New York Codes, Rules and Regulations › Title 18 - DEPARTMENT OF SOCIAL SERVICES › Chapter II - Regulations of the Department of Social Services › Subchapter B - Public Assistance › Article 2 - Determination of Eligibility-Categorical › Part 360 - MEDICAL ASSISTANCE › Subpart 360-7 - Payment For Services › Section 360-7.5 - Method of payment for medical care

Current through Register Vol. 46, No. 28, July 10, 2024
(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.