§ 364-I — Medical assistance presumptive eligibility program

New York § 364-I

• Jurisdiction: New York
• Law SOS: Social Services
• Title 11: Medical Assistance For Needy Persons
• Art. 5: Assistance and Care

Text

§ 364-i. Medical assistance presumptive eligibility program. 1. An\nindividual, upon application for medical assistance, shall be presumed\neligible for such assistance for a period of sixty days from the date of\ntransfer from a general hospital, as defined in section twenty-eight\nhundred one of the public health law to a certified home health agency\nor long term home health care program, as defined in section thirty-six\nhundred two of the public health law, or to a hospice as defined in\nsection four thousand two of the public health law, or to a residential\nhealth care facility as defined in section twenty-eight hundred one of\nthe public health law, if the local department of social services\ndetermines that the applicant meets each of the following criteria: (a)\nthe applicant is receiving acute care in such hospital; (b) a physician\ncertifies that such applicant no longer requires acute hospital care,\nbut still requires medical care which can be provided by a certified\nhome health agency, long term home health care program, hospice or\nresidential health care facility; (c) the applicant or his\nrepresentative states that the applicant does not have insurance\ncoverage for the required medical care and that such care cannot be\nafforded; (d) it reasonably appears that the applicant is otherwise\neligible to receive medical assistance; (e) it reasonably appears that\nthe amount expended by the state and the local social services district\nfor medical assistance in a certified home health agency, long term home\nhealth care program, hospice or residential health care facility, during\nthe period of presumed eligibility, would be less than the amount the\nstate and the local social services district would expend for continued\nacute hospital care for such person; and (f) such other determinative\ncriteria as the commissioner shall provide by rule or regulation. If a\nperson has been determined to be presumptively eligible for medical\nassistance, pursuant to this subdivision, and is subsequently determined\nto be ineligible for such assistance, the commissioner, on behalf of the\nstate and the local social services district shall have the authority to\nrecoup from the individual the sums expended for such assistance during\nthe period of presumed eligibility.\n 2. Payment for up to sixty days of care for services provided under\nthe medical assistance program shall be made for an applicant presumed\neligible for medical assistance pursuant to subdivision one of this\nsection provided, however, that such payment shall not exceed sixty-five\npercent of the rate payable under this title for services provided by a\ncertified home health agency, long term home health care program,\nhospice or residential health care facility. Notwithstanding any other\nprovision of law, no federal financial participation shall be claimed\nfor services provided to a person while presumed eligible for medical\nassistance under this program until such person has been determined to\nbe eligible for medical assistance by the local social services\ndistrict. During the period of presumed medical assistance eligibility,\npayment for services provided persons presumed eligible under this\nprogram shall be made from state funds. Upon the final determination of\neligibility by the local social services district, payment shall be made\nfor the balance of the cost of such care and services provided to such\napplicant for such period of eligibility and a retroactive adjustment\nshall be made by the department to appropriately reflect federal\nfinancial participation and the local share of costs for the services\nprovided during the period of presumptive eligibility. Such federal and\nlocal financial participation shall be the same as that which would have\noccurred if a final determination of eligibility for medical assistance\nhad been made prior to the provision of the services provided during the\nperiod of presumptive eligibility. In instances where an individual who\nis presumed eligible for medical assistance is subsequently determined\nto be ineligible, the cost for services provided to such individual\nshall be reimbursed in accordance with the provisions of section three\nhundred sixty-eight-a of this article. Provided, however, if upon audit\nthe department determines that there are subsequent determinations of\nineligibility for medical assistance in at least fifteen percent of the\ncases in which presumptive eligibility has been granted in a local\nsocial services district, payments for services provided to all persons\npresumed eligible and subsequently determined ineligible for medical\nassistance shall be divided equally by the state and the district.\n 3. On or before March thirty-first, nineteen hundred ninety-seven, the\ndepartment shall submit to the governor and legislature an evaluation of\nthe program, including the program's effects on access, quality and cost\nof care, and any recommendations for future modifications to improve the\nprogram.\n 4. (a) Notwithstanding any inconsistent provision of law to the\ncontrary, a child shall be presumed to be eligible for medical\nassistance under this title beginning on the date that a qualified\nentity, as defined in paragraph (c) of this subdivision, determine, on\nthe basis of preliminary information, that the MAGI household income of\nthe child does not exceed the applicable level for eligibility as\nprovided for pursuant to subparagraph two or three of paragraph (b) of\nsubdivision one of section three hundred sixty-six of this title.\n (b) Such presumptive eligibility shall continue through the earlier of\nthe day on which eligibility is determined pursuant to this title, or in\nthe case of a child on whose behalf an application is not filed by the\nlast day of the month following the month during which the qualified\nentity makes a preliminary determination, the last day of the month\nfollowing the month in which the qualified entity makes a determination\nin paragraph (a) of this subdivision.\n (c) For the purposes of this subdivision, and consistent with the\napplicable provisions of section 1920A of the federal social security\nact, "qualified entity" means an entity determined by the department of\nhealth to be capable of making presumptive eligibility determinations.\n (d) Notwithstanding any inconsistent provision of law to the contrary,\ncare, services and supplies, as set forth in section three hundred\nsixty-five-a of this title, that are furnished to a child during a\npresumptive eligibility period by an entity that is eligible for\npayments under this title shall be deemed to be medical assistance for\npurposes of payment and state and federal reimbursement.\n (e) Presumptive eligibility pursuant to this subdivision shall be\nimplemented effective December first, two thousand seven contingent upon\na determination by the commissioner of health that all necessary systems\nand processes are in place to enroll children appropriately in\naccordance with the requirements set forth in this title; provided,\nhowever, presumptive eligibility pursuant to this subdivision shall be\nimplemented no later than April first, two thousand eight.\n 5. Persons in need of treatment for breast, cervical, colon or\nprostate cancer; presumptive eligibility. (a) An individual shall be\npresumed to be eligible for medical assistance under this title\nbeginning on the date that a qualified entity, as defined in paragraph\n(c) of this subdivision, determines, on the basis of preliminary\ninformation, that the individual meets the requirements of paragraph (d)\nor (e) of subdivision four of section three hundred sixty-six of this\ntitle.\n (b) Such presumptive eligibility shall continue through the earlier of\nthe day on which a determination is made with respect to the eligibility\nof such individual for services, or in the case of such an individual\nwho does not file an application by the last day of the month following\nthe month during which the qualified entity makes the determination of\npresumptive eligibility, such last day.\n (c) For the purposes of this subdivision, "qualified entity" means an\nentity that provides medical assistance approved under this title, and\nis determined by the department of health to be capable of making\ndeterminations of presumptive eligibility under this subdivision.\n (d) Care, services and supplies, as set forth in section three hundred\nsixty-five-a of this title, that are furnished to an individual during a\npresumptive eligibility period under this subdivision by an entity that\nis eligible for payments under this title shall be deemed to be medical\nassistance for purposes of payment and state reimbursement.\n 6. (a) A pregnant woman shall be presumed to be eligible for medical\nassistance under this title, excluding inpatient services and\ninstitutional long term care, beginning on the date that a prenatal care\nprovider, licensed under article twenty-eight of the public health law\nor other prenatal care provider approved by the department of health\ndetermines, on the basis of preliminary information, that the pregnant\nwoman's MAGI household income does not exceed the MAGI-equivalent of two\nhundred percent of the federal poverty line for the applicable family\nsize.\n (a-2) At the time of application for presumptive eligibility pursuant\nto this subdivision, a pregnant woman who resides in a social services\ndistrict that has implemented the state's managed care program pursuant\nto section three hundred sixty-four-j of this title must choose a\nmanaged care provider. If a managed care provider is not chosen at the\ntime of application, the pregnant woman will be assigned to a managed\ncare provider in accordance with subparagraphs (ii), (iii), (iv) and (v)\nof paragraph (f) of subdivision four of section three hundred\nsixty-four-j of this title.\n (b) Such presumptive eligibility shall continue through the earlier\nof: the day on which eligibility is determined pursuant to this title;\nor the last day of the month following the month in which the provider\nmakes preliminary determination, in the case of a pregnant woman who\ndoes not file an application for medical assistance on or before such\nday.\n (c) The department of health shall provide prenatal care providers\nlicensed under article twenty-eight of the public health law and other\napproved prenatal care providers with such forms as are necessary for a\npregnant woman to apply and information on how to assist such women in\ncompleting and filing such forms. A qualified provider which determines\nthat a pregnant woman is presumptively eligible shall notify the social\nservices district in which the pregnant woman resides of the\ndetermination within five working days after the date on which such\ndetermination is made and shall inform the woman at the time the\ndetermination is made that she is required to make application by the\nlast day of the month following the month in which the determination is\nmade.\n (d) Notwithstanding any other provision of law, care that is furnished\nto a pregnant woman pursuant to this subdivision during a presumptive\neligibility period shall be deemed as medical assistance for purposes of\npayment and state reimbursement.\n (e) Facilities licensed under article twenty-eight of the public\nhealth law providing prenatal care services shall perform presumptive\neligibility determinations and assist women in submitting appropriate\ndocumentation to the social services district as required by the\ncommissioner; provided, however, that a facility may apply to the\ncommissioner for exemption from this requirement on the basis of undue\nhardship.\n (f) All prenatal care providers enrolled in the medicaid program must\nprovide prenatal care services to eligible service recipients determined\npresumptively eligible for medical assistance but not yet enrolled in\nthe medical assistance program, and assist women in submitting\nappropriate documentation to the social services district as required by\nthe commissioner.\n 7. Notwithstanding any other section of law, where care, services, or\nsupplies are received prior to the date an individual is determined\neligible for assistance under this title, medical assistance\nreimbursement, regardless of funding source, shall be available for such\ncare, services, or supplies only (a) if the care, services, or supplies\nare received during the three month period preceding the month of\napplication for medical assistance and the recipient is determined to\nhave been eligible in the month in which the care, service, or supply\nwas received, or (b) if provided during a period of presumptive\neligibility pursuant to this section.\n 8. (a) The following individuals shall be presumed to be eligible for\nmedical assistance under this title beginning on the date that a\nqualified hospital, as defined in paragraph (b) of this subdivision,\ndetermines, on the basis of preliminary information, that:\n (1) a child has MAGI household income that does not exceed the\napplicable level for eligibility as provided for pursuant to\nsubparagraph two or three of paragraph (b) of subdivision one of section\nthree hundred sixty-six of this title;\n (2) a pregnant woman has MAGI household income that does not exceed\nthe MAGI-equivalent of two hundred percent of the federal poverty line\nfor the applicable family size;\n (3) a parent or caretaker relative has MAGI household income that does\nnot exceed the MAGI-equivalent of one hundred thirty percent of the\nhighest amount that ordinarily would have been paid to a person without\nany income or resources under the family assistance program as it\nexisted on the first day of November, nineteen hundred ninety-seven, or\nhas net available income, including available support from responsible\nrelatives, that does not exceed the amounts set forth in paragraph (a)\nof subdivision two of section three hundred sixty-six of this title;\n (4) an individual in need of treatment of breast, cervical, colon, or\nprostate cancer meets the requirements of paragraph (d) or (e) of\nsubdivision four of section three hundred sixty-six of this title;\n (5) an individual age nineteen or older and under age sixty-five meets\nthe requirements of subparagraph one of paragraph (b) of subdivision one\nof section three hundred sixty-six of this title;\n (6) an individual under twenty-six years of age meets the requirements\nof subparagraph nine of paragraph (c) of subdivision one of section\nthree hundred sixty-six of this title; and\n (7) an individual has income that does not exceed the MAGI-equivalent\nof two hundred percent of the federal poverty line for the applicable\nfamily size, and the individual meets the requirements of subparagraph\nsix of paragraph (b) of subdivision one of section three hundred\nsixty-six of this title; coverage pursuant to this subparagraph shall be\nlimited to family planning services reimbursed by the federal government\nat a rate of ninety percent.\n (b) For the purposes of this subdivision, "qualified hospital" means a\nhospital that:\n (1) is licensed as a general hospital under article twenty-eight of\nthe public health law;\n (2) is enrolled as a provider in the program of medical assistance\nunder this title;\n (3) has notified the department of health of its election to make\npresumptive eligibility determinations under this subdivision, and\nagrees to make such determinations in accordance with policies and\nprocedures established by the department;\n (4) has been designated by the department of health as a certified\napplication counselor to provide information to individuals concerning\nqualified health plans offered through a health insurance exchange and\nother insurance affordability programs, assist individuals to apply for\ncoverage through a qualified health plan or insurance affordability\nprogram, and help facilitate the enrollment of eligible individuals in\nsuch plans or programs; and\n (5) has not been disqualified by the department of health pursuant to\nparagraph (c) of this subdivision.\n (c) The department of health may disqualify a hospital as a qualified\nhospital if the department determines that the hospital is not:\n (1) making, or is not capable of making, presumptive eligibility\ndeterminations in accordance with the policies and procedures\nestablished by the department; or\n (2) meeting such standards as may be established by the department\nwith respect to the proportion of individuals determined presumptively\neligible by the hospital who are found by the medical assistance program\nto be eligible for ongoing medical assistance after the end of the\npresumptive eligibility period.\n (d) Care, services and supplies, as set forth in section three hundred\nsixty-five-a of this title, that are furnished to an individual during a\npresumptive eligibility period under this subdivision by an entity that\nis eligible for payments under this title shall be deemed to be medical\nassistance for purposes of payment and state reimbursement.\n