reglab/statecodes huggingface dataset:
New York Codes, Rules and Regulations › Title 9 - EXECUTIVE DEPARTMENT › Subtitle JJ - St. Lawrence - Eastern Ontario Commission › Part 9500 - Rules And Regulations For Project Review › Section 9500.2 - Definitions

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Area means the
				commission's jurisdictional service area consisting of the Towns of Massena,
				Louisville, Waddington, Lisbon, Oswegatchie, Morristown and Hammond, the
				villages therein and the City of Ogdensburg in St. Lawrence County, the Towns
				of Alexandria, Orleans, Clayton, Cape Vincent, Lyme, Brownville, Hounsfield,
				Henderson and Ellisburg and the villages therein in Jefferson County, the Towns
				of Sandy Creek, Richland, Mexico, New Haven, Scriba and Oswego, the villages
				therein and the City of Oswego in Oswego County, and the Town of Sterling and
				village therein in Cayuga County.
(b) Commission means the St. Lawrence -
				Eastern Ontario Commission.
(c)
				Development means any activity which materially affects the existing condition,
				use or appearance of any land, structure or improvement, including the division
				of any land into parcels, or units, but shall not include the division of any
				land resulting from devise, inheritance, gift or operation of law.
(d) Land means the earth, on or below the
				surface of the ground, including water and air above and the flora and
				fauna.
(e) Land use means any
				existing activity or activities associated with land, including structures and
				improvements to structures.
(f)
				Local government means a government of a county, city, town or village located
				within the jurisdictional area of the commission.
(g) Person means public or private
				corporation, company, association, society, firm, partnership, joint stock
				company, individual, the United States and the State of New York and any of its
				political subdivisions or agents.
(h) Project means any actual or proposed
				construction, land development, demolition, excavation or other similar action
				which may significantly alter or change the appearance or use of the land or
				water or any structures thereon.
(i) Project sponsor means person undertaking
				any project in the jurisdictional area of the commission.
(j) Rules and regulations means the existing
				definitions, standards and procedures established for the review of
				projects.
(k) Structure means any
				object constructed, installed or placed on land or in the water to facilitate
				land use, including but not limited to buildings, sheds, mobile homes, signs,
				tanks, shore protection and recreation devices, commercial and residential
				facilities and any fixtures, additions and alterations to any of the
				above.
New York Codes, Rules and Regulations › Title 9 - EXECUTIVE DEPARTMENT › Subtitle JJ - St. Lawrence - Eastern Ontario Commission › Part 9500 - Rules And Regulations For Project Review › Section 9500.3 - Projects subject to review

Current through Register Vol. 46, No. 28, July 10, 2024
Any project, unless exempted from review under section
				  9500.4,
				  9500.6(b),
				  9500.7(b)
				 or
				  9500.10  of
				  this Part, undertaken by a project sponsor, shall be subject to review if it is
				  in the jurisdictional area of the commission, and which:
(a) might destroy or substantially impair
				significant scenic, historic, recreational, ecological, conservational or
				natural resources; or
(b) might
				bring about a significant change in the appearance or use of the water in the
				St. Lawrence River or eastern Lake Ontario or in the surrounding
				land.
New York Codes, Rules and Regulations › Title 9 - EXECUTIVE DEPARTMENT › Subtitle JJ - St. Lawrence - Eastern Ontario Commission › Part 9500 - Rules And Regulations For Project Review › Section 9500.4 - Projects exempt from review

Current through Register Vol. 46, No. 28, July 10, 2024
(a) No
				project described in subdivision (b) of this section shall be subject to review
				unless the project sponsor informs the commission in writing of the sponsor's
				desire to have the project reviewed, or the commission, at its discretion
				determines that the project might result in significant impairment of the
				scenic, historic, recreational, ecological, conservational or natural resources
				of the area and informs the project sponsor in writing of its intention to
				review the project.
(b) The
				following projects are exempt from review:
(1) residential projects consisting of five
				or less dwelling units;
(2)
				projects consisting of landscape improvements, interior alterations, ordinary
				improvements and repairs necessary for the maintenance of existing buildings,
				roads and other structures;
(3)
				electric power line projects of a rating of 69 KV or less, unless private
				right-of-way or easements are to be acquired;
(4) gas distribution line projects of six
				inches or less in diameter, unless private right-of-way or easements are to be
				acquired;
(5) water distribution
				line projects of 12 inches or less in diameter;
(6) sewer line projects of 12 inches in
				diameter; and
(7) all projects
				sponsored by the New York State Department of Transportation, the New York
				State Department of Environmental Conservation, and the New York State Office
				of Parks, Recreation and Historic Preservation unless such projects are to be
				reviewed at the discretion of the project sponsor or the commission as provided
				in subdivision (a) of this section.
New York Codes, Rules and Regulations › Title 9 - EXECUTIVE DEPARTMENT › Subtitle JJ - St. Lawrence - Eastern Ontario Commission › Part 9500 - Rules And Regulations For Project Review › Section 9500.5 - Standards for review

Current through Register Vol. 46, No. 28, July 10, 2024
To determine whether a project might have a significant
				  adverse effect upon the scenic, historic, recreational, ecological,
				  conservational or natural resources of the area and to determine the
				  commercial, industrial, agricultural, residential or other benefits of the
				  project, the commission will consider:
(a) impacts on significant scenic, historic,
				recreational, ecological, conservational or natural resources;
(b) impacts on commercial, industrial,
				agricultural and residential resources;
(c) impacts on local and regional economies,
				including tax implications and employment opportunities;
(d) application and conformity to municipal
				comprehensive plans, local laws and ordinances, the standards of other public
				agencies or other regulations, including those of adjacent
				municipalities;
(e) impacts on
				local services and facilities, including sewers, water supply, electricity,
				police, fire, schools and thoroughfares;
(f) impacts on land, water and air qualities
				and adjacent land uses;
(g) impacts
				on drainage, flooding and soil erosion;
(h) impacts on visual appreciation, odor
				levels and noise levels; and
(i)
				impacts on existing buildings and surrounding landscape.
New York Codes, Rules and Regulations › Title 9 - EXECUTIVE DEPARTMENT › Subtitle JJ - St. Lawrence - Eastern Ontario Commission › Part 9500 - Rules And Regulations For Project Review › Section 9500.6 - Preliminary consultation before initial review

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Any project sponsor may ask the
				commission for a confidential preliminary consultation and for preliminary
				approval or recommendations with respect to the project. The project sponsor
				shall submit to the commission a description of the project and a map (of a
				scale of one inch equals one mile or larger) showing project location and data
				concerning dimensions of any proposed structures.
(b) The commission shall notify the sponsor
				in writing, if the project is subject to review or not. If the project is
				subject to review, the commission will offer the sponsor the opportunity to
				discuss the project informally.
(c)
				The commission shall inform the sponsor of any recommendations it may have and
				of other public agencies having review responsibilities concerning the
				project.
(d) If the commission
				gives preliminary approval to the project, it shall notify the sponsor in
				writing. Such approval shall not relieve the sponsor from the necessity of
				submitting the project for initial review.
New York Codes, Rules and Regulations › Title 9 - EXECUTIVE DEPARTMENT › Subtitle JJ - St. Lawrence - Eastern Ontario Commission › Part 9500 - Rules And Regulations For Project Review › Section 9500.7 - Initial review

Current through Register Vol. 46, No. 28, July 10, 2024
(a) A
				description of a proposed project shall be submitted by the project sponsor for
				review by the commission, if the sponsor has not yet submitted such information
				during preliminary consultation. Such description shall be submitted to
				commission offices and will be provided in the form and manner prescribed in
				the Information Request Form (Appendix CC-1, infra), together with such
				additional information and data as the commission may deem pertinent for
				review.
(b) If the commission
				determines that the project is not within its jurisdiction, or is not subject
				to review, the commission shall notify the sponsor promptly in
				writing.
(c) The commission shall
				inform the sponsor by certified mail when it has received all the information
				necessary to review the project. For a period of 30 days after the date of such
				notice, or such shorter period as the commission may specify in such notice,
				the sponsor shall not undertake or continue the project.
(d) If the commission finds that the project
				might have a significant adverse effect upon the scenic, historic,
				recreational, ecological, conservational or natural resources of the area, it
				shall issue an order to the sponsor by certified mail, within such 30-day
				period, stating that the sponsor not undertake or continue such project for an
				additional period of 60 days immediately following such 30-day period, or until
				the commission completes its final review as provided under section
				9500.8  of this Part,
				whichever occurs first.
(e) If at
				the end of such 30-day period the commission has not issued such an order, the
				sponsor may undertake or continue the project.
New York Codes, Rules and Regulations › Title 9 - EXECUTIVE DEPARTMENT › Subtitle JJ - St. Lawrence - Eastern Ontario Commission › Part 9500 - Rules And Regulations For Project Review › Section 9500.8 - Final review

Current through Register Vol. 46, No. 28, July 10, 2024
If the commission does issue such an order, it shall, within
				  such 60-day period:
(a) further review
				the project;
(b) hold one or more
				public hearings, one of which shall be near the project site; or
(c) report its findings to the project
				sponsor, to any public agency having the power of review or approval of such
				project, and to the public through appropriate and available news and
				communication media.
New York Codes, Rules and Regulations › Title 9 - EXECUTIVE DEPARTMENT › Subtitle JJ - St. Lawrence - Eastern Ontario Commission › Part 9500 - Rules And Regulations For Project Review › Section 9500.9 - Hearings

Current through Register Vol. 46, No. 28, July 10, 2024
(a) At least 10
				days before the date of the hearing or hearings, one of which shall be near the
				project site, the commission shall notify the sponsor by certified mail of the
				time and place of the hearing or hearings, and notify the public by
				advertisement in a newspaper of general circulation in the area in which the
				proposed project is located. The advertisement shall briefly describe the
				project. A copy of such notice shall be filed with the clerks of the local
				governments in which the project is located.
(b) All hearings shall be open to the public.
				Any person wishing to be heard may appear at the hearing and make a statement
				for or against the project, orally or in writing. Statements shall be made a
				part of the record of the hearing. Those wishing to make statements may be
				represented by an attorney or other qualified person.
(c) Hearings shall be conducted by the
				commission or a member or officer of the commission. The hearing officer shall
				have full authority to control the conduct and procedure of the hearing and the
				record of it, to admit or exclude testimony or other evidence and to rule on
				all motions and objections.
(d) A
				record of each hearing shall be made by a stenographer, designated by the
				commission, who shall deliver the original transcript of the hearing to the
				commission and one copy to the project sponsor. Any interested person may
				secure a copy from the stenographer, upon the payment of such reasonable fee as
				may be agreed upon between the stenographer and the person desiring such
				transcript.
(e) The commission
				shall not be bound by common law or statutory rules of evidence or by technical
				or formal rules of procedure. The commission may receive in evidence such
				affidavits, data or other materials which are relevant to the project under
				review.
(f) The commission, in its
				discretion, may consolidate two or more hearings.
(g) The project sponsor and all other persons
				wishing to be heard should be prepared to proceed on the date of the hearing.
				Application for adjournments will not be granted, except for good
				cause.
New York Codes, Rules and Regulations › Title 9 - EXECUTIVE DEPARTMENT › Subtitle JJ - St. Lawrence - Eastern Ontario Commission › Part 9500 - Rules And Regulations For Project Review › Section 9500.10 - Emergency projects

Current through Register Vol. 46, No. 28, July 10, 2024
An emergency project which is immediately necessary for the
				  protection of life or property shall not be subject to review. Any person
				  undertaking a project which is believed to be an emergency project shall inform
				  the commission by certified mail or telegram within 48 hours after the project
				  is commenced. If the commission determines that such project is not immediately
				  necessary for the protection of life or property and that it is subject to
				  review, it shall so inform such person.
New York Codes, Rules and Regulations › Title 9 - EXECUTIVE DEPARTMENT › Subtitle JJ - St. Lawrence - Eastern Ontario Commission › Part 9500 - Rules And Regulations For Project Review › Section 9500.11 - Determination and findings

Current through Register Vol. 46, No. 28, July 10, 2024
The findings of the commission shall be filed at the place of
				  business of the St. Lawrence - Eastern Ontario Commission together with all
				  plans, maps, exhibits and other papers and records relating to the project.
				  These documents may be examined and copies thereof made at the place of
				  business of the commission during business hours.
New York Codes, Rules and Regulations › Title 9 - EXECUTIVE DEPARTMENT › Subtitle KK - Program for Elderly Pharmaceutical Insurance Coverage › Part 9600 - General › Section 9600.1 - Scope

Current through Register Vol. 46, No. 28, July 10, 2024
These regulations govern the application and eligibility
				  determination process under the Program for Elderly Pharmaceutical Insurance
				  Coverage and establish the rights and responsibilities of applicants,
				  participants and the contractor in that process.
New York Codes, Rules and Regulations › Title 9 - EXECUTIVE DEPARTMENT › Subtitle KK - Program for Elderly Pharmaceutical Insurance Coverage › Part 9600 - General › Section 9600.3 - Information concerning application/coverage

Current through Register Vol. 46, No. 28, July 10, 2024
Any person shall be entitled to receive information
				  concerning:
(a) the eligibility
				requirements of the program under which he/she is applying;
(b) his/her responsibility for reporting all
				facts material to a proper determination of eligibility;
(c) the applicant's responsibility for
				securing, wherever possible, records or documents to support his/her statements
				concerning eligibility;
(d) the
				kinds of verification needed;
(e)
				the fact that an investigation to determine eligibility may be
				undertaken;
(f) the cost-sharing
				responsibilities of the program.
New York Codes, Rules and Regulations › Title 9 - EXECUTIVE DEPARTMENT › Subtitle KK - Program for Elderly Pharmaceutical Insurance Coverage › Part 9600 - General › Section 9600.4 - Confidentiality

Current through Register Vol. 46, No. 28, July 10, 2024
(a) All applicants
				and participants have the right to confidentiality concerning any information
				provided to determine their eligibility for coverage and any information
				discovered in the course of an investigation of eligibility.
(b) Information received by the contractor,
				his agents, employees or any other person or agency concerning applicants for
				or participants in the program may be disclosed or used only for purposes
				directly related to and necessary for the proper administration of the
				program.
New York Codes, Rules and Regulations › Title 9 - EXECUTIVE DEPARTMENT › Subtitle KK - Program for Elderly Pharmaceutical Insurance Coverage › Part 9600 - General › Section 9600.5 - Statistical reports

Current through Register Vol. 46, No. 28, July 10, 2024
(a) The
				contractor shall maintain a record of every application or request for coverage
				and the disposition thereof.
(b)
				Additionally, the contractor shall maintain statistical reports as required by
				the executive director and provide the executive director with a periodic
				report of all applications denied, actions affecting coverage and
				reconsiderations made.
New York Codes, Rules and Regulations › Title 9 - EXECUTIVE DEPARTMENT › Subtitle KK - Program for Elderly Pharmaceutical Insurance Coverage › Part 9610 - Application And Determination Of Eligibility › Section 9610.1 - Application for coverage

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Any
				person who believes that he/she is eligible for coverage has the right to make
				application for coverage. The applicant himself/herself or an authorized
				representative shall have the right to make application on his/her
				behalf.
(b) Applications may be
				submitted by mail or by other means authorized by the contractor and approved
				by the State.
(c) Home visits shall
				be available where the physical or mental inability of the applicant makes it
				impracticable for him/her to submit a written application by mail.
(d) Applications and program information may
				be obtained from the contractor by calling the designated toll-free telephone
				number, by writing the contractor or contacting a designated outreach
				agency.
(e) Local in-person
				assistance shall be available for assisting applicants to apply and to answer
				questions.
New York Codes, Rules and Regulations › Title 9 - EXECUTIVE DEPARTMENT › Subtitle KK - Program for Elderly Pharmaceutical Insurance Coverage › Part 9610 - Application And Determination Of Eligibility › Section 9610.2 - Use of the application form

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
				The State-approved form must be completed:
(1) for each applicant upon initial
				application and recertification;
(2) when there is a change in status
				affecting eligibility; and
(3) in
				the event of a reapplication more than 30 days following the end of any
				eligibility period.
New York Codes, Rules and Regulations › Title 9 - EXECUTIVE DEPARTMENT › Subtitle KK - Program for Elderly Pharmaceutical Insurance Coverage › Part 9610 - Application And Determination Of Eligibility › Section 9610.3 - Eligibility for coverage

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
				Residents of the State who are at least 65 years of age, who have incomes
				within the limitations prescribed by statute and who are not in receipt of
				medical assistance shall be eligible for coverage upon meeting the required
				registration fee, premium or deductible requirements of the program.
(b) Each applicant and participant shall
				furnish evidence, and when requested provide verification of, those factors
				which affect eligibilty and the amount of registration fee, premium or
				deductible, including:
(1) Age. The applicant
				or participant shall furnish evidence that he/she is at least 65 years of
				age.
(2) Receiving medical
				assistance. The applicant or participant shall furnish current and accurate
				information concerning the availability of his/her receipt of medical
				assistance.
(3) Residence.
				Information shall be provided sufficient to establish that the applicant or
				participant is residing within the State.
(4) Spouse. For each married applicant the
				following information shall be furnished concerning his/her spouse: full name
				and date of birth.
(5)
				[Reserved]
(6) Income. The
				applicant or participant shall furnish sufficient information in order to
				permit calculation of his/her income.
(7) Insurance coverage. The applicant or
				participant shall furnish current and accurate information concerning the
				availability of coverage of prescription drug expenses under a third-party
				assistance or insurance plan.
New York Codes, Rules and Regulations › Title 9 - EXECUTIVE DEPARTMENT › Subtitle KK - Program for Elderly Pharmaceutical Insurance Coverage › Part 9610 - Application And Determination Of Eligibility › Section 9610.4 - Decision on eligibility

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
				Decision on eligibility is the conclusion or determination reached in the
				application process. Such decision shall constitute the decision of the
				contractor. The decision shall be one of the following:
(1) Accepted for coverage. This means that
				eligibility has been established through review and verification to the
				satisfaction of the contractor.
(2)
				Not accepted for coverage. Applications are denied when:
(i) in the course of the application process
				the information given by the applicant establishes, without the need for
				further review and verification, that he/she is ineligible;
(ii) ineligibility is determined in the
				course of or upon completion of a review and verification, or if the applicant
				refuses to comply with any requirement essential to the determination of
				eligibility; or
(iii) the
				application is incomplete.
(3) No decision is required when:
(i) an application is withdrawn by the
				applicant; or
(ii) the contractor
				documents that the applicant has died, cannot be located, or has left the State
				prior to the completion of the review and verification.
New York Codes, Rules and Regulations › Title 9 - EXECUTIVE DEPARTMENT › Subtitle KK - Program for Elderly Pharmaceutical Insurance Coverage › Part 9610 - Application And Determination Of Eligibility › Section 9610.5 - Responsibility for prompt determination of eligibility

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Upon receipt of an application for
				coverage, the contractor shall conduct an appropriate review and verification
				and secure, record and evaluate its findings in order to promptly determine
				eligibility or ineligibility.
(b)
				The decision to accept or deny the application shall be made as soon as the
				facts to support it have been established, but not later than 30 days from the
				date of application, except where the applicant requests additional time or
				where difficulties in verification lead to unusual delay.
New York Codes, Rules and Regulations › Title 9 - EXECUTIVE DEPARTMENT › Subtitle KK - Program for Elderly Pharmaceutical Insurance Coverage › Part 9610 - Application And Determination Of Eligibility › Section 9610.6 - Notification

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Applicants have
				the right to adequate notice of their determination of eligibility.
(1) Notification shall be given within three
				days of the decision to accept or deny an application (except during the
				120-day period beginning July 1, 1987, when notification of denial shall be
				given within 10 days of a decision to deny.)
(2) Notification of denial shall clearly set
				forth the decision of the contractor and the specific reason why the
				application was denied. Notification of acceptance shall clearly set forth the
				decision and the cost-sharing responsibilities of the applicant.
New York Codes, Rules and Regulations › Title 9 - EXECUTIVE DEPARTMENT › Subtitle KK - Program for Elderly Pharmaceutical Insurance Coverage › Part 9610 - Application And Determination Of Eligibility › Section 9610.7 - Issuance of identification cards

Current through Register Vol. 46, No. 28, July 10, 2024
(a) The contractor shall issue an
				identification card to each person determined eligible for benefits within
				three days of the applicant's meeting his/her registration fee or premium or
				deductible requirements.
(b) The
				card shall include on its face the following information:
(1) participant's full name;
(2) participant's identification
				number;
(3) participant's annual
				coverage period; and
(4) any
				restriction on use.
New York Codes, Rules and Regulations › Title 9 - EXECUTIVE DEPARTMENT › Subtitle KK - Program for Elderly Pharmaceutical Insurance Coverage › Part 9620 - Investigation And Verification › Section 9620.1 - Investigation

Current through Register Vol. 46, No. 28, July 10, 2024
(a) The contractor
				is responsible for reviewing all aspects of eligibility and obtaining
				verification of information received. Appropriate inquiry shall be made of the
				applicant and secondary sources of information as the efficient administration
				of the program may require taking into account the administrative costs of full
				review and verification of each application and the need to maintain the fiscal
				integrity of the program. In this respect the contractor may defer full review
				and verification or fully review and verify only a statistically valid random
				sample of the applications filed with the approval of the executive
				director.
(b) Any review and
				verification of eligibility shall be conducted in a manner that will not result
				in practices that violate an applicant's or participant's constitutional
				rights. An applicant or participant shall be permitted to appear with an
				attorney or other representative at any interview, conference or
				redetermination with a representative of the contractor, whenever such
				interview, conference or redetermination relates the questions of eligibility
				for assistance, or the amount of the registration fee, premium or deductible
				which the person interviewed is or was required to pay.
New York Codes, Rules and Regulations › Title 9 - EXECUTIVE DEPARTMENT › Subtitle KK - Program for Elderly Pharmaceutical Insurance Coverage › Part 9620 - Investigation And Verification › Section 9620.2 - Aspects of investigation of eligibility

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Documents, personal observation, personal
				and collateral interviews and contacts, reports, correspondence and conferences
				are means of verification of information supplied.
(b) When information is sought from
				collateral sources other than public records because the applicant or
				participant cannot provide verification, there shall be a clear interpretation
				to the applicant, participant or his/her representative of what information is
				desired, why it is needed and how it will be used.
New York Codes, Rules and Regulations › Title 9 - EXECUTIVE DEPARTMENT › Subtitle KK - Program for Elderly Pharmaceutical Insurance Coverage › Part 9630 - Reconsiderations › Section 9630.1 - Required procedures for reconsiderations

Current through Register Vol. 46, No. 28, July 10, 2024
(a) The contractor shall use reconsiderations
				to explain actions taken or to be taken and to settle disputes with applicants
				and participants.
(b) When an
				applicant or participant makes any oral or written request of a contractor's
				employee which indicates a desire to have any action of the contractor
				reviewed, and the matter cannot be resolved by that employee, the applicant or
				participant shall be informed of the right to reconsideration by the
				contractor.
(c) If the applicant or
				participant indicates that he/she wants a reconsideration one shall be
				arranged.
(d) An employee of the
				contractor, who has authority to reverse the action, or failure to act, and who
				did not participate in the determination to take the action complained of,
				shall conduct the reconsideration. The reconsideration shall be made at such a
				time and in a manner as to afford a meaningful opportunity to resolve the
				dispute. Provisions shall be made for reconsiderations by mail, telephone and
				in person.
(e) A determination on
				the reconsideration shall be made within 30 days of the request and a notice of
				determination after reconsideration shall be mailed to the applicant or
				participant at his/her designated address. Where a reconsideration is favorable
				to the applicant, this determination notice will include a statement that the
				applicants will be reimbursed for program-eligible costs incurred from the date
				on which the annual coverage period would have commenced if the application was
				approved initially.
New York Codes, Rules and Regulations › Title 9 - EXECUTIVE DEPARTMENT › Subtitle KK - Program for Elderly Pharmaceutical Insurance Coverage › Part 9640 - Personal Expenditures Reporting › Section 9640.1 - Personal expenditures reporting system

Current through Register Vol. 46, No. 28, July 10, 2024
The contractor shall establish the system whereby each
				  participant in the catastrophic coverage portion of the program who elects the
				  deductible option shall have his/her personal covered drug expenditures
				  recorded upon payment of a nominal charge.
New York Codes, Rules and Regulations › Title 9 - EXECUTIVE DEPARTMENT › Subtitle KK - Program for Elderly Pharmaceutical Insurance Coverage › Part 9650 - Recovery Of Overpayments › Section 9650.1 - Responsibility for repayment of overpayments

Current through Register Vol. 46, No. 28, July 10, 2024
Participants are responsible for repaying the value of any
				  benefits or payments made under the program that were based on applications or
				  claims submitted in violation of the eligibility requirements of the
				  program.
New York Codes, Rules and Regulations › Title 9 - EXECUTIVE DEPARTMENT › Subtitle KK - Program for Elderly Pharmaceutical Insurance Coverage › Part 9650 - Recovery Of Overpayments › Section 9650.2 - Recovery of overpayments

Current through Register Vol. 46, No. 28, July 10, 2024
(a) The
				contractor shall establish a procedure to ensure that the value of any benefits
				received by any person in violation of the eligibility requirements of article
				19-K of the Executive Law and these regulations is recovered from the person
				prior to his/her recertification for entitlement to benefits for any period
				beyond the initial annual eligibility period.
(b) Where after authorization of benefits to
				an applicant it is discovered that the applicant was not entitled to benefits
				or that a participant has received benefits in excess of those to which he/she
				was entitled, the contractor shall promptly notify the applicant or participant
				of the overpayment and request that the value thereof be refunded.
(c) Where repayment is not forthcoming from
				the applicant or participant, the contractor shall attempt collection in a
				manner consistent with the State debt collection procedures law. Where the
				contractor is unsuccessful in its collection efforts, the matter shall be
				referred to the executive director for collection proceedings consistent with
				the economies of effective administration.
(d) Notwithstanding any provision in this
				section to the contrary, no person shall be deemed eligible to receive benefits
				under the program until he/she has repaid the full value of any benefits
				previously furnished to or on behalf of that person in violation of article
				19-K of the Executive Law and these regulations, or has entered into a plan for
				repayment and remains current with such plan.
New York Codes, Rules and Regulations › Title 9 - EXECUTIVE DEPARTMENT › Subtitle KK - Program for Elderly Pharmaceutical Insurance Coverage › Part 9650 - Recovery Of Overpayments › Section 9650.3 - Right to reimbursement of covered drug expenses

Current through Register Vol. 46, No. 28, July 10, 2024
Participants have the right to be reimbursed for excess
				  copayments and for personal covered drug expenses, less required copayments,
				  made in excess of their required deductible payments, made prior to receipt of
				  their new identification card or appropriate adjustment to the eligibility
				  file.
New York Codes, Rules and Regulations › Title 9 - EXECUTIVE DEPARTMENT › Subtitle KK - Program for Elderly Pharmaceutical Insurance Coverage › Part 9660 - Fraud And Abuse › Section 9660.1 - Referral of suspected fraud and abuse

Current through Register Vol. 46, No. 28, July 10, 2024
Whenever, in the conduct of a review and verification into
				  the eligibility of an applicant or the recertification of a participant, the
				  evaluation of utilization review reports or participant profiles, there is
				  evidence of program fraud or abuse by an applicant or participant, the
				  contractor shall promptly refer the matter to the executive director for
				  review.
New York Codes, Rules and Regulations › Title 9 - EXECUTIVE DEPARTMENT › Subtitle KK - Program for Elderly Pharmaceutical Insurance Coverage › Part 9660 - Fraud And Abuse › Section 9660.2 - Fraud and abuse

Current through Register Vol. 46, No. 28, July 10, 2024
(a) The
				executive director shall maintain a statewide program for investigation and
				referral for prosecution of violations of State laws pertaining to fraud or
				abuse in the program.
(b) Where
				initial review of a contractor referral indicates substantial potential for
				criminal prosecution, the executive director shall refer the matter to the
				Attorney General or local prosecutive authority. Where initial review does not
				indicate substantial potential for criminal prosecution, the executive director
				shall conduct further review to determine whether or not a participant's
				participation in the program should be restricted or terminated.
(c) Where review indicates substantial
				evidence of abusive practices, the participant may be removed from the program
				or restricted to a single provider.
New York Codes, Rules and Regulations › Title 9 - EXECUTIVE DEPARTMENT › Subtitle KK - Program for Elderly Pharmaceutical Insurance Coverage › Part 9700 - Fair Hearings › Section 9700.1 - General

Current through Register Vol. 46, No. 28, July 10, 2024
(a) These
				regulations govern the fair hearing process for applicants for coverage under
				and participation in the Program for Elderly Pharmaceutical Insurance Coverage
				and establish the rights and obligations of those applicants, participants and
				the contractor.
(b) The State
				Department of Health will consider all appeals from the contractor's written
				decisions after reconsideration on the basis of the eligibility requirements of
				the program and the reasonable application of discretionary judgments properly
				exercised by the contractor.
New York Codes, Rules and Regulations › Title 9 - EXECUTIVE DEPARTMENT › Subtitle KK - Program for Elderly Pharmaceutical Insurance Coverage › Part 9700 - Fair Hearings › Section 9700.2 - Applicants/participants

Current through Register Vol. 46, No. 28, July 10, 2024
For applicants and participants, these regulations govern the
				  following:
(a) Notice. These
				regulations set forth what information applicants and participants are entitled
				to receive with the notice of determination after reconsideration, if coverage
				has been refused or if there is to be a change in the coverage which the
				participant has been receiving.
(b)
				Timing. These regulations set forth the time periods within which applicants
				and participants are obligated to request a fair hearing after a written
				determination after reconsideration by the contractor.
(c) Procedures. These regulations set forth
				what applicants and participants are required to do to have a determination
				after reconsideration reviewed when you are refused coverage or there is a
				change in the coverage which you are receiving; how to request another hearing
				date if you are unable to go to the fair hearing on the day it is to be held;
				how to get an interpreter if you do not speak English or if you are deaf; and
				who may come with you to a fair hearing.
(d) Decision. These regulations set forth
				what you should do if the contractor refuses to comply with the fair hearing
				decision.
New York Codes, Rules and Regulations › Title 9 - EXECUTIVE DEPARTMENT › Subtitle KK - Program for Elderly Pharmaceutical Insurance Coverage › Part 9700 - Fair Hearings › Section 9700.3 - Contractor

Current through Register Vol. 46, No. 28, July 10, 2024
For the contractor, these regulations govern the
				  following:
(a) notices to be sent to
				applicants and participants under the program;
(b) information and documents to be provided
				to applicants/participants, or their representatives, who have requested a fair
				hearing;
(c) the fair hearing
				process; and
(d) compliance with
				fair hearing decisions.
New York Codes, Rules and Regulations › Title 9 - EXECUTIVE DEPARTMENT › Subtitle KK - Program for Elderly Pharmaceutical Insurance Coverage › Part 9710 - Definitions › Section 9710.1 - Definitions

Current through Register Vol. 46, No. 28, July 10, 2024
The definitions set forth in Part 9600 of this Title shall
				  also apply here and, in addition, the following terms shall have the following
				  meanings:
(a) Appellant. An applicant
				or participant who requests a fair hearing shall be termed an
				appellant.
(b) A reconsideration is
				the procedure by which an applicant or participant has an action, or the
				failure to act, of the contractor reviewed by a contractor employee with
				authority to reverse the action, or failure to act.
(c) Department means the State Department of
				Health.
(d) Fair hearing is the
				procedure by which an applicant or participant may appeal from certain
				reconsiderations of the contractor and have a hearing thereon.
(e) Hearing officer means the person who is
				employed by the department exclusively to conduct fair hearings.
(f) The parties to a fair hearing shall be
				the appellant and the contractor whose decision after reconsideration is being
				reviewed.
(g) Notice of
				determination after reconsideration means a notice from the contractor advising
				an applicant or participant that the contractor has reconsidered its action, or
				failure to act, and the contractor intends to take, or has taken, action to
				discontinue, suspend, or reduce coverage.
(h) Witness means a person who presents
				testimony and/or documentary evidence at a fair hearing, other than the
				applicant, participant or his/her representative or the representative of the
				contractor.
New York Codes, Rules and Regulations › Title 9 - EXECUTIVE DEPARTMENT › Subtitle KK - Program for Elderly Pharmaceutical Insurance Coverage › Part 9720 - Rights And Obligations Of The Applicant/participant › Section 9720.1 - Introduction

Current through Register Vol. 46, No. 28, July 10, 2024
The rights and obligations of applicants and participants
				  with respect to the fair hearing process are governed by this
				  Part.
New York Codes, Rules and Regulations › Title 9 - EXECUTIVE DEPARTMENT › Subtitle KK - Program for Elderly Pharmaceutical Insurance Coverage › Part 9720 - Rights And Obligations Of The Applicant/participant › Section 9720.2 - Right to a fair hearing

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
				Applicants and participants shall be entitled to a fair hearing to have a
				contractor's determination after reconsideration reviewed on the following
				grounds:
(1) denial of benefits;
(2) failure to determine the applicant's
				eligibility or, if found eligible, failure to issue a card or authorize
				services within three days from the date the applicant met his/her registration
				fee, premium or deductible requirement;
(3) discontinuance or suspension of coverage,
				in whole or in part;
(4)
				computation of his/her cost-sharing responsibilities;
(5) any other grounds affecting the applicant
				or participant's coverage, including a determination of the receipt of medical
				assistance or equivalent or better public or private insurance
				benefits.
New York Codes, Rules and Regulations › Title 9 - EXECUTIVE DEPARTMENT › Subtitle KK - Program for Elderly Pharmaceutical Insurance Coverage › Part 9720 - Rights And Obligations Of The Applicant/participant › Section 9720.3 - Information concerning the right to a fair hearing

Current through Register Vol. 46, No. 28, July 10, 2024
Every applicant and participant has the right to receive
				  certain information in writing when the contractor issues a written
				  determination after reconsideration which affects the applicant's/participant's
				  coverage. Each applicant and participant has the right to a notice which
				  advises:
(a) of his/her right to a
				State fair hearing;
(b) of the
				method by which he/she may obtain a hearing;
(c) that he/she may be represented by legal
				counsel, or by a relative, friend or other spokesman, or he/she may represent
				himself/herself;
(d) of the
				community legal services and senior citizen services available to assist
				him/her in the reconsideration or fair hearing; and
(e) of the types of information he/she may
				submit at the hearing.
New York Codes, Rules and Regulations › Title 9 - EXECUTIVE DEPARTMENT › Subtitle KK - Program for Elderly Pharmaceutical Insurance Coverage › Part 9720 - Rights And Obligations Of The Applicant/participant › Section 9720.4 - Notice of determination after reconsideration

Current through Register Vol. 46, No. 28, July 10, 2024
(a) After having reviewed an action, or
				failure to act, which denied, discontinued, suspended or reduced coverage
				pursuant to the mandatory reconsideration process provided for in Part 9630 of
				this Title, the contractor shall issue a written notice of determination after
				reconsideration to the applicant or participant requesting the
				reconsideration.
(b) The notice
				shall be issued within three days of the determination and mailed to the
				applicant's/participant's designated address.
(c) The notice shall clearly state the
				determination made, the basis and specific reasons for the determination, the
				action to be taken and the effective date of the action, and shall include
				information concerning the right to a fair hearing.
New York Codes, Rules and Regulations › Title 9 - EXECUTIVE DEPARTMENT › Subtitle KK - Program for Elderly Pharmaceutical Insurance Coverage › Part 9720 - Rights And Obligations Of The Applicant/participant › Section 9720.5 - Rights in fair hearing process

Current through Register Vol. 46, No. 28, July 10, 2024
When an applicant or participant requests a fair hearing,
				  he/she becomes the appellant and has the right to:
(a) examine his/her file and receive copies
				of documents in the file needed to prepare for the fair hearing;
(b) examine and receive copies of all
				documents and records which will be submitted into evidence at the fair hearing
				by the contractor;
(c) reschedule
				the hearing (adjournment);
(d) be
				represented by an attorney or other representative or to represent
				himself/herself;
(e) have an
				interpreter, at no charge, if he/she does not speak English or is deaf (the
				appellant must advise the department prior to the hearing if an interpreter
				will be needed); and
(f) have
				witnesses present written and oral evidence to explain why action taken was
				wrong.
New York Codes, Rules and Regulations › Title 9 - EXECUTIVE DEPARTMENT › Subtitle KK - Program for Elderly Pharmaceutical Insurance Coverage › Part 9720 - Rights And Obligations Of The Applicant/participant › Section 9720.6 - Request for a fair hearing

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Any
				clear communication to the department by or on behalf of an applicant or
				participant requesting review of a contractor's determination after a
				reconsideration shall constitute a request for a fair hearing if made within 60
				days of the written determination after reconsideration.
(b) A fair hearing may be requested in
				writing, by telephone or in person.
(1)
				Telephone requests should be made to the toll-free telephone number specified
				by the contractor in the notice of determination after
				reconsideration.
(2) Written
				requests should be made to the department by writing:
Fair Hearing Section
EPIC
P.O. Box 1930
Albany, NY 12201
New York Codes, Rules and Regulations › Title 9 - EXECUTIVE DEPARTMENT › Subtitle KK - Program for Elderly Pharmaceutical Insurance Coverage › Part 9720 - Rights And Obligations Of The Applicant/participant › Section 9720.7 - Examination of file prior to hearing

Current through Register Vol. 46, No. 28, July 10, 2024
(a) If copies of the documentary evidence
				which the contractor plans to use at the hearing have not already been provided
				to the appellant or his/her representative, an opportunity to examine such
				documents, if requested, shall be afforded the appellant or his representative
				at a reasonable time before the date of the hearing.
(b) The appellant or the representative shall
				be afforded an opportunity to examine the entire case file at a reasonable time
				before the hearing and to make copies of any documents contained in the file
				without charge.
New York Codes, Rules and Regulations › Title 9 - EXECUTIVE DEPARTMENT › Subtitle KK - Program for Elderly Pharmaceutical Insurance Coverage › Part 9720 - Rights And Obligations Of The Applicant/participant › Section 9720.8 - Authorization of representative

Current through Register Vol. 46, No. 28, July 10, 2024
An individual or organization, other than an attorney,
				  representing an appellant must have a written authorization, unless the
				  condition of the appellant makes it impracticable for him to execute
				  one.
New York Codes, Rules and Regulations › Title 9 - EXECUTIVE DEPARTMENT › Subtitle KK - Program for Elderly Pharmaceutical Insurance Coverage › Part 9730 - Rights And Obligations Of The Contractor › Section 9730.2 - Proposed actions

Current through Register Vol. 46, No. 28, July 10, 2024
When the contractor proposes to deny, discontinue, suspend or
				  reduce coverage, it shall:
(a) review,
				or cause to be reviewed, the proposed action to determine its correctness on
				the basis of the available evidence in support of such action which shall be
				included in the case file;
(b) if,
				after the review, it is decided that the proposed action would be correct, send
				a timely and adequate notice of the proposed action to the
				applicant/participant at least 10 days before the date the action is to be
				taken on forms approved by the State;
(c) upon request of the applicant or
				participant, promptly reconsider its determination and send written notice of
				its determination after reconsideration to the applicant/participant, together
				with the information concerning the applicant's/participant's right to a fair
				hearing as required by sections
				9720.2
				and
				9720.3 
				of this Title.