Opinion ID: 610562
Heading Depth: 2
Heading Rank: 3

Heading: Implementation of the Co-Payment Scheme

Text: 8 In May 1992, DSS mailed form letters to the approximately 1.2 million Medicaid households announcing that the co-payment requirement would begin on June 1, 1992. DSS also mailed a Medicaid Update Bulletin and form letter to pharmacists and to the approximately 76,000 Medicaid providers explaining how to collect the co-payments. Finally, DSS sent notices to local commissioners of DSS. 9 These materials instructed providers not to adjust their Medicaid claims to reflect co-payments because DSS will automatically reduce the provider's Medicaid reimbursement. The provider thus bears the burden of collecting the co-payment from recipients. In the case of an inability to pay, the reimbursement is nevertheless reduced. However, if the recipient or the services the recipient receives are otherwise exempt from co-payments, as identified by either the DSS computer or the provider's exemption claim form, the provider's reimbursement will not be reduced. 10 DSS promulgated a number of regulations and policies to identify recipients who do not have the ability to pay or who meet one of the statutory exemptions. With regard to the inability-to-pay provision, a simple statement by the recipient that he or she is unable to pay is sufficient. The provider may not contest the recipient's statement that he or she cannot pay. Moreover, it is an unacceptable practice for a provider to refuse to provide services after the recipient has expressed an inability to pay. See id. § 367-a(6)(g)(i); N.Y.Comp.Codes R. & Regs. tit. 18, §§ 360-7.12(a) & 515.2(17) (1992). A provider that has engaged in an unacceptable practice is subject to censure, monetary penalties, or termination from the Medicaid program. N.Y.Comp.Codes R. & Regs. tit. 18, §§ 515.1, 515.3 (1992). 11 With regard to the under-21 exemption, the recipient's date of birth is on his or her Medicaid card. Next, the DSS's Medicaid computer system (the Electronic Medicaid Eligibility Verification System (EMEVS)) identifies recipients who are exempt because of their enrollment in managed care programs, Comprehensive Medicaid Case Management Programs, and Intermediate Care Facilities of the Developmentally Disabled. A recipient can request a hearing to challenge whether the date of birth is correct on the Medicaid card or whether he or she is in an HMO or managed care program. 12 Other methods of documentation are used for less permanent conditions. For example, pregnant women may demonstrate their eligibility for exemption in several ways--(1) by requesting a service that is pregnancy-related; (2) by a note from their doctor confirming pregnancy; (3) by their physical appearance; and (4) by any other method, including contact with the women's physician or by identifying a prescription/order source as a Prenatal Care Assistance Program. Similarly, to implement the exemption for residents in Office of Mental Retardation or Office of Mental Health (OMR/OMH) Community Residences, written documentation is provided to residents by the staff. 13 If a provider refuses services, the recipient may phone a toll-free hotline staffed by persons trained in the co-payment regulations and programs. Upon receiving a call, the staffer's first responsibility is to ensure that the recipient has received the needed care and, if not, to give instructions to go to another provider. The staffer then records all relevant information, such as the provider's name and date of the denial of service, and forwards a report to the DSS's Office of Audit and Quality Control, which conducts an investigation.