New York Codes, Rules and Regulations › Title 18 - DEPARTMENT OF SOCIAL SERVICES › Chapter II - Regulations of the Department of Social Services › Subchapter F - Finance; Claims for Reimbursement by Social Services Districts › Article 4 - Supplementary Assistance Reimbursement Claiming › Part 635 - Medical Assistance Reimbursement Claiming › Section 635.2 - Conditions for reimbursement for MA

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Costs related to the provision of MA
			 which are required to be allocated or distributed by regulation or direction of
			 the department shall be claimed and allocated as required by such regulations
			 or direction. Costs shall be allocated or distributed in accordance with the
			 requirements set forth in department regulations pertaining to the allocation
			 of expenditures for public assistance and care.
(b) Except as otherwise directed by the
			 department no claims shall be made for reimbursement of any portion of any
			 payments disbursed by the department or its fiscal intermediary as payments to
			 providers on behalf of social services districts as a function of the Medicaid
			 Management Information System (MMIS) if such payment or other adjustment is
			 reimbursed or charged to the district as provided by the provisions of section 367-b  of the Social Services
			 Law.
(c) Any adjustments of claims
			 for reimbursement, including adjustments to claims as a result of recoveries or
			 collections, shall be made in accordance with procedures, instructions or
			 directions of the department.
(d)
			 Amounts claimed by a social services district or other governmental agency as
			 Federal incentives under title XIX of the Social Security Act may be retained
			 or claimed as a portion of the Federal share of the amount collected as medical
			 support or assigned third-party benefits when such district or agency, pursuant
			 to an agreement with such district, has collected such medical support or
			 third-party benefits on behalf of an MA recipient whose rights to medical
			 support or third-party benefits have been assigned to the State or to the
			 appropriate social services official, provided that (1) Federal participation
			 is available for such claims, and (2) such claims are appropriately made and
			 actually reimbursed, paid or credited to the State.
(e) No amounts shall be claimed as
			 reimbursement for payments pursuant to title XIX of the Federal Social Security
			 Act for benefits available under title XVIII of such act without documentation
			 that title XVIII claims have been filed and denied.
(f) No amounts shall be claimed as
			 reimbursement for MA if such amounts would not have been expended, or a
			 recovery would have been made, if the district had not failed to establish the
			 liability of and seek reimbursement from a liable third party.
(g) No amounts shall be claimed as
			 reimbursement for payments made to providers excluded from the Medicaid
			 program, except that such amounts may be claimed in accordance with specific
			 directions of the department with respect to a particular provider, provided
			 that Federal participation shall not be available to the district if it is not
			 available to the State.
(h) Any
			 amounts that have been recovered or could have been recovered as attributable
			 to the MA program shall be reported and credited in accordance with Federal and
			 State law and regulations, except that such amounts shall be reported or
			 credited in accordance with any specific direction of the State with respect to
			 those particular amounts, provided that Federal participation to the district
			 may be reduced to the extent it is not available to the State.
(i) No amounts shall be claimed as
			 reimbursement for payments made to providers or other entities when the
			 district has been informed or otherwise should have known that payments to such
			 entities should have been withheld, denied, reduced or otherwise not
			 paid.
(j) Except as otherwise
			 specifically authorized by Federal and State law or regulation or as
			 specifically directed by the department, no amounts shall be claimed as
			 reimbursement for payments made directly to a recipient of MA, an individual
			 eligible to receive MA or such person's representative.
(k) Retrospective adjustments of rates of
			 payment to providers shall be reflected in the claims of districts in
			 accordance with directions of the department.
(l) No amounts claimed for MA reimbursement
			 shall include expenditures for capital additions or improvements.
(m) Amounts claimed shall be reduced in
			 accordance with instructions and directions of the department to reflect any
			 penalty or other charges accruing to the district.
(n) Any claims for reimbursement pursuant to
			 this Part shall not be predicated upon any rate or amount that is greater than
			 rates or amounts permitted by the department or by the Social Services Law or
			 other State law, regulation or policy.
(o) No amount shall be claimed as
			 reimbursement for MA if it does not represent or relate to payment of part or
			 all of the cost of care, services and supplies which are necessary to prevent,
			 diagnose, correct or cure conditions in the person that cause acute suffering,
			 endanger life, result in illness or infirmity, interfere with his or her
			 capacity for normal activity or threaten some significant handicap, and which
			 are furnished an eligible person in accordance with the Social Services Law and
			 regulations of the department, and include care, services and supplies
			 described in that portion of the Social Services Law relating to character and
			 adequacy of assistance rendered as MA.
(p) Claims for MA reimbursement which do not
			 seek Federal participation shall not be submitted to the department if such
			 claims could be made with Federal participation, except as otherwise
			 specifically directed by the department.
(q) Sums expended or claimed for MA
			 reimbursement attributable to the design, development or installation of
			 mechanized claims processing and retrieval systems meeting the conditions of
			 the Federal Social Security Act and the United States Secretary of Health and
			 Human Services shall be claimed at the enhanced rate of Federal participation
			 for such expenditures.
(r) Sums
			 expended under the MA program which are attributable to the operation of
			 systems, attributable to compensation or training of skilled professional
			 medical personnel and staff directly supporting such personnel or attributable
			 to any activity for which an enhanced rate of Federal participation is
			 available, shall be claimed at the enhanced rate of Federal participation for
			 such expenditures.
(s) Any claims
			 for reimbursement for expenditures which are subsequently determined by the
			 department to be reimbursable from, or for which reimbursement is actually
			 received or credited from, another program for which Federal participation
			 could be received, shall be reduced in an amount equivalent to the amount
			 determined by the department to be due as a result of the availability of
			 Federal participation.
(t) Any
			 claims for reimbursement from any portion of a program or activity for which
			 Federal participation is available which were not fully reimbursed as claimed
			 and which were properly made at the time they were originally claimed may be
			 claimed from programs for which Federal participation is available if they
			 could have been so claimed when originally submitted, provided that the revised
			 claim is timely and an adjustment to reduce the original claim is
			 simultaneously submitted to the department.