§ 366-A — Applications for assistance; investigations; reconsideration

§ 366-a. Applications for assistance; investigations; reconsideration.\n1. Any person requesting medical assistance may make application\ntherefor by a written application to the social services official of the\ncounty in which the applicant resides or is found or to the department\nof health or its agent; a phone application; or an on-line application.\nNotwithstanding any provision of law to the contrary, an in-person\ninterview with the applicant or with the person who made application on\nhis or her behalf shall not be required as part of a determination of\ninitial or continuing eligibility pursuant to this title.\n 1-a. Every person making application for medical assistance, and every\nperson on whose behalf an application is made, shall, if interested, be\ngiven the New York state department of health model health care proxy\nform by the person taking the application, except where doing so would\nimpede the immediate provision of health care services.\n 2. (a) Upon receipt of such application, the appropriate social\nservices official, or the department of health or its agent shall verify\nthe eligibility of such applicant. In accordance with the regulations of\nthe department of health, it shall be the responsibility of the\napplicant to provide information and documentation necessary for the\ndetermination of initial and ongoing eligibility for medical assistance.\nIf an applicant or recipient is unable to provide necessary\ndocumentation, the social services official or the department of health\nor its agent shall promptly cause an investigation to be made. Where an\ninvestigation is necessary, sources of information other than public\nrecords will be consulted only with permission of the applicant or\nrecipient. In the event that such permission is not granted by the\napplicant or recipient, or necessary documentation cannot be obtained,\nthe social services official or the department of health or its agent\nmay suspend or deny medical assistance until such time as it may be\nsatisfied as to the applicant's or recipient's eligibility therefor.\n (b) Notwithstanding the provisions of paragraph (a) of this\nsubdivision, an applicant or recipient may attest to the amount of his\nor her accumulated resources, unless such applicant or recipient is\nseeking medical assistance payment for long term care services. For\npurposes of this paragraph, long term care services shall mean care,\ntreatment, maintenance, and services described in paragraph (b) of\nsubdivision 1 of section three hundred sixty-seven-f of this title, with\nthe exception of short term rehabilitation, as defined by the\ncommissioner of health.\n (c) Notwithstanding the provisions of paragraph (a) of this\nsubdivision, an applicant or recipient providing written documentation\nof income eligibility of a child for free or reduced breakfast or lunch\nthrough the school meal program certified by the child's school shall\nmeet the evidentiary requirement necessary to document income.\n * (d) Notwithstanding the provisions of paragraph (a) of this\nsubdivision, an applicant or recipient whose eligibility under this\ntitle is determined without regard to the amount of his or her\naccumulated resources may attest to the amount of interest income\ngenerated by such resources if the amount of such interest income is\nexpected to be immaterial to medical assistance eligibility, as\ndetermined by the commissioner of health. In the event there is an\ninconsistency between the information reported by the applicant or\nrecipient and any information obtained by the commissioner of health\nfrom other sources and such inconsistency is material to medical\nassistance eligibility, the commissioner of health shall request that\nthe applicant or recipient provide adequate documentation to verify his\nor her interest income.\n * NB There are 2 par (d)'s\n * (d) The commissioner of health may verify the accuracy of the\ninformation provided by the applicant or recipient pursuant to\nparagraphs (b) and (c) of this subdivision, by matching it against\ninformation to which the commissioner of health has access, including\nunder subdivision eight of this section. In the event there is an\ninconsistency between the information reported by the applicant or\nrecipient and any information obtained by the commissioner of health\nfrom other sources and such inconsistency is material to medical\nassistance eligibility, the commissioner of health shall request that\nthe applicant or recipient provide adequate documentation to verify his\nor her resources.\n * NB There are 2 par (d)'s\n 3. Upon the receipt of such application, and after the completion of\nany investigation that shall be deemed necessary, the appropriate social\nservices official or the department of health or its agent shall\n (a) decide whether the applicant is eligible for and should receive\nmedical assistance, the amount thereof and the date on which it shall\nbegin, which shall be the date of the application or, subject to\napplicable department regulations, such earlier or later date as may be\ndeemed reasonable;\n (b) notify the applicant in writing of the decision, and where such\napplicant is found eligible, provide a tamper resistant identification\ncard containing a photo image of the applicant for use in securing\nmedical assistance under this title provided, however, that an\nidentification card need not contain a photo image of a person other\nthan an adult member of an eligible household or a single-person\neligible household. The department is not required to provide, but shall\nseek practical methods for providing, a card with such picture to a\nperson when such person is homebound or is a resident of a residential\nhealth care facility, or an in-patient psychiatric facility, or is\nexpected to remain hospitalized for an extended period. The commissioner\nshall have the authority to define categories of recipients who are not\nrequired to have a photo identification card where such card would be\nlimited, unnecessary or impracticable.\n (c) with respect to a person determined eligible for assistance under\nthis title by the federal social security administration under an\nagreement between the department and the secretary of health, education\nand welfare pursuant to section three hundred sixty-three-b of this\ntitle issue a medical assistance identification card which shall be\nvalid for periods determined by the local social services official, but\nnot to exceed six months.\n 4. Every applicant or recipient shall promptly advise the public\nwelfare district of any change in his financial condition or income,\nnumber of wage earners and members in the family unit on such forms and\nin such manner as the department by regulation may prescribe. In the\nevent that any applicant or recipient shall no longer be eligible for\nmedical assistance, he shall promptly return his identification card\nissued pursuant to the provisions of this article to the public welfare\ndistrict.\n 5. (a) All continuing assistance under this title shall be\nreconsidered from time to time, or as frequently as may be required by\nthe regulations of the department. After such further investigation as\nthe social services official may deem necessary or the department may\nrequire, the assistance may be modified or withdrawn if it is found that\nthe recipient's circumstances have changed sufficiently to warrant such\naction. The assistance may be cancelled for cause, and payment thereof\nmay be suspended for cause for such periods as may be deemed necessary,\nsubject to review by the department as provided in section twenty-two of\nthis chapter.\n (b) The commissioner shall develop a simplified statewide\nrecertification form for use in redetermining eligibility under this\ntitle. The form may include requests only for such information that is:\n (i) reasonably necessary to determine continued eligibility for\nmedical assistance under this title; and\n (ii) subject to change since the date of the recipient's initial\napplication.\n (c) The regulations required by paragraph (a) of this subdivision\nshall provide that:\n (i) the redetermination of eligibility will be made based on reliable\ninformation possessed or available to the department of health or its\nagent, including information accessed from databases pursuant to\nsubdivision eight of this section;\n (ii) if the department of health or its agent is unable to renew\neligibility based on available information, the recipient will be\nrequested to supply any such information as is necessary to determine\ncontinued eligibility for medical assistance under this title; and\n (iii) for persons whose medical assistance eligibility is based on\nmodified adjusted gross income, eligibility must be renewed at least\nonce every twelve months, unless the department of health or its agent\nreceives information about a change in a recipient's circumstances that\nmay affect eligibility.\n * (d) An in-person interview with the recipient shall not\nautomatically be required as part of a redetermination of eligibility\npursuant to this subdivision unless the department of health determines\notherwise.\n * NB There are 2 par (d)'s\n * (d) The commissioner of health shall verify the accuracy of the\ninformation provided by an applicant or recipient by matching it against\ninformation to which the commissioner of health has access, including\nunder subdivision eight of this section. In the event the information\nreported by the recipient is not reasonably compatible with any\ninformation obtained by the commissioner of health from other sources\nand such incompatibility is material to medical assistance eligibility,\nthe commissioner of health shall request that the recipient provide\nadequate documentation to verify his or her place of residence or\nincome, as applicable. In addition to the documentation of residence and\nincome authorized by this paragraph, the commissioner of health is\nauthorized to periodically require a reasonable sample of recipients to\nprovide documentation of residence and income at recertification. The\ncommissioner of health shall consult with the medicaid inspector general\nregarding income and residence verification practices and procedures\nnecessary to maintain program integrity and deter fraud and abuse.\n * NB There are 2 par (d)'s\n 6. Notwithstanding any other provisions of this chapter or other law,\nthe investigations, decisions and actions required to be made or taken\nby a public welfare official pursuant to this section shall be made or\ntaken only by the chief executive officer of the public welfare\ndepartment of a public welfare district, or by an employee of such\nwelfare department designated by such chief executive officer.\n 7. Local social services districts shall be authorized, with the\napproval of the department, to station local social services employees\nat federal social security offices for the purpose of providing\ninformation and referral services relating to medical assistance to\neligible persons.\n 8. (a) Notwithstanding subdivisions two and five of this section,\ninformation concerning income and resources of applicants for and\nrecipients of medical assistance may be verified by matching client\ninformation with information contained in the wage reporting system\nestablished by section one hundred seventy-one-a of the tax law and in\nsimilar systems operating in other geographically contiguous states, by\nmeans of an income verification performed pursuant to a memorandum of\nunderstanding with the department of taxation and finance pursuant to\nsubdivision four of section one hundred seventy-one-b of the tax law,\nand, to the extent required by federal law, with information contained\nin the non-wage income file maintained by the United States internal\nrevenue service, in the beneficiary data exchange maintained by the\nUnited States department of health and human services, and in the\nunemployment insurance benefits file. Such matching shall provide for\nprocedures which document significant inconsistent results of matching\nactivities. Nothing in this section shall be construed to prohibit\nactivities the department reasonably believes necessary to conform with\nfederal requirements under section one thousand one hundred thirty-seven\nof the social security act.\n (b) Any verification response by the department of taxation and\nfinance pursuant to paragraph (a) of this subdivision shall not be a\npublic record and shall not be released except pursuant to this\nparagraph. Information disclosed pursuant to this paragraph shall be\nlimited to information necessary for verification. Information so\ndisclosed shall be kept confidential by the party receiving such\ninformation. Such information shall be expunged within a reasonable time\nto be determined by the commissioner and the department of taxation and\nfinance.\n 9. (a) Every applicant for or recipient of medical assistance who has\ndependent children shall be informed in writing at the time of\napplication and at the time of any action affecting his or her receipt\nof such assistance of the availability of:\n (i) medical assistance without cash assistance under this title;\n (ii) transitional medical assistance under paragraphs (a), (b) and (c)\nof subdivision four of section three hundred sixty-six of this title;\n (iii) the expanded eligibility provisions for pregnant women and\nchildren under paragraphs (m), (n), (o), (p) and (q), (s) and (t) of\nsubdivision four of section three hundred sixty-six of this title;\n (iv) medical assistance for aged, blind or disabled persons under\nsubdivision one of section three hundred sixty-six of this title;\n (v) family health plus under section three hundred sixty-nine-ee of\nthis article; and,\n (vi) child health plus under title one-A of article twenty-five of the\npublic health law.\n (b) Every applicant for or recipient of medical assistance who has no\ndependent children shall be informed in writing at the time of\napplication and at the time of any action affecting his or her receipt\nof such assistance of the availability of:\n (i) medical assistance without cash assistance under this title;\n (ii) the expanded eligibility provisions for pregnant women under\nparagraphs (m) and (o) of subdivision four of section three hundred\nsixty-six of this title;\n (iii) medical assistance for aged, blind or disabled persons under\nsubdivision one of section three hundred sixty-six of this title; and,\n (iv) family health plus under section three hundred sixty-nine-ee of\nthis article.\n (10) As a condition for the provision of medical assistance for\nnursing facility services, the application of an individual for such\nassistance, including any recertification of eligibility for such\nassistance, shall disclose a description of any interest the individual\nor community spouse has in an annuity or similar financial instrument,\nregardless of whether the annuity is irrevocable or is treated as an\nasset. Such application or recertification form shall include a\nstatement that the state of New York becomes a remainder beneficiary\nunder such annuity or similar financial instrument by virtue of the\nprovision of such medical assistance.\n 11. (a) Notwithstanding any inconsistent provision of law, rule or\nregulation, the commissioner of health is authorized to (i) establish\nstandards and procedures for express lane enrollment and renewal\nimplemented in accordance with section 1902(e)(13) of the federal social\nsecurity act, including but not limited to reliance on a finding made by\nan express lane agency, as defined in section 1902(e)(13)(F) and (H) of\nthe federal social security act, to determine whether a child meets one\nor more of the eligibility criteria for medical assistance; (ii) specify\nsuch standards and procedures in the medical assistance state plan\nestablished under title XIX of the federal social security act; and\n(iii) waive any information and documentation requirements set forth in\nthis section necessary to implement express lane eligibility; provided,\nhowever, information and documentation required pursuant to section one\nhundred twenty-two of this chapter may not be waived.\n (b) Subject to federal approval, such standards and procedures shall\nspecify that information and documentation regarding citizenship and\nimmigration status collected by an express lane agency and provided to\nthe commissioner for the purpose of express lane eligibility may be used\nto satisfy the requirements of section one hundred twenty-two of this\nchapter.\n (c) Such standards and procedures shall also include a process for\ndetermining enrollment error rates and implementing corrective actions\nas required by section 1902(e)(13)(E) of the federal social security\nact.\n (d) For purposes of a medical assistance eligibility determination\nmade in accordance with this subdivision, a child shall be deemed to\nsatisfy the income eligibility criteria for medical assistance if an\nexpress lane agency, as defined in section 1902(e)(13)(F) and (H) of the\nfederal social security act and specified in the standards and\nprocedures established pursuant to paragraph (a) of this subdivision,\nhas determined that: the child's family has income that does not exceed\na screening threshold amount, as determined by the commissioner of\nhealth, equal to a percentage of the federal poverty line (as defined\nand annually revised by the United States department of health and human\nservices) that exceeds by thirty percentage points the highest income\neligibility level applicable to a family of the same size under the\nmedical assistance program.\n 12. The commissioner shall develop expedited procedures for\ndetermining medical assistance eligibility for any medical assistance\napplicant with an immediate need for personal care or consumer directed\npersonal assistance services pursuant to paragraph (e) of subdivision\ntwo of section three hundred sixty-five-a of this title or section three\nhundred sixty-five-f of this title, respectively. Such procedures shall\nrequire that a final eligibility determination be made within seven days\nof the date of a complete medical assistance application.\n