 5 - Assistance and Care › Title 11 - Medical Assistance for Needy Persons › 364-I - Medical Assistance Presumptive Eligibility Program.

§  364-i.  Medical  assistance  presumptive eligibility program. 1. An
individual, upon application for medical assistance, shall  be  presumed
eligible for such assistance for a period of sixty days from the date of
transfer  from  a  general  hospital, as defined in section twenty-eight
hundred one of the public health law to a certified home  health  agency
or  long term home health care program, as defined in section thirty-six
hundred two of the public health law, or to  a  hospice  as  defined  in
section  four thousand two of the public health law, or to a residential
health care facility as defined in section twenty-eight hundred  one  of
the  public  health  law,  if  the  local  department of social services
determines that the applicant meets each of the following criteria:  (a)
the  applicant is receiving acute care in such hospital; (b) a physician
certifies that such applicant no longer requires  acute  hospital  care,
but  still  requires  medical  care which can be provided by a certified
home health agency, long term  home  health  care  program,  hospice  or
residential   health   care   facility;   (c)   the   applicant  or  his
representative  states  that  the  applicant  does  not  have  insurance
coverage  for  the  required  medical  care and that such care cannot be
afforded; (d) it reasonably appears  that  the  applicant  is  otherwise
eligible  to  receive medical assistance; (e) it reasonably appears that
the amount expended by the state and the local social services  district
for medical assistance in a certified home health agency, long term home
health care program, hospice or residential health care facility, during
the  period  of  presumed eligibility, would be less than the amount the
state and the local social services district would expend for  continued
acute  hospital  care  for such person; and (f) such other determinative
criteria as the commissioner shall provide by rule or regulation.  If  a
person  has  been  determined  to  be presumptively eligible for medical
assistance, pursuant to this subdivision, and is subsequently determined
to be ineligible for such assistance, the commissioner, on behalf of the
state and the local social services district shall have the authority to
recoup from the individual the sums expended for such assistance  during
the period of presumed eligibility.
2.  Payment  for  up to sixty days of care for services provided under
the medical assistance program shall be made for an  applicant  presumed
eligible  for  medical  assistance  pursuant  to subdivision one of this
section provided, however, that such payment shall not exceed sixty-five
percent of the rate payable under this title for services provided by  a
certified  home  health  agency,  long  term  home  health care program,
hospice or residential health care facility. Notwithstanding  any  other
provision  of  law,  no federal financial participation shall be claimed
for services provided to a person while presumed  eligible  for  medical
assistance  under  this program until such person has been determined to
be  eligible  for  medical  assistance  by  the  local  social  services
district.  During the period of presumed medical assistance eligibility,
payment for services  provided  persons  presumed  eligible  under  this
program  shall be made from state funds. Upon the final determination of
eligibility by the local social services district, payment shall be made
for the balance of the cost of such care and services provided  to  such
applicant  for  such  period of eligibility and a retroactive adjustment
shall be  made  by  the  department  to  appropriately  reflect  federal
financial  participation  and  the local share of costs for the services
provided during the period of presumptive eligibility. Such federal  and
local financial participation shall be the same as that which would have
occurred  if a final determination of eligibility for medical assistance
had been made prior to the provision of the services provided during the
period of presumptive eligibility. In instances where an individual  who
is  presumed  eligible for medical assistance is subsequently determined

to be ineligible, the cost for  services  provided  to  such  individual
shall  be  reimbursed in accordance with the provisions of section three
hundred sixty-eight-a of this article. Provided, however, if upon  audit
the  department  determines  that there are subsequent determinations of
ineligibility for medical assistance in at least fifteen percent of  the
cases  in  which  presumptive  eligibility  has  been granted in a local
social services district, payments for services provided to all  persons
presumed  eligible  and  subsequently  determined ineligible for medical
assistance shall be divided equally by the state and the district.
3. On or before March thirty-first, nineteen hundred ninety-seven, the
department shall submit to the governor and legislature an evaluation of
the program, including the program's effects on access, quality and cost
of care, and any recommendations for future modifications to improve the
program.
4. (a) Notwithstanding  any  inconsistent  provision  of  law  to  the
contrary,  a  child  shall  be  presumed  to  be  eligible  for  medical
assistance under this title beginning  on  the  date  that  a  qualified
entity,  as  defined in paragraph (c) of this subdivision, determine, on
the basis of preliminary information, that the MAGI household income  of
the  child  does  not  exceed  the  applicable  level for eligibility as
provided for pursuant to subparagraph two or three of paragraph  (b)  of
subdivision one of section three hundred sixty-six of this title.
(b) Such presumptive eligibility shall continue through the earlier of
the day on which eligibility is determined pursuant to this title, or in
the  case  of a child on whose behalf an application is not filed by the
last day of the month following the month  during  which  the  qualified
entity  makes  a  preliminary  determination,  the last day of the month
following the month in which the qualified entity makes a  determination
in paragraph (a) of this subdivision.
(c)  For  the  purposes  of  this subdivision, and consistent with the
applicable provisions of section 1920A of the  federal  social  security
act,  "qualified entity" means an entity determined by the department of
health to be capable of making presumptive eligibility determinations.
(d) Notwithstanding any inconsistent provision of law to the contrary,
care, services and supplies, as  set  forth  in  section  three  hundred
sixty-five-a  of  this  title,  that  are  furnished to a child during a
presumptive eligibility  period  by  an  entity  that  is  eligible  for
payments  under  this title shall be deemed to be medical assistance for
purposes of payment and state and federal reimbursement.
(e) Presumptive eligibility pursuant  to  this  subdivision  shall  be
implemented effective December first, two thousand seven contingent upon
a determination by the commissioner of health that all necessary systems
and   processes  are  in  place  to  enroll  children  appropriately  in
accordance with the requirements set  forth  in  this  title;  provided,
however,  presumptive  eligibility pursuant to this subdivision shall be
implemented no later than April first, two thousand eight.
5. Persons in  need  of  treatment  for  breast,  cervical,  colon  or
prostate  cancer;  presumptive  eligibility.  (a) An individual shall be
presumed  to  be  eligible  for  medical  assistance  under  this  title
beginning  on  the date that a qualified entity, as defined in paragraph
(c) of  this  subdivision,  determines,  on  the  basis  of  preliminary
information, that the individual meets the requirements of paragraph (d)
or  (e)  of  subdivision four of section three hundred sixty-six of this
title.
(b) Such presumptive eligibility shall continue through the earlier of
the day on which a determination is made with respect to the eligibility
of such individual for services, or in the case of  such  an  individual
who  does not file an application by the last day of the month following

the month during which the qualified entity makes the  determination  of
presumptive eligibility, such last day.
(c)  For the purposes of this subdivision, "qualified entity" means an
entity that provides medical assistance approved under this  title,  and
is  determined  by  the  department  of  health  to be capable of making
determinations of presumptive eligibility under this subdivision.
(d) Care, services and supplies, as set forth in section three hundred
sixty-five-a of this title, that are furnished to an individual during a
presumptive eligibility period under this subdivision by an entity  that
is  eligible for payments under this title shall be deemed to be medical
assistance for purposes of payment and state reimbursement.
6. (a) A pregnant woman shall be presumed to be eligible  for  medical
assistance   under   this   title,   excluding  inpatient  services  and
institutional long term care, beginning on the date that a prenatal care
provider, licensed under article twenty-eight of the public  health  law
or  other  prenatal  care  provider approved by the department of health
determines, on the basis of preliminary information, that  the  pregnant
woman's MAGI household income does not exceed the MAGI-equivalent of two
hundred  percent  of  the federal poverty line for the applicable family
size.
(a-2) At the time of application for presumptive eligibility  pursuant
to  this  subdivision, a pregnant woman who resides in a social services
district that has implemented the state's managed care program  pursuant
to  section  three  hundred  sixty-four-j  of  this  title must choose a
managed care provider. If a managed care provider is not chosen  at  the
time  of  application,  the pregnant woman will be assigned to a managed
care provider in accordance with subparagraphs (ii), (iii), (iv) and (v)
of  paragraph  (f)  of  subdivision  four  of  section   three   hundred
sixty-four-j of this title.
(b)  Such  presumptive  eligibility shall continue through the earlier
of:  the day on which eligibility is determined pursuant to this  title;
or  the  last day of the month following the month in which the provider
makes preliminary determination, in the case of  a  pregnant  woman  who
does  not  file  an application for medical assistance on or before such
day.
(c) The department of health shall  provide  prenatal  care  providers
licensed  under  article twenty-eight of the public health law and other
approved prenatal care providers with such forms as are necessary for  a
pregnant  woman  to apply and information on how to assist such women in
completing and filing such forms. A qualified provider which  determines
that  a pregnant woman is presumptively eligible shall notify the social
services  district  in  which  the  pregnant  woman   resides   of   the
determination  within  five  working  days  after the date on which such
determination is made and  shall  inform  the  woman  at  the  time  the
determination  is  made  that she is required to make application by the
last day of the month following the month in which the determination  is
made.
(d) Notwithstanding any other provision of law, care that is furnished
to  a  pregnant  woman pursuant to this subdivision during a presumptive
eligibility period shall be deemed as medical assistance for purposes of
payment and state reimbursement.
(e) Facilities licensed  under  article  twenty-eight  of  the  public
health  law  providing  prenatal care services shall perform presumptive
eligibility determinations and assist women  in  submitting  appropriate
documentation  to  the  social  services  district  as  required  by the
commissioner; provided, however,  that  a  facility  may  apply  to  the
commissioner  for  exemption from this requirement on the basis of undue
hardship.
(f) All prenatal care providers enrolled in the medicaid program  must
provide prenatal care services to eligible service recipients determined
presumptively  eligible  for  medical assistance but not yet enrolled in
the  medical  assistance  program,  and  assist  women   in   submitting
appropriate documentation to the social services district as required by
the commissioner.
7.  Notwithstanding any other section of law, where care, services, or
supplies are received prior to the  date  an  individual  is  determined
eligible   for   assistance   under   this   title,  medical  assistance
reimbursement, regardless of funding source, shall be available for such
care, services, or supplies only (a) if the care, services, or  supplies
are  received  during  the  three  month  period  preceding the month of
application for medical assistance and the recipient  is  determined  to
have  been  eligible  in the month in which the care, service, or supply
was received,  or  (b)  if  provided  during  a  period  of  presumptive
eligibility pursuant to this section.
8.  (a) The following individuals shall be presumed to be eligible for
medical assistance under  this  title  beginning  on  the  date  that  a
qualified  hospital,  as  defined  in paragraph (b) of this subdivision,
determines, on the basis of preliminary information, that:
(1) a child has  MAGI  household  income  that  does  not  exceed  the
applicable   level   for   eligibility   as  provided  for  pursuant  to
subparagraph two or three of paragraph (b) of subdivision one of section
three hundred sixty-six of this title;
(2) a pregnant woman has MAGI household income that  does  not  exceed
the  MAGI-equivalent  of two hundred percent of the federal poverty line
for the applicable family size;
(3) a parent or caretaker relative has MAGI household income that does
not exceed the MAGI-equivalent of one  hundred  thirty  percent  of  the
highest  amount that ordinarily would have been paid to a person without
any income or resources  under  the  family  assistance  program  as  it
existed  on the first day of November, nineteen hundred ninety-seven, or
has net available income, including available support  from  responsible
relatives,  that  does not exceed the amounts set forth in paragraph (a)
of subdivision two of section three hundred sixty-six of this title;
(4) an individual in need of treatment of breast, cervical, colon,  or
prostate  cancer  meets  the  requirements  of  paragraph  (d) or (e) of
subdivision four of section three hundred sixty-six of this title;
(5) an individual age nineteen or older and under age sixty-five meets
the requirements of subparagraph one of paragraph (b) of subdivision one
of section three hundred sixty-six of this title;
(6) an individual under twenty-six years of age meets the requirements
of subparagraph nine of paragraph (c)  of  subdivision  one  of  section
three hundred sixty-six of this title; and
(7)  an individual has income that does not exceed the MAGI-equivalent
of two hundred percent of the federal poverty line  for  the  applicable
family  size,  and the individual meets the requirements of subparagraph
six of paragraph  (b)  of  subdivision  one  of  section  three  hundred
sixty-six of this title; coverage pursuant to this subparagraph shall be
limited to family planning services reimbursed by the federal government
at a rate of ninety percent.
(b) For the purposes of this subdivision, "qualified hospital" means a
hospital that:
(1)  is  licensed  as a general hospital under article twenty-eight of
the public health law;
(2) is enrolled as a provider in the  program  of  medical  assistance
under this title;
(3)  has  notified  the  department  of health of its election to make
presumptive  eligibility  determinations  under  this  subdivision,  and
agrees  to  make  such  determinations  in  accordance with policies and
procedures established by the department;
(4)  has  been  designated  by the department of health as a certified
application counselor to provide information to  individuals  concerning
qualified  health  plans offered through a health insurance exchange and
other insurance affordability programs, assist individuals to apply  for
coverage  through  a  qualified  health  plan or insurance affordability
program, and help facilitate the enrollment of eligible  individuals  in
such plans or programs; and
(5)  has not been disqualified by the department of health pursuant to
paragraph (c) of this subdivision.
(c) The department of health may disqualify a hospital as a  qualified
hospital if the department determines that the hospital is not:
(1)  making,  or  is  not  capable  of making, presumptive eligibility
determinations  in  accordance  with   the   policies   and   procedures
established by the department; or
(2)  meeting  such  standards  as may be established by the department
with respect to the proportion of individuals  determined  presumptively
eligible by the hospital who are found by the medical assistance program
to  be  eligible  for  ongoing  medical  assistance after the end of the
presumptive eligibility period.
(d) Care, services and supplies, as set forth in section three hundred
sixty-five-a of this title, that are furnished to an individual during a
presumptive eligibility period under this subdivision by an entity  that
is  eligible for payments under this title shall be deemed to be medical
assistance for purposes of payment and state reimbursement.