New York Codes, Rules and Regulations › Title 14 - DEPARTMENT OF MENTAL HYGIENE › Chapter XIV - Office for People With Developmental Disabilities › Part 635 - General Quality Control and Administrative Requirements Applicable to Programs, services or Facilities Funded or Certified by the Office for People With Developmental Disabilities › Subpart 635-12 - Liability for Services › Section 635-12.7 - Obligations of individuals receiving or requesting services and liable parties-preexisting services

Current through Register Vol. 46, No. 28, July 10, 2024
(a) This section
				  applies only to preexisting services.
(b)
Responsibility to provide
				  information.
(1) Individuals receiving
				  preexisting services and other liable parties shall, by the payment start date,
				  provide information upon the provider's request regarding personal and
				  financial information as may be reasonably required to identify liable parties
				  and to ascertain the individual's and any other liable parties' ability to pay
				  for services or the individual's ability to obtain and maintain full Medicaid
				  coverage.
(2) Subsequent to the
				  provision of the information required in paragraph (1) of this subdivision and
				  throughout the period that preexisting services are received, the individual
				  and other liable parties shall notify the provider of any changes in liable
				  parties, any changes in the individual's Medicaid coverage and any changes that
				  may affect the individual's eligibility for full Medicaid coverage and/or the
				  individual's and other liable parties' ability to pay for services. If the
				  individual or any other party receives a notice from the Medicaid district that
				  the individual is losing full Medicaid coverage, the individual or party must
				  inform the provider within five days of receipt of the notice.
(3) Prior to the payment start date, each
				  individual receiving preexisting services must:
(i) present evidence of full Medicaid
				  coverage; or
(ii) take all
				  necessary steps to obtain full Medicaid coverage; or
(iii) disclose to the provider such
				  information as may be reasonably required to obtain and maintain full Medicaid
				  coverage, and allow the provider to assist the individual to take all necessary
				  steps to obtain and maintain full Medicaid coverage or to apply on behalf of
				  the individual; or
(iv) agree to
				  pay for the services in accordance with the applicable fee schedule in section
				  635-12.9 
				  of this Subpart. Liable parties may agree in lieu of the individual;
				  or
(v) agree to pay for the
				  services in accordance with the reduced fee established by the provider and
				  acknowledge that any reduction of the fee shall not constitute nor be construed
				  as a release of the individual or any liable party from liability for payment
				  of the full fee. Other liable parties may agree and acknowledge same in lieu of
				  the individual; or
(vi) acknowledge
				  that the fee has been waived by the provider and that any waiver of the fee
				  shall not constitute nor be construed as a release of the individual or any
				  liable party from liability for payment of the full fee. Other liable parties
				  may acknowledge same in lieu of the individual.
(4) In addition, if an individual not already
				  enrolled in the HCBS waiver is receiving preexisting services that are offered
				  through the HCBS waiver, the individual must take all necessary steps to enroll
				  in the HCBS waiver by the payment start date and must take all necessary steps
				  to maintain enrollment in the HCBS waiver.
(5) Unless the fee is waived by the provider,
				  if the individual does not obtain full Medicaid coverage by the payment start
				  date, or if the individual loses full Medicaid coverage on or after the payment
				  start date, the individual and/or liable parties must either:
(i) pay for the preexisting services
				  delivered on or after the payment start date in accordance with the applicable
				  fee schedule in section
				  635-12.9 
				  of this Subpart; or
(ii) pay for
				  the preexisting services delivered on or after the payment start date with the
				  reduced fees established by the provider.
(6) For Medicaid service coordination; day
				  treatment services; the following HCBS waiver services: at home residential
				  habilitation services, prevocational services, supported employment services,
				  respite services; and blended and comprehensive services: If a notice from the
				  Medicaid district has been received prior to March 15, 2010, which states that
				  the individual is losing full Medicaid coverage on or after March 15, 2010, the
				  individual or other party receiving the notice shall notify the provider about
				  such notice by March 22, 2010.
(7)
				  On or after the preexisting compliance date, if the individual or any other
				  party receives a notice from the Medicaid district that the individual is
				  losing full Medicaid coverage, the individual or party must inform the provider
				  within five days of receipt of the notice.