reglab/statecodes huggingface dataset:
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 360-6 - Entitlement To Medical Assistance › Section 360-6.4 - Restriction of recipient access to services (recipient restriction program)

Current through Register Vol. 46, No. 28, July 10, 2024
The social services district and the department may
				restrict a recipient's access to MA care and services if, upon review, it is
				found that the recipient has received duplicative, excessive, contraindicated
				or conflicting health care services, drugs, or supplies. In such cases, the
				social services district and the department may require that the recipient
				access specific types of medical care and services through a designated primary
				provider or providers. The State medical review team (SMRT) designated by the
				department performs recipient utilization reviews and identifies candidates for
				the recipient restriction program.
(a)
			   Definitions. When used in this section:
(1)
			   Good cause for a restricted recipient to request a change of primary provider
			   means the existence of one or more of the following circumstances:
(i) the provider no longer wishes to be a
			   primary provider for the recipient; or
(ii) the provider has closed his/her office
			   or pharmacy, or moved to a location not convenient to the recipient;
			   or
(iii) the provider has been
			   suspended or disqualified from participation in the MA program; or
(iv) the provider is a pharmacist and/or a
			   durable medical equipment (DME) dealer who cannot stock an item for which the
			   recipient has a legitimate prescription or fiscal order; or
(v) the recipient has moved; or
(vi) other circumstances exist that make it
			   necessary to change providers.
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 360-6 - Entitlement To Medical Assistance › Section 360-6.5 - Fair hearing requirements in utilization review cases

Current through Register Vol. 46, No. 28, July 10, 2024
When a utilization review committee determines that MA
				payments should be reduced or discontinued, the following steps must be
				taken:
(a) If the recipient is in a
			   long-term care facility (a skilled nursing facility, intermediate care facility
			   or mental hospital) or is a chronic care patient in a general hospital
			   facility:
(1) The recipient, his/her
			   representative, or an appropriate relative must be notified of the action in
			   writing by the utilization review committee. The notice must be notified of the
			   action in writing by the utilization review committee. The notice must be both
			   timely and adequate as defined in Part 358 of this Title. The notice and action
			   must be consistent with both State and Federal requirements on utilization
			   review.
(2) If the recipient
			   requests a fair hearing before the effective date of the action, payment for
			   the recipient's care in a long-term care facility or for long-term care in a
			   general hospital will be continued until the fair hearing decision is
			   rendered.
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 360-6 - Entitlement To Medical Assistance › Section 360-6.6 - Where care and services may be provided

Current through Register Vol. 46, No. 28, July 10, 2024
Medical care and services under the MA program may be
				provided to a recipient residing in his/her own home or in an approved medical
				institution or facility.
(a) A
			   recipient's home may be a home where he/she receives room and board, a family
			   home or boarding home, an approved nonprofit institution for child care, a
			   licensed public child care institution which accommodates no more than 25
			   children and is not operated primarily for delinquent children or family-type
			   group, or a family-type, family care or residential care facility certified by
			   the department or an office of the State Department of Mental
			   Hygiene.
(b) An approved medical
			   institution or facility includes the following when operated according to the
			   Public Health Law or other applicable law:
(1) a private proprietary or nonprofit
			   nursing home;
(2) the approved
			   infirmary section of a home for the aged;
(3) a public home infirmary or other similar
			   public facility for the chronically ill;
(4) an intermediate care facility;
(5) a facility or part of a facility for the
			   treatment of narcotic addiction which is operated pursuant to the provisions of
			   article 23 of the Mental Hygiene Law, as long as Federal aid is
			   available;
(6) an inpatient
			   alcoholism facility;
(7) an
			   approved hospital, nursing home, or intermediate care facility section of a
			   public institution operated for the care of the mentally disabled;
(8) a State hospital for the mentally
			   disabled operated by the State Department of Mental Hygiene; and
(9) a hospital other than one caring
			   primarily for the mentally disabled.
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 360-6 - Entitlement To Medical Assistance › Section 360-6.7

Current through Register Vol. 46, No. 28, July 10, 2024
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 360-6 - Entitlement To Medical Assistance › Section 360-6.8 - Medical care coordinator program (MCCP)

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Policy. Effective July 1, 1992, a
			   recipient who is eligible for medical assistance (MA) solely as a result of
			   being eligible for or in receipt of home relief (HR) and who is at least 21
			   years of age but under the age of 65 (MA/HR recipient), may receive certain MA
			   services only if the recipient is enrolled in a health maintenance organization
			   or other entity which provides comprehensive health services, a managed care
			   program, a primary provider program, or a voluntary medical care coordinator
			   program (MCCP).
(b) Scope. This
			   section defines the MCCP; specifies the rights of participating recipients;
			   establishes the qualifications and responsibilities of participating primary
			   physicians, diagnostic and treatment centers, hospital out-patient departments
			   and pharmacies in providing and coordinating medical care, services and
			   supplies for participating recipients; and sets forth the responsibilities of
			   social services districts in administering the MCCP.
(c) Definitions. As used in this section,
			   unless expressly stated otherwise or unless the context of the subject matter
			   requires a different interpretation:
(1) MCCP
			   means a program in which an MA/HR recipient voluntarily enrolls with a primary
			   physician, diagnostic and treatment center or hospital out-patient department
			   and a primary pharmacy which will provide or refer the MA recipient to
			   medically necessary services and will further coordinate the use of medical
			   services to assure that the recipient receives appropriate medical care,
			   services and supplies and that MA is provided in an appropriate and
			   cost-effective manner.
(2) MA/HR
			   recipient means a person who is eligible for MA solely as a result of being
			   eligible for or in receipt of HR and who is at least 21 years of age but under
			   the age of 65.
(3) Primary provider
			   means a physician, diagnostic and treatment center, or hospital out-patient
			   department enrolled in the MA program which has agreed to coordinate the health
			   care of an MA/HR recipient and to provide and/or direct all medically necessary
			   care, services and supplies for which the MA/HR recipient is
			   eligible.
(4) Primary pharmacy
			   means a pharmacy enrolled in the MA program which has agreed to provide all
			   drugs and pharmaceutical supplies ordered for an MA/HR recipient enrolled in
			   the MCCP.
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 360-7.1 - Introduction

Current through Register Vol. 46, No. 28, July 10, 2024
This Subpart specifies:
(a) when MA will pay for covered medical care
			   and services;
(b) who may receive
			   MA payment for providing covered medical care and services;
(c) that recipients must cooperate in
			   obtaining payments from third parties; and
(d) that MA may pay for certain insurance
			   premiums, coinsurance and deductibles, and for reserved beds in medical
			   institutions.
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 360-7.2 - MA program as payment source of last resort

Current through Register Vol. 46, No. 28, July 10, 2024
Where a third party, such as a health insurer or
				responsible person, has a legal liability to pay for MA-covered services on
				behalf of a recipient, the department or social services district will pay only
				the amount by which the MA reimbursement rate for the services exceeds the
				amount of the third party liability. The department or social services district
				will also pay if the third party payment will not be made within a reasonable
				time. The department or social services district will seek reimbursement for
				any payments for care and services it makes for which a third party is legally
				responsible. They will seek reimbursement to the extent of the third party's
				legal liability unless the amount reasonably expected to be recovered is less
				than the cost of making the recovery.
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 360-7.3 - Use of health, hospital or accident insurance

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Definitions used in this section.
(1) Insurance providing full coverage. A
			   recipient's insurance is providing full coverage when the recipient's care is
			   paid for under the insurance contract without the payment of any coinsurance
			   amount, deductible, or Medicare.
(2) Insurance providing partial coverage. A
			   recipient's insurance is providing partial coverage when payment for his/her
			   care under the insurance contract is subject to payment of a coinsurance
			   amount, deductible, or Medicare.
(3) Indemnity insurance coverage is any
			   insurance benefit a recipient receives because of accident or injury. Examples
			   of this type of insurance are automobile and liability insurance and workers'
			   compensation benefits.
(4)
			   Coinsurance amount or deductible are amounts an insurance beneficiary must pay
			   when he/she receives care or services.
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 360-7.4 - Liability of third parties

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
(1) When care and services are or may be
			   provided to an applicant/recipient for treatment of injury, disease or
			   disability, the State or social services district will take all reasonable
			   measures to ascertain the legal liability of third parties (including health
			   insurers) to pay for such care and services.
(2) The social services district, when
			   determining or redetermining eligibility, must collect sufficient information
			   to enable the State to pursue claims against such third parties, including all
			   information specifically required by the department.
(3) As a condition of eligibility, an
			   applicant/recipient must cooperate with the State or social services district
			   in identifying third parties who may be liable to pay for care. The
			   applicant/recipient must provide information to assist the State in pursuing
			   such third parties. An applicant/recipient may refuse to cooperate only for
			   good cause.
(4) As a condition of
			   eligibility, an applicant/recipient with the legal capacity to execute an
			   assignment, must assign to the State and social services district any rights
			   against any third party for support (specified as support for medical care by a
			   court or administrative order) and for payment of medical care. The requirement
			   extends to any person with the legal authority to execute an assignment on
			   behalf of an applicant/recipient.
(5) The State or social services district
			   will seek reimbursement for MA when there is a third party legal liability and
			   the expected amount of reimbursement is more than the costs of making the
			   recovery.
(6) Upon furnishing MA to
			   a recipient, the social services district or the department will be subrogated,
			   to the extent of the expenditures by such district or the department, to any
			   rights the recipient may have to medical support or third party reimbursement.
			   For purposes of this section, the term medical support means the right to
			   support for purposes of medical care as specified by court or administrative
			   order. The social services district or the department will issue a written
			   notice of the exercise of subrogation rights to the appropriate party or
			   parties.
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 360-7.6 - Payment for services or supplies

Current through Register Vol. 46, No. 28, July 10, 2024
(a) For most services, rates of payment are
			   established pursuant to section 367-a  of the Social Services Law. They are
			   contained in Subchapter E of this Title. Where rates of payment are not
			   otherwise established, each social services district must set a schedule of
			   rates of payment for services and supplies provided under the MA program. These
			   rates of payment must be set to assure that adequate services and supplies will
			   be provided. Each social services district must require that payment of rates
			   made according to established schedules, including any portion to be paid by
			   the recipient, will constitute full payment for the services or supplies
			   provided to the MA recipient.
(b)
(1) Payment for the following medical care,
			   services and supplies provided to a recipient who is eligible for medical
			   assistance (MA) solely as a result of being eligible for or in receipt of home
			   relief (HR) and who is at least 21 years of age but under the age of 65 is
			   available only if the recipient is enrolled in a health maintenance
			   organization or other entity which provides comprehensive health services, a
			   managed care program, a primary provider program, or a voluntary medical care
			   coordinator program (MCCP):
(i) home health
			   services;
(ii) personal
			   care;
(iii) physical, speech and
			   occupational therapy;
(iv)
			   transportation;
(v) private duty
			   nursing;
(vi) optometric
			   care;
(vii) audiology
			   services;
(viii) clinical
			   psychology;
(ix) orthotic
			   devices;
(x) sick room supplies;
			   and
(xi) nursing home in-patient
			   care unless the recipient was an in-patient nursing home resident on July 1,
			   1992.
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 360-7.7 - Payments of deductibles and coinsurance under title XVIII of the Social Security Act (Medicare)

Current through Register Vol. 46, No. 28, July 10, 2024
(a) The MA
			   program will pay on behalf of qualified Medicare beneficiaries, as defined in
			   subdivision (g) of this section, the full amount of any deductible and
			   coinsurance costs incurred under part A or B of title XVIII of the Social
			   Security Act (Medicare).
(1) The MA program
			   will pay the full amount of such deductible and coinsurance costs for care,
			   services or supplies included in the MA program and for care, services or
			   supplies that are not included in the MA program.
(2) The MA program will pay the full amount
			   of such deductible and coinsurance costs for qualified Medicare beneficiaries
			   who are otherwise eligible for MA and for qualified Medicare beneficiaries who
			   are not otherwise eligible for MA.
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 360-7.8 - Payments of premiums under title XVIII of the Social Security Act (Medicare)

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
			   Payment of Medicare part A monthly premiums will be made by the MA program for
			   qualified Medicare beneficiaries and qualified disabled and working
			   individuals, as defined in section
			   360-7.7 
			   of this Subpart. Payment of Medicare part A monthly premiums for a qualified
			   Medicare beneficiary will begin with the month following the month he or she
			   applies for MA payment of these amounts.
(b) Payment of Medicare part B premiums will
			   be made by the MA program if a recipient is:
(1) enrolled in a voluntary insurance program
			   under Medicare part B;
(2)
			   receiving cash grants as an eligible recipient of public assistance;
(3) receiving chronic care in a medical
			   institution;
(4) receiving care in
			   a public home;
(5) a qualified
			   Medicare beneficiary, as defined in section
			   360-7.7(g) 
			   of this Subpart. The MA program will pay the Medicare part B monthly premiums
			   for a qualified Medicare beneficiary beginning with the month following the
			   month he or she applies for MA payment of these amounts; or
(6) a specified low-income Medicare
			   beneficiary as defined in section 360- 7.7(i) of this Subpart. The MA program
			   will pay the Medicare part B monthly premiums for a specified low-income
			   Medicare beneficiary.
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 360-7.9 - Special needs of MA recipients subject to chronic care budgeting

Current through Register Vol. 46, No. 28, July 10, 2024
A recipient subject to chronic care budgeting in a
				medical facility or an intermediate care facility will receive a grant to
				satisfy unmet needs and expenses if his/her monthly income is less than the
				amount allowed by the department for incidental needs and expenses. The grant
				will be from the category of assistance for which he/she is
				eligible.
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 360-7.10

Current through Register Vol. 46, No. 28, July 10, 2024
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 360-7.11 - Medical assistance liens and recoveries

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Liens. The social services district may
			   not impose any lien against a person's property prior to his or her death for
			   MA paid or to be paid on his or her behalf except:
(1) based upon a court judgment for benefits
			   incorrectly paid; or
(2) against
			   claims and suits for personal injuries, to recover the amount of MA furnished
			   to a person on and after the date the person incurred the injuries;
			   or
(3) with respect to the real
			   property of a person who is an in-patient in a nursing facility, intermediate
			   care facility for the mentally retarded, or other medical institution, and who
			   is not reasonably expected to be discharged from the medical institution and
			   return home, provided that:
(i) any such lien
			   will dissolve upon the person's discharge and return home; and
(ii) no lien may be imposed on the person's
			   home if the person's spouse, child under 21 years of age, certified blind or
			   certified disabled child of any age, or sibling who has an equity interest in
			   the home and who resided in the home for at least one year immediately before
			   the date of the person's admission to the medical institution, is lawfully
			   residing in the home.
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 360-7.12 - Co-payments by recipients

Current through Register Vol. 46, No. 28, July 10, 2024
(a) In
			   accordance with section 367-a (6)  of the Social Services Law, nominal
			   co-payments must be imposed upon recipients for certain care, services and
			   supplies furnished under the medical assistance program. Payments for claims
			   for services specified in subdivision (d) of this section will be reduced by
			   the amounts determined in subdivision (f) of this section. The providers of
			   such services may charge recipients the co-payments. However, providers may not
			   deny services to recipients because of their inability to pay the
			   co-payments.
(b)
Definitions.
(1) For purposes of
			   this section,
drugs with FDA-approved indications for the treatment of
			   tuberculosis
means aminosalicylate sodium (para-aminosalicylate
			   sodium), capreomycin sulfate, cycloserine, ethambutol, ethionamide, isoniazid,
			   pyrazinamide, rifampin, and streptomycin.
(2)
Medical facility
means
			   residential health care facility or an intermediate care facility for the
			   developmentally disabled.
(3) For
			   purposes of this section,
psychotropic drugs
means
			   acetazolamide, acetophenazine, alprazolam, amantadine, amitriptyline,
			   amoxapine, benztropine, biperiden, bupropion, buspirone, butabarbital,
			   cabamazepine, chloral hydrate, chlordiazepoxide, chlormezanone, chlorpromazine,
			   chlorprothixene, clomipramine, clonazepam, clorazepate dipotassium, clozapine,
			   desipramine, diazepam, diphenhydramine, doxepin, estazolam, ethopropazine HCl,
			   ethosuximide, ethotoin, fluoxetine, fluphenazine, flurazepam, halazepam,
			   haloperidol, hydroxyzine HCl, hydroxyzine pamoate, imipramine, isocarboxazid,
			   lithium, lorazepam, loxapine, maprotiline, mephenytoin, mephobarbital,
			   meprobamate, methsuximide, mesoridazine, molindone, nortriptyline, oxazepam,
			   paraldehyde, paramethadione, pentobarbital, perphenazine, phenacemide,
			   phenelzine, phenobarbital, phensuximide, phenytoin, pimozide, prazepam,
			   primidone, prochlorperazine, procyclidine, promazine, protriptyline, quazepam,
			   secobarbital, sertraline, temazepam, thioridazine, thiothixene,
			   tranylcypromine, trazodone, triazolam, trifluoperazine, triflupromazine,
			   trihexyphenidyl HCl, trimethadione, trimipramine, and valproic acid and its
			   derivatives.
(4)
X-ray
			   services
means diagnostic radiology, diagnostic ultrasound, nuclear
			   medicine or radiation oncology.
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 360-9 - Catastrophic Health Care Expense Program › Section 360-9.1 - Scope

Current through Register Vol. 46, No. 28, July 10, 2024
As part of a comprehensive response to the difficulties
				individuals and families face in obtaining access to medical care and the
				extraordinary costs of such care, the Legislature enacted title 11-A of article
				5 of the Social Services Law. That title established the Catastrophic Health
				Care Expense Program (CHCEP) to test ways to expand the availability of health
				insurance coverage on a demonstration basis in no more than three social
				services districts. These regulations implement the provisions of the
				CHCEP.
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 360-9 - Catastrophic Health Care Expense Program › Section 360-9.2 - Demonstration applications

Current through Register Vol. 46, No. 28, July 10, 2024
A social services district may apply to participate in
				the CHCEP by submitting a proposal which describes how the program would be
				implemented in the district if the department approved the proposal. All
				proposals must be submitted by February 28, 1989, or such later date specified
				by the department.
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 360-9 - Catastrophic Health Care Expense Program › Section 360-9.3 - Definitions

Current through Register Vol. 46, No. 28, July 10, 2024
For the purposes of this Subpart:
(a) Adjusted family income means the family
			   income during a calendar year reduced by documented alimony payments, support
			   payments, FICA contributions and Federal, State and local income tax
			   payments.
(b) Eligible catastrophic
			   health care expenses means those health care expenses which can be paid for
			   under the Medical Assistance (MA) program excluding expenses incurred for
			   services provided to in-patients or residents of health care facilities, other
			   than expenses incurred for acute care services that are provided by general
			   hospitals. Eligible catastrophic health care expenses must be incurred in a
			   calendar year after the time when a family's total health care expenses exceed
			   50 percent of the difference between the annual adjusted family income and the
			   maximum amount of public assistance (PA) the family would receive if it were
			   eligible for PA.
(c) Hardship.
			   Hardship means an applicant's adjusted annual family income does not exceed 200
			   percent of the comparable Federal income official poverty line (as defined and
			   annually revised by the Federal Office of Management and Budget) for a family
			   of the same size and the family's total countable resources, computed according
			   to Subpart 360-4 of this Part, do not exceed $10,000.
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 360-9 - Catastrophic Health Care Expense Program › Section 360-9.4 - Eligibility for the CHCEP services

Current through Register Vol. 46, No. 28, July 10, 2024
(a) The CHCEP is available to a family which:
			   is ineligible for MA and PA; meets the residency requirements of section 369-c 
			   of the Social Services Law; and has eligible catastrophic health care
			   expenses.
(b)
(1) The CHCEP assistance with cost sharing of
			   eligible catastrophic health care expenses is available to a family if its
			   health care expenses, after deducting health insurance benefits, are in excess
			   of 50 percent, but are no more than 75 percent, of the difference between the
			   adjusted or projected annual family income and the maximum PA grant it would
			   receive if it were eligible for PA.
(2) For a family which is eligible for the
			   CHCEP assistance with cost sharing under paragraph (1) of this subdivision, the
			   CHCEP will pay a percentage of the expenses for covered services and the family
			   must pay the remainder. The Commissioner of Health has established a schedule
			   setting forth the cost-sharing percentages which will be used to allocate costs
			   between families and the CHCEP for the various CHCEP services (10 NYCRR 85.42).
			   The CHCEP share of the expenses will be determined by multiplying the cost
			   sharing percentage by the MA rate for the service or the rate charged by the
			   provider of the service, whichever is less.
(3) A family in receipt of the CHCEP
			   assistance with cost sharing may be reimbursed only for paid bills for health
			   care services incurred during the previous calendar year, unless the family
			   demonstrates hardship as defined in section
			   360-9.3  of
			   this Subpart. If hardship is demonstrated, the family in receipt of the CHCEP
			   may be reimbursed up to the MA rate for the current year's expenses. When the
			   social services district determines that hardship exists, payments may be made
			   directly to the provider of the health care services. The social services
			   district may determine that hardship exists at the time a family applies for an
			   interim authorization or assistance with or without cost sharing under this
			   Subpart.
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 360-9 - Catastrophic Health Care Expense Program › Section 360-9.5 - Responsibilities of the CHCEP applicant and recipient

Current through Register Vol. 46, No. 28, July 10, 2024
(a) An applicant for the CHCEP assistance
			   must submit to the social services district an application for such assistance
			   together with documentation of any third-party health insurance benefits which
			   are available to family members.
(b) A family which has received an interim
			   authorization for CHCEP assistance must notify the appropriate social services
			   official of any change in family size, income or estimated income upon which
			   the eligibility determination was based within 30 days of the change.
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 360-9 - Catastrophic Health Care Expense Program › Section 360-9.6 - Powers and responsibilities of the social services district

Current through Register Vol. 46, No. 28, July 10, 2024
Each social services district that participates in the
				CHCEP must:
(a) determine eligibility
			   of a family to participate in the CHCEP within 90 days from receipt of an
			   application;
(b) not require that a
			   new application be submitted by an applicant who reapplies within 30 days of a
			   notice of denial;
(c) ensure that
			   the application date is the date of original application for any applicant who
			   reapplies within 30 days of the notice of denial;
(d) provide written notice to the department
			   if a problem arises which threatens the continuation or completion of the
			   project. Such notice must be provided within three days after the problem
			   arises or is discovered, including recommendations for resolving the
			   problem;
(e) submit claims for
			   payment to the department on a monthly basis;
(f) transfer to the department any funds
			   received from sources other than the CHCEP for medical expenses which would be
			   paid under the CHCEP;
(g) prepare
			   quarterly progress and financial reports and submit the reports to the
			   department no later than 30 days after the close of each calendar
			   quarter;
(h) provide notice of the
			   termination of the project to the department not less than 30 days prior to the
			   effective date of termination if the district determines that continuing the
			   CHCEP in the district is not feasible;
(i) use interim authorization and vendor
			   billing forms approved by the department; and
(j) give applicants for or families in
			   receipt of CHCEP assistance notices which comply with sections
			   358-2.2 and
			   358-3.3  of
			   this Title.
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 360-9 - Catastrophic Health Care Expense Program › Section 360-9.7 - Powers and responsibilities of the department

Current through Register Vol. 46, No. 28, July 10, 2024
The department may:
(a) withhold up to 10 percent of any CHCEP
			   grant money owed to the district if the district does not comply with the
			   provisions of section
			   360-9.6(h) 
			   of this Subpart; the department may pay the district the withheld amount only
			   when the district complies with such provisions; and
(b) terminate the demonstration project in a
			   social services district when it determines that termination would be in the
			   State's best interest. Written notice of the termination must be provided to
			   the district not less than 30 days prior to the effective date of the
			   notice.
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 360-10 - MEDICAID MANAGED CARE PROGRAMS › Section 360-10.1 - Introduction

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Most Medicaid
			   recipients are required and some recipients may elect to receive health
			   services from a Medicaid managed care organization (MMCO). Individuals eligible
			   for Family Health Plus, except for those who participate in the Family Health
			   Plus Premium Assistance Program, are required to receive health care services
			   from a MMCO.
(b) An MMCO must
			   provide or arrange for the provision of all services set forth in its benefit
			   package to its enrollees. The commissioner shall assure that Medicaid
			   recipients in managed care have access to all services to which they are
			   entitled under the Medicaid program, including services, if any, that are not
			   included in their MMCO's benefit package and provided through the Medicaid Fee
			   for Service Program. Family Health Plus enrollees are eligible for the services
			   specified in section 369-ee  of the Social Services Law.
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 360-10 - MEDICAID MANAGED CARE PROGRAMS › Section 360-10.2 - Scope

Current through Register Vol. 46, No. 28, July 10, 2024
This Subpart describes:
(a) individuals required to enroll in an
			   MMCO;
(b) individuals exempt or
			   excluded from enrollment in an MMCO;
(c) good cause reasons for permitting an
			   enrollee to change or disenroll from an MMCO;
(d) good cause reasons for permitting an
			   enrollee to change primary care providers (PCPs);
(e) the fair hearing rights for managed care
			   enrollees;
(f) marketing/outreach
			   requirements for MMCOs;
(g) MMCO
			   unacceptable practices;
(h) MMCO
			   sanctions and due process.
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 360-10 - MEDICAID MANAGED CARE PROGRAMS › Section 360-10.3 - Definitions

Current through Register Vol. 46, No. 28, July 10, 2024
As used in this Subpart, unless expressly stated
				otherwise or unless the context of the subject matter requires different
				interpretation:
(a)
Action
means, in the case of an MMCO or its management
			   contractor:
(1) the denial or limited
			   authorization of a requested service, including type or level of service;
			   or
(2) the reduction, suspension,
			   or termination of a previously authorized service; or
(3) the denial, in whole or in part, of
			   payment for a service; or
(4) the
			   failure to provide services in a timely manner, as set forth in the guidelines
			   established by the commissioner; or
(5) the failure to act to resolve service
			   authorization requests, complaints, grievances, and appeals with reasonable
			   promptness.
Reasonable promptness
shall mean compliance with
			   the timeframes established by Public Health Law and applicable Federal
			   regulations, as set forth in the guidelines established by the
			   commissioner;
(6) the denial of a
			   request for out of network services for a managed care enrollee who is required
			   to receive medical assistance services from an MMCO and who resides in a social
			   services district where there is only one MMCO participating in the Medicaid
			   Managed Care Program; or
(7) the
			   restriction of an enrollee to certain providers under the MMCO's recipient
			   restriction program.
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 360-10 - MEDICAID MANAGED CARE PROGRAMS › Section 360-10.4 - Individuals required to enroll in an MMCO

Current through Register Vol. 46, No. 28, July 10, 2024
(a) All Medicaid recipients, except for those
			   who are eligible for an exemption or an exclusion pursuant to section
			   360-10.5 
			   of this Subpart, residing in a social services district that has been approved
			   to implement mandatory enrollment must enroll in an MMCO.
(b) Excluded populations may not enroll in an
			   MMCO.
(c) Exempt populations are
			   not required to enroll in an MMCO in a social services district where
			   enrollment is mandatory; however, they may elect to voluntarily
			   enroll.
(d) All FHP eligible
			   individuals, except for those participating in the FHP premium assistance
			   program, must enroll in an MMCO to receive services.
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 360-10 - MEDICAID MANAGED CARE PROGRAMS › Section 360-10.5 - Individuals exempt or excluded from enrollment in an MMCO

Current through Register Vol. 46, No. 28, July 10, 2024
(a) A Medicaid recipient is exempt from
			   enrollment in an MMCO if the recipient meets one of the criteria for exemption
			   identified in section 364-j (3)(b)  of the Social
			   Services Law.
(b) A Medicaid
			   recipient identified in section 364-j (3)(e)  of the Social
			   Services Law is exempt from enrollment unless the commissioner has established
			   program features for that population.
(c) A Medicaid recipient shall be excluded
			   from enrollment in an MMCO if the recipient meets one of the criteria
			   identified in section 364-j (3)(c)  of the Social
			   Services Law.
(d) Determination of
			   a Medicaid recipient's eligibility for an exemption or exclusion shall be the
			   responsibility of the social services district.
(1) Determinations made prior to enrollment.
			   Determinations made prior to enrollment.
(i)
			   If a Medicaid recipient requests an exemption or exclusion from enrollment in
			   an MMCO, the Medicaid recipient or the Medicaid recipient's representative must
			   file a written request with the appropriate social services district. The
			   social services district shall require the Medicaid recipient to provide
			   documentation to support the request for an exemption or exclusion where
			   appropriate.
(ii) The social
			   services district must make a determination within 10 days after receipt of all
			   necessary information and notify the Medicaid recipient in writing whether the
			   request for an exemption or exclusion is granted or denied.
(iii) When a request for an exemption or
			   exclusion is denied, the social services district must provide a written notice
			   that explains the reason for the denial, states the facts upon which the denial
			   is based, cites the relevant statutory or regulatory authority for the denial,
			   and advises the Medicaid recipient of his or her right to a fair hearing. The
			   notice must comply with section
			   358-2.2(a) 
			   of this Title.
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 360-10 - MEDICAID MANAGED CARE PROGRAMS › Section 360-10.6 - Good cause for changing or disenrolling from an MMCO

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
Medicaid recipients.
(1) A recipient who is required to enroll in
			   an MMCO and who resides in a social services district with more than one MMCO
			   available has good cause to change his or her MMCO during the lock-in period
			   if:
(i) the MMCO has failed to furnish
			   accessible and appropriate medical care, services or supplies to which the
			   enrollee is entitled under the terms of the contract under which the MMCO has
			   agreed to provide services. This includes, but is not limited to the failure
			   to:
(a) arrange for the provision of primary
			   care services;
(b) arrange for the
			   provision of inpatient care;
(c)
			   arrange for consultation with specialists and other ancillary service
			   providers;
(d) arrange for covered
			   services with qualified licensed or certified providers; or
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 360-10 - MEDICAID MANAGED CARE PROGRAMS › Section 360-10.7 - Good cause for changing primary care practitioners

Current through Register Vol. 46, No. 28, July 10, 2024
(a) An MMCO must allow enrollees to change
			   PCPs without cause within 30 days of the enrollee's first appointment with the
			   PCP. After the first 30 days, the MMCO may elect to limit enrollees to changing
			   PCPs every six months without cause. This subdivision does not apply to
			   enrollees restricted pursuant to section
			   360-6.4 
			   of this Part or the MMCO's recipient restriction program.
(b) If the MMCO has elected to restrict PCP
			   changes, or an enrollee has been restricted pursuant to section
			   360-6.4 
			   of this Part or the MMCO's recipient restriction program, an enrollee
			   nevertheless has good cause to change PCPs at any time if:
(1) the provider has failed to furnish
			   accessible and appropriate medical care, services or supplies to which the
			   enrollee is entitled under the terms of the contract under which the MMCO has
			   agreed to provide services. This includes, but is not limited to, the failure
			   to:
(i) provide primary care
			   services;
(ii) arrange for
			   inpatient care, consultations with specialists, or laboratory or radiological
			   services when reasonably necessary;
(iii) arrange for consultation
			   appointments;
(iv) coordinate and
			   interpret any consultation findings with an emphasis on continuity of medical
			   care;
(v) arrange for services with
			   qualified licensed or certified providers;
(vi) coordinate the enrollee's overall
			   medical care such as periodic immunizations and diagnosis and treatment of any
			   illness or injury; or
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 360-10 - MEDICAID MANAGED CARE PROGRAMS › Section 360-10.8 - Fair hearings

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Part
			   358 of this Title is incorporated by reference as if set forth fully herein and
			   is applicable to enrollees, MMCOs, and management contractors, except that,
			   where a provision in this section is inconsistent with Part 358 of this Title,
			   the provision in this section will apply.
(b) In addition to the fair hearing rights in
			   Part 358 of this Title, enrollees have a right to a fair hearing if:
(1) a social services district denies a
			   request for an exemption or exclusion from Medicaid managed care;
(2) a social services district denies a
			   request to enroll in, disenroll from, or change an MMCO;
(3) the social services district requires the
			   enrollee to disenroll from an MMCO;
(4) a PCPCP has upheld the decision of a PCP
			   to: deny a request for a referral; deny or reduce a benefit or service; or
			   authorize a service in an amount less than requested; or
(5) an MMCO, or its management contractor,
			   has taken an action, as defined in section
			   360-10.3 
			   of this Subpart.