2006 New York Code - Medical Assistance Presumptive Eligibility Program.

 
    * §  364-i.  Medical assistance presumptive eligibility program. 1. An
  individual, upon application for medical assistance, shall  be  presumed
  eligible for such assistance for a period of sixty days from the date of
  transfer  from  a  general  hospital, as defined in section twenty-eight
  hundred one of the public health law to a certified home  health  agency
  or  long term home health care program, as defined in section thirty-six
  hundred two of the public health law, or to  a  hospice  as  defined  in
  section  four thousand two of the public health law, or to a residential
  health care facility as defined in section twenty-eight hundred  one  of
  the  public  health  law,  if  the  local  department of social services
  determines that the applicant meets each of the following criteria:  (a)
  the  applicant is receiving acute care in such hospital; (b) a physician
  certifies that such applicant no longer requires  acute  hospital  care,
  but  still  requires  medical  care which can be provided by a certified
  home health agency, long term  home  health  care  program,  hospice  or
  residential   health   care   facility;   (c)   the   applicant  or  his
  representative  states  that  the  applicant  does  not  have  insurance
  coverage  for  the  required  medical  care and that such care cannot be
  afforded; (d) it reasonably appears  that  the  applicant  is  otherwise
  eligible  to  receive medical assistance; (e) it reasonably appears that
  the amount expended by the state and the local social services  district
  for medical assistance in a certified home health agency, long term home
  health care program, hospice or residential health care facility, during
  the  period  of  presumed eligibility, would be less than the amount the
  state and the local social services district would expend for  continued
  acute  hospital  care  for such person; and (f) such other determinative
  criteria as the commissioner shall provide by rule or regulation.  If  a
  person  has  been  determined  to  be presumptively eligible for medical
  assistance, pursuant to this subdivision, and is subsequently determined
  to be ineligible for such assistance, the commissioner, on behalf of the
  state and the local social services district shall have the authority to
  recoup from the individual the sums expended for such assistance  during
  the period of presumed eligibility.
    2.  Payment  for  up to sixty days of care for services provided under
  the medical assistance program shall be made for an  applicant  presumed
  eligible  for  medical  assistance  pursuant  to subdivision one of this
  section provided, however, that such payment shall not exceed sixty-five
  percent of the rate payable under this title for services provided by  a
  certified  home  health  agency,  long  term  home  health care program,
  hospice or residential health care facility. Notwithstanding  any  other
  provision  of  law,  no federal financial participation shall be claimed
  for services provided to a person while presumed  eligible  for  medical
  assistance  under  this program until such person has been determined to
  be  eligible  for  medical  assistance  by  the  local  social  services
  district.  During the period of presumed medical assistance eligibility,
  payment for services  provided  persons  presumed  eligible  under  this
  program  shall be made from state funds. Upon the final determination of
  eligibility by the local social services district, payment shall be made
  for the balance of the cost of such care and services provided  to  such
  applicant  for  such  period of eligibility and a retroactive adjustment
  shall be  made  by  the  department  to  appropriately  reflect  federal
  financial  participation  and  the local share of costs for the services
  provided during the period of presumptive eligibility. Such federal  and
  local financial participation shall be the same as that which would have
  occurred  if a final determination of eligibility for medical assistance
  had been made prior to the provision of the services provided during the
  period of presumptive eligibility. In instances where an individual  who
  is  presumed  eligible for medical assistance is subsequently determined
  to be ineligible, the cost for  services  provided  to  such  individual
  shall  be  reimbursed in accordance with the provisions of section three
  hundred sixty-eight-a of this article. Provided, however, if upon  audit
  the  department  determines  that there are subsequent determinations of
  ineligibility for medical assistance in at least fifteen percent of  the
  cases  in  which  presumptive  eligibility  has  been granted in a local
  social services district, payments for services provided to all  persons
  presumed  eligible  and  subsequently  determined ineligible for medical
  assistance shall be divided equally by the state and the district.
    3. On or before March thirty-first, nineteen hundred ninety-seven, the
  department shall submit to the governor and legislature an evaluation of
  the program, including the program's effects on access, quality and cost
  of care, and any recommendations for future modifications to improve the
  program.
    ** 4. (a) Notwithstanding any inconsistent provision  of  law  to  the
  contrary,  a  child  shall  be  presumed  to  be  eligible  for  medical
  assistance under this title beginning  on  the  date  that  a  qualified
  entity,  as defined in paragraph (c) of this subdivision, determines, on
  the basis of preliminary information, that the net household  income  of
  the  child  does  not  exceed  the  applicable  level for eligibility as
  provided for pursuant to paragraph (u) of subdivision  four  of  section
  three hundred sixty-six of this title.
    (b) Such presumptive eligibility shall continue through the earlier of
  the day on which eligibility is determined pursuant to this title, or in
  the  case  of a child on whose behalf an application is not filed by the
  last day of the month following the month  during  which  the  qualified
  entity  makes  a  preliminary  determination,  the last day of the month
  following the month in which the qualified entity makes a  determination
  in paragraph (a).
    (c)  For  the  purposes  of  this subdivision, and consistent with the
  applicable provisions of section 1920A of the  federal  social  security
  act,  "qualified entity" means an entity determined by the department of
  health to be capable of making presumptive eligibility determinations.
    (d) Notwithstanding any inconsistent provision of law to the contrary,
  care, services and supplies, as  set  forth  in  section  three  hundred
  sixty-five-a  of  this  title,  that  are  furnished to a child during a
  presumptive eligibility  period  by  an  entity  that  is  eligible  for
  payments  under  this title shall be deemed to be medical assistance for
  purposes of payment and state and federal reimbursement.
    (e) Notwithstanding any other provision of law, this section shall not
  be implemented until paragraph (t) of subdivision four of section  three
  hundred sixty-six of this title shall take effect.
    ** NB Expired April 1, 2005
    * NB Effective until July 31, 2006
    * §  364-i.  Medical assistance presumptive eligibility program. 1. An
  individual, upon application for medical assistance, shall  be  presumed
  eligible for such assistance for a period of sixty days from the date of
  transfer  from  a  general  hospital, as defined in section twenty-eight
  hundred one of the public health law to a certified home  health  agency
  or  long term home health care program, as defined in section thirty-six
  hundred two of the public health law, if the local department of  social
  services  determines  that  the  applicant  meets  each of the following
  criteria: (a) the applicant is receiving acute care  in  such  hospital;
  (b)  a  physician certifies that such applicant no longer requires acute
  hospital care, but still requires medical care which can be provided  by
  a  certified home health agency or a long term home health care program;
  (c) the applicant or his representative states that the  applicant  does
  not  have insurance coverage for the required medical care and that such
  care cannot be afforded; (d) it reasonably appears that the applicant is
  otherwise eligible to receive  medical  assistance;  (e)  it  reasonably
  appears  that  the  amount  expended  by  the state and the local social
  services  district  for  medical  assistance  in a certified home health
  agency or long term home health  care  program,  during  the  period  of
  presumed  eligibility,  would  be less than the amount the state and the
  local social services district would expend for continued acute hospital
  care for such person; and (f) such other determinative criteria  as  the
  commissioner  shall  provide by rule or regulation. If a person has been
  determined to be presumptively eligible for medical assistance, pursuant
  to this subdivision, and is subsequently determined to be ineligible for
  such assistance, the commissioner, on behalf of the state and the  local
  social  services  district  shall  have the authority to recoup from the
  individual the sums expended for such assistance during  the  period  of
  presumed eligibility.
    2.  Payment  for  up to sixty days of care for services provided under
  the medical assistance program shall be made for an  applicant  presumed
  eligible  for  medical  assistance  pursuant  to subdivision one of this
  section provided, however, that such payment shall not exceed sixty-five
  percent of the rate payable under this title for services provided by  a
  certified  home  health  agency or a long term home health care program.
  Notwithstanding  any  other  provision  of  law,  no  federal  financial
  participation  shall  be claimed for services provided to a person while
  presumed eligible for medical assistance under this program  until  such
  person  has been determined to be eligible for medical assistance by the
  local social services district. During the period  of  presumed  medical
  assistance  eligibility,  payment for services provided persons presumed
  eligible under this program shall be made from  state  funds.  Upon  the
  final   determination  of  eligibility  by  the  local  social  services
  district, payment shall be made for the balance of the cost of such care
  and services provided to such applicant for such period  of  eligibility
  and  a  retroactive  adjustment  shall  be  made  by  the  department to
  appropriately reflect federal  financial  participation  and  the  local
  share   of  costs  for  the  services  provided  during  the  period  of
  presumptive eligibility. Such federal and local financial  participation
  shall  be  the  same  as  that  which  would  have  occurred  if a final
  determination of eligibility for medical assistance had been made  prior
  to  the  provision  of  the  services  provided  during  the  period  of
  presumptive  eligibility.  In  instances  where  an  individual  who  is
  presumed  eligible  for medical assistance is subsequently determined to
  be ineligible, the cost for services provided to such  individual  shall
  be reimbursed in accordance with the provisions of section three hundred
  sixty-eight-a  of  this  article.  Provided,  however, if upon audit the
  department  determines  that  there  are  subsequent  determinations  of
  ineligibility  for medical assistance in at least fifteen percent of the
  cases in which presumptive eligibility  has  been  granted  in  a  local
  social  services district, payments for services provided to all persons
  presumed eligible and subsequently  determined  ineligible  for  medical
  assistance shall be divided equally by the state and the district.
    3.  On or before March thirty-first, nineteen hundred eighty-nine, the
  department shall submit to the governor and the legislature  an  initial
  evaluation   of   the  impact  of  the  medical  assistance  presumptive
  eligibility  program,  including  recommendations   regarding   possible
  modifications  and  on  or  before  March thirty-first, nineteen hundred
  ninety, the department shall submit to the governor  and  legislature  a
  second  evaluation of the program, including further recommendations for
  future modifications.
    * NB Effective July 31, 2006