N.Y. Social Services Law § 366-a: Applications for assistance; investigations; reconsideration

§ 366-a. Applications for assistance; investigations; reconsideration.

1. Any person requesting medical assistance may make application

therefor by a written application to the social services official of the

county in which the applicant resides or is found or to the department

of health or its agent; a phone application; or an on-line application.

Notwithstanding any provision of law to the contrary, an in-person

interview with the applicant or with the person who made application on

his or her behalf shall not be required as part of a determination of

initial or continuing eligibility pursuant to this title.

1-a. Every person making application for medical assistance, and every

person on whose behalf an application is made, shall, if interested, be

given the New York state department of health model health care proxy

form by the person taking the application, except where doing so would

impede the immediate provision of health care services.

2. (a) Upon receipt of such application, the appropriate social

services official, or the department of health or its agent shall verify

the eligibility of such applicant. In accordance with the regulations of

the department of health, it shall be the responsibility of the

applicant to provide information and documentation necessary for the

determination of initial and ongoing eligibility for medical assistance.

If an applicant or recipient is unable to provide necessary

documentation, the social services official or the department of health

or its agent shall promptly cause an investigation to be made. Where an

investigation is necessary, sources of information other than public

records will be consulted only with permission of the applicant or

recipient. In the event that such permission is not granted by the

applicant or recipient, or necessary documentation cannot be obtained,

the social services official or the department of health or its agent

may suspend or deny medical assistance until such time as it may be

satisfied as to the applicant's or recipient's eligibility therefor.

(b) Notwithstanding the provisions of paragraph (a) of this

subdivision, an applicant or recipient may attest to the amount of his

or her accumulated resources, unless such applicant or recipient is

seeking medical assistance payment for long term care services. For

purposes of this paragraph, long term care services shall mean care,

treatment, maintenance, and services described in paragraph (b) of

subdivision 1 of section three hundred sixty-seven-f of this title, with

the exception of short term rehabilitation, as defined by the

commissioner of health.

(c) Notwithstanding the provisions of paragraph (a) of this

subdivision, an applicant or recipient providing written documentation

of income eligibility of a child for free or reduced breakfast or lunch

through the school meal program certified by the child's school shall

meet the evidentiary requirement necessary to document income.

* (d) Notwithstanding the provisions of paragraph (a) of this

subdivision, an applicant or recipient whose eligibility under this

title is determined without regard to the amount of his or her

accumulated resources may attest to the amount of interest income

generated by such resources if the amount of such interest income is

expected to be immaterial to medical assistance eligibility, as

determined by the commissioner of health. In the event there is an

inconsistency between the information reported by the applicant or

recipient and any information obtained by the commissioner of health

from other sources and such inconsistency is material to medical

assistance eligibility, the commissioner of health shall request that

the applicant or recipient provide adequate documentation to verify his

or her interest income.

* NB There are 2 par (d)'s

* (d) The commissioner of health may verify the accuracy of the

information provided by the applicant or recipient pursuant to

paragraphs (b) and (c) of this subdivision, by matching it against

information to which the commissioner of health has access, including

under subdivision eight of this section. In the event there is an

inconsistency between the information reported by the applicant or

recipient and any information obtained by the commissioner of health

from other sources and such inconsistency is material to medical

assistance eligibility, the commissioner of health shall request that

the applicant or recipient provide adequate documentation to verify his

or her resources.

* NB There are 2 par (d)'s

3. Upon the receipt of such application, and after the completion of

any investigation that shall be deemed necessary, the appropriate social

services official or the department of health or its agent shall

(a) decide whether the applicant is eligible for and should receive

medical assistance, the amount thereof and the date on which it shall

begin, which shall be the date of the application or, subject to

applicable department regulations, such earlier or later date as may be

deemed reasonable;

(b) notify the applicant in writing of the decision, and where such

applicant is found eligible, provide a tamper resistant identification

card containing a photo image of the applicant for use in securing

medical assistance under this title provided, however, that an

identification card need not contain a photo image of a person other

than an adult member of an eligible household or a single-person

eligible household. The department is not required to provide, but shall

seek practical methods for providing, a card with such picture to a

person when such person is homebound or is a resident of a residential

health care facility, or an in-patient psychiatric facility, or is

expected to remain hospitalized for an extended period. The commissioner

shall have the authority to define categories of recipients who are not

required to have a photo identification card where such card would be

limited, unnecessary or impracticable.

(c) with respect to a person determined eligible for assistance under

this title by the federal social security administration under an

agreement between the department and the secretary of health, education

and welfare pursuant to section three hundred sixty-three-b of this

title issue a medical assistance identification card which shall be

valid for periods determined by the local social services official, but

not to exceed six months.

4. Every applicant or recipient shall promptly advise the public

welfare district of any change in his financial condition or income,

number of wage earners and members in the family unit on such forms and

in such manner as the department by regulation may prescribe. In the

event that any applicant or recipient shall no longer be eligible for

medical assistance, he shall promptly return his identification card

issued pursuant to the provisions of this article to the public welfare

district.

5. (a) All continuing assistance under this title shall be

reconsidered from time to time, or as frequently as may be required by

the regulations of the department. After such further investigation as

the social services official may deem necessary or the department may

require, the assistance may be modified or withdrawn if it is found that

the recipient's circumstances have changed sufficiently to warrant such

action. The assistance may be cancelled for cause, and payment thereof

may be suspended for cause for such periods as may be deemed necessary,

subject to review by the department as provided in section twenty-two of

this chapter.

(b) The commissioner shall develop a simplified statewide

recertification form for use in redetermining eligibility under this

title. The form may include requests only for such information that is:

(i) reasonably necessary to determine continued eligibility for

medical assistance under this title; and

(ii) subject to change since the date of the recipient's initial

application.

(c) The regulations required by paragraph (a) of this subdivision

shall provide that:

(i) the redetermination of eligibility will be made based on reliable

information possessed or available to the department of health or its

agent, including information accessed from databases pursuant to

subdivision eight of this section;

(ii) if the department of health or its agent is unable to renew

eligibility based on available information, the recipient will be

requested to supply any such information as is necessary to determine

continued eligibility for medical assistance under this title; and

(iii) for persons whose medical assistance eligibility is based on

modified adjusted gross income, eligibility must be renewed at least

once every twelve months, unless the department of health or its agent

receives information about a change in a recipient's circumstances that

may affect eligibility.

* (d) An in-person interview with the recipient shall not

automatically be required as part of a redetermination of eligibility

pursuant to this subdivision unless the department of health determines

otherwise.

* NB There are 2 par (d)'s

* (d) The commissioner of health shall verify the accuracy of the

information provided by an applicant or recipient by matching it against

information to which the commissioner of health has access, including

under subdivision eight of this section. In the event the information

reported by the recipient is not reasonably compatible with any

information obtained by the commissioner of health from other sources

and such incompatibility is material to medical assistance eligibility,

the commissioner of health shall request that the recipient provide

adequate documentation to verify his or her place of residence or

income, as applicable. In addition to the documentation of residence and

income authorized by this paragraph, the commissioner of health is

authorized to periodically require a reasonable sample of recipients to

provide documentation of residence and income at recertification. The

commissioner of health shall consult with the medicaid inspector general

regarding income and residence verification practices and procedures

necessary to maintain program integrity and deter fraud and abuse.

* NB There are 2 par (d)'s

6. Notwithstanding any other provisions of this chapter or other law,

the investigations, decisions and actions required to be made or taken

by a public welfare official pursuant to this section shall be made or

taken only by the chief executive officer of the public welfare

department of a public welfare district, or by an employee of such

welfare department designated by such chief executive officer.

7. Local social services districts shall be authorized, with the

approval of the department, to station local social services employees

at federal social security offices for the purpose of providing

information and referral services relating to medical assistance to

eligible persons.

8. (a) Notwithstanding subdivisions two and five of this section,

information concerning income and resources of applicants for and

recipients of medical assistance may be verified by matching client

information with information contained in the wage reporting system

established by section one hundred seventy-one-a of the tax law and in

similar systems operating in other geographically contiguous states, by

means of an income verification performed pursuant to a memorandum of

understanding with the department of taxation and finance pursuant to

subdivision four of section one hundred seventy-one-b of the tax law,

and, to the extent required by federal law, with information contained

in the non-wage income file maintained by the United States internal

revenue service, in the beneficiary data exchange maintained by the

United States department of health and human services, and in the

unemployment insurance benefits file. Such matching shall provide for

procedures which document significant inconsistent results of matching

activities. Nothing in this section shall be construed to prohibit

activities the department reasonably believes necessary to conform with

federal requirements under section one thousand one hundred thirty-seven

of the social security act.

(b) Any verification response by the department of taxation and

finance pursuant to paragraph (a) of this subdivision shall not be a

public record and shall not be released except pursuant to this

paragraph. Information disclosed pursuant to this paragraph shall be

limited to information necessary for verification. Information so

disclosed shall be kept confidential by the party receiving such

information. Such information shall be expunged within a reasonable time

to be determined by the commissioner and the department of taxation and

finance.

9. (a) Every applicant for or recipient of medical assistance who has

dependent children shall be informed in writing at the time of

application and at the time of any action affecting his or her receipt

of such assistance of the availability of:

(i) medical assistance without cash assistance under this title;

(ii) transitional medical assistance under paragraphs (a), (b) and (c)

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

(iii) the expanded eligibility provisions for pregnant women and

children under paragraphs (m), (n), (o), (p) and (q), (s) and (t) of

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

(iv) medical assistance for aged, blind or disabled persons under

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

(v) family health plus under section three hundred sixty-nine-ee of

this article; and,

(vi) child health plus under title one-A of article twenty-five of the

public health law.

(b) Every applicant for or recipient of medical assistance who has no

dependent children shall be informed in writing at the time of

application and at the time of any action affecting his or her receipt

of such assistance of the availability of:

(i) medical assistance without cash assistance under this title;

(ii) the expanded eligibility provisions for pregnant women under

paragraphs (m) and (o) of subdivision four of section three hundred

sixty-six of this title;

(iii) medical assistance for aged, blind or disabled persons under

subdivision one of section three hundred sixty-six of this title; and,

(iv) family health plus under section three hundred sixty-nine-ee of

this article.

(10) As a condition for the provision of medical assistance for

nursing facility services, the application of an individual for such

assistance, including any recertification of eligibility for such

assistance, shall disclose a description of any interest the individual

or community spouse has in an annuity or similar financial instrument,

regardless of whether the annuity is irrevocable or is treated as an

asset. Such application or recertification form shall include a

statement that the state of New York becomes a remainder beneficiary

under such annuity or similar financial instrument by virtue of the

provision of such medical assistance.

11. (a) Notwithstanding any inconsistent provision of law, rule or

regulation, the commissioner of health is authorized to (i) establish

standards and procedures for express lane enrollment and renewal

implemented in accordance with section 1902(e)(13) of the federal social

security act, including but not limited to reliance on a finding made by

an express lane agency, as defined in section 1902(e)(13)(F) and (H) of

the federal social security act, to determine whether a child meets one

or more of the eligibility criteria for medical assistance; (ii) specify

such standards and procedures in the medical assistance state plan

established under title XIX of the federal social security act; and

(iii) waive any information and documentation requirements set forth in

this section necessary to implement express lane eligibility; provided,

however, information and documentation required pursuant to section one

hundred twenty-two of this chapter may not be waived.

(b) Subject to federal approval, such standards and procedures shall

specify that information and documentation regarding citizenship and

immigration status collected by an express lane agency and provided to

the commissioner for the purpose of express lane eligibility may be used

to satisfy the requirements of section one hundred twenty-two of this

chapter.

(c) Such standards and procedures shall also include a process for

determining enrollment error rates and implementing corrective actions

as required by section 1902(e)(13)(E) of the federal social security

act.

(d) For purposes of a medical assistance eligibility determination

made in accordance with this subdivision, a child shall be deemed to

satisfy the income eligibility criteria for medical assistance if an

express lane agency, as defined in section 1902(e)(13)(F) and (H) of the

federal social security act and specified in the standards and

procedures established pursuant to paragraph (a) of this subdivision,

has determined that: the child's family has income that does not exceed

a screening threshold amount, as determined by the commissioner of

health, equal to a percentage of the federal poverty line (as defined

and annually revised by the United States department of health and human

services) that exceeds by thirty percentage points the highest income

eligibility level applicable to a family of the same size under the

medical assistance program.

12. The commissioner shall develop expedited procedures for

determining medical assistance eligibility for any medical assistance

applicant with an immediate need for personal care or consumer directed

personal assistance services pursuant to paragraph (e) of subdivision

two of section three hundred sixty-five-a of this title or section three

hundred sixty-five-f of this title, respectively. Such procedures shall

require that a final eligibility determination be made within seven days

of the date of a complete medical assistance application.