N.Y. Social Services Law § 364-i: 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. Persons in need of treatment for breast, cervical, colon or

prostate cancer; presumptive eligibility. (a) An individual 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 individual meets the requirements of paragraph (d)

or (e) 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 a determination is made with respect to the eligibility

of such individual for services, or in the case of such an individual

who does not file an application by the last day of the month following

the month during which the qualified entity makes the determination of

presumptive eligibility, such last day.

(c) For the purposes of this subdivision, "qualified entity" means an

entity that provides medical assistance approved under this title, and

is determined by the department of health to be capable of making

determinations of presumptive eligibility under this subdivision.

(d) Care, services and supplies, as set forth in section three hundred

sixty-five-a of this title, that are furnished to an individual during a

presumptive eligibility period under this subdivision by an entity that

is eligible for payments under this title shall be deemed to be medical

assistance for purposes of payment and state reimbursement.

5. (a) A pregnant woman shall be presumed to be eligible for medical

assistance under this title, excluding inpatient services and

institutional long term care, beginning on the date that a prenatal care

provider, licensed under article twenty-eight of the public health law

or other prenatal care provider approved by the department of health

determines, on the basis of preliminary information, that the pregnant

woman's MAGI household income does not exceed the MAGI-equivalent of two

hundred percent of the federal poverty line for the applicable family

size.

(a-2) At the time of application for presumptive eligibility pursuant

to this subdivision, a pregnant woman who resides in a social services

district that has implemented the state's managed care program pursuant

to section three hundred sixty-four-j of this title must choose a

managed care provider. If a managed care provider is not chosen at the

time of application, the pregnant woman will be assigned to a managed

care provider in accordance with subparagraphs (ii), (iii), (iv) and (v)

of paragraph (f) of subdivision four of section three hundred

sixty-four-j 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 the last day of the month following the month in which the provider

makes preliminary determination, in the case of a pregnant woman who

does not file an application for medical assistance on or before such

day.

(c) The department of health shall provide prenatal care providers

licensed under article twenty-eight of the public health law and other

approved prenatal care providers with such forms as are necessary for a

pregnant woman to apply and information on how to assist such women in

completing and filing such forms. A qualified provider which determines

that a pregnant woman is presumptively eligible shall notify the social

services district in which the pregnant woman resides of the

determination within five working days after the date on which such

determination is made and shall inform the woman at the time the

determination is made that she is required to make application by the

last day of the month following the month in which the determination is

made.

(d) Notwithstanding any other provision of law, care that is furnished

to a pregnant woman pursuant to this subdivision during a presumptive

eligibility period shall be deemed as medical assistance for purposes of

payment and state reimbursement.

(e) Facilities licensed under article twenty-eight of the public

health law providing prenatal care services shall perform presumptive

eligibility determinations and assist women in submitting appropriate

documentation to the social services district as required by the

commissioner; provided, however, that a facility may apply to the

commissioner for exemption from this requirement on the basis of undue

hardship.

(f) All prenatal care providers enrolled in the medicaid program must

provide prenatal care services to eligible service recipients determined

presumptively eligible for medical assistance but not yet enrolled in

the medical assistance program, and assist women in submitting

appropriate documentation to the social services district as required by

the commissioner.

6. Notwithstanding any other section of law, where care, services, or

supplies are received prior to the date an individual is determined

eligible for assistance under this title, medical assistance

reimbursement, regardless of funding source, shall be available for such

care, services, or supplies only (a) if the care, services, or supplies

are received during the three month period preceding the month of

application for medical assistance and the recipient is determined to

have been eligible in the month in which the care, service, or supply

was received, or (b) if provided during a period of presumptive

eligibility pursuant to this section.

7. (a) The following individuals shall be presumed to be eligible for

medical assistance under this title beginning on the date that a

qualified hospital, as defined in paragraph (b) of this subdivision,

determines, on the basis of preliminary information, that:

(1) a child has MAGI household income that does not exceed the

applicable level for eligibility as provided for pursuant to

subparagraph two or three of paragraph (b) of subdivision one of section

three hundred sixty-six of this title;

(2) a pregnant woman has MAGI household income that does not exceed

the MAGI-equivalent of two hundred percent of the federal poverty line

for the applicable family size;

(3) a parent or caretaker relative has MAGI household income that does

not exceed the MAGI-equivalent of one hundred thirty percent of the

highest amount that ordinarily would have been paid to a person without

any income or resources under the family assistance program as it

existed on the first day of November, nineteen hundred ninety-seven, or

has net available income, including available support from responsible

relatives, that does not exceed the amounts set forth in paragraph (a)

of subdivision two of section three hundred sixty-six of this title;

(4) an individual in need of treatment of breast, cervical, colon, or

prostate cancer meets the requirements of paragraph (d) or (e) of

subdivision four of section three hundred sixty-six of this title;

(5) an individual age nineteen or older and under age sixty-five meets

the requirements of subparagraph one of paragraph (b) of subdivision one

of section three hundred sixty-six of this title;

(6) an individual under twenty-six years of age meets the requirements

of subparagraph nine of paragraph (c) of subdivision one of section

three hundred sixty-six of this title; and

(7) an individual has income that does not exceed the MAGI-equivalent

of two hundred percent of the federal poverty line for the applicable

family size, and the individual meets the requirements of subparagraph

six of paragraph (b) of subdivision one of section three hundred

sixty-six of this title; coverage pursuant to this subparagraph shall be

limited to family planning services reimbursed by the federal government

at a rate of ninety percent.

(b) For the purposes of this subdivision, "qualified hospital" means a

hospital that:

(1) is licensed as a general hospital under article twenty-eight of

the public health law;

(2) is enrolled as a provider in the program of medical assistance

under this title;

(3) has notified the department of health of its election to make

presumptive eligibility determinations under this subdivision, and

agrees to make such determinations in accordance with policies and

procedures established by the department;

(4) has been designated by the department of health as a certified

application counselor to provide information to individuals concerning

qualified health plans offered through a health insurance exchange and

other insurance affordability programs, assist individuals to apply for

coverage through a qualified health plan or insurance affordability

program, and help facilitate the enrollment of eligible individuals in

such plans or programs; and

(5) has not been disqualified by the department of health pursuant to

paragraph (c) of this subdivision.

(c) The department of health may disqualify a hospital as a qualified

hospital if the department determines that the hospital is not:

(1) making, or is not capable of making, presumptive eligibility

determinations in accordance with the policies and procedures

established by the department; or

(2) meeting such standards as may be established by the department

with respect to the proportion of individuals determined presumptively

eligible by the hospital who are found by the medical assistance program

to be eligible for ongoing medical assistance after the end of the

presumptive eligibility period.

(d) Care, services and supplies, as set forth in section three hundred

sixty-five-a of this title, that are furnished to an individual during a

presumptive eligibility period under this subdivision by an entity that

is eligible for payments under this title shall be deemed to be medical

assistance for purposes of payment and state reimbursement.