360-2.3 Investigation of eligibility.
(a) Generally.
(1) The social services district has a
continuing obligation to collect,verify, record and evaluate factual information
concerning an MA applicant's/recipient's eligibility for MA.
(2) The MA applicant/recipient has a continuing
obligation to provide accurate and complete information on his/her income, resources, and
other factors that affect eligibility. The applicant/recipient must also provide
information on the income and resources of a non-applying legally responsible relative,
even if the relative is not living with the applicant/recipient; if the
applicant/recipient does not possess this information, he/she must cooperate with the
social services district in obtaining it. An applicant/recipient will not have eligibility
denied or discontinued solely because he/she does not possess and cannot obtain
information about the income or resources of a non-applying legally responsible relative
who is not living with him/her.
(3) The applicant/recipient is the primary
source of eligibility information. When an applicant/recipient is unable to document the
information provided, the social services district must conduct an investigation to verify
such information. The social services district must also conduct such an investigation if
it believes that information provided by an applicant/recipient is inaccurate. The
district may examine records, other than public records, only with the
applicant's/recipient's permission. If the applicant/recipient refuses such permission and
the social services district is unable to verify information through public records, the
applicant/recipient will be informed that the district is unable to determine MA
eligibility. The application then will be denied, or eligibility will be discontinued.
(4) Part 351 of this Title sets forth
additional requirements which must be met in the investigation process.
(b) Non-financial eligibility requirements. The social services
district must verify that applicants and recipients meet the non-financial eligibility
requirements contained in Subpart 360-3 of this Title.
(c) Financial eligibility requirements.
(1) Evaluation of financial circumstances. In
determining whether an applicant/recipient is financially eligible for MA under
subdivisions 360-3.3(b) or 360-3.3(c) of this Part, the social services district must
review all sources of income and resources available or potentially available to the
applicant/recipient. The district must consider the income and resources of all legally
responsible relatives. The review will be based on information in the application and from
a personal interview with the applicant/recipient or the person applying on his/her
behalf. The district must consider only available income and resources, as defined in
Subpart 360-4 of this Part. To be eligible for MA, the applicant must pursue any potential
income and resources that may be available. As soon as income or resources become
available, the applicant must report them to the district. The district must reevaluate
the applicant's eligibility for MA based on the new financial information.
(2) Verification of income. The applicant must
submit with his/her application documentation of wages received by all employed family
members who are included in the application and by all legally responsible relatives
living with the applicant. Acceptable forms of documentation are pay envelopes, wage
stubs, or an employer's statement of wages. If the applicant's income varies, the
documentation must show all wages earned in the past four weeks. If the applicant cannot
supply such documentation, the social services district can accept other forms of
information which it determines will verify the wages earned. All other income also must
be documented and a determination made as to its availability. The social services
district must record the type of information used to verify other available income.
(3) Verification of resources.
(i) The applicant
may attest to the amount of his or her resources, unless the applicant is seeking coverage
long-term care services. For purposes of this paragraph, long-term care services shall
include those services defined in subparagraph (ii) of this paragraph, with the exception
of short-term rehabilitation as defined in subparagraph (iii) of this paragraph. The
applicant must provide documentation of all available or potentially available resources
when applying for long-term care services. The social services district must record the
documentation provided and determine the availability of such resources.
(ii) Long-term care
services shall include, but not be limited to care, treatment, maintenance, and services:
provided in a nursing facility licensed under article twenty-eight of the public health
law; provided in an intermediate care facility certified under article sixteen of the
mental hygiene law; provided in a developmental center operated by the Office of Mental
Retardation and Developmental Disabilities; provided by a home care services agency,
certified home health agency or long-term home health care program as defined in section
thirty-six hundred two of the public health law; provided by an adult day health care
program in accordance with regulations of the department of health; provided by a personal
care provider licensed or regulated by any other state or local agency; provided in a
hospital that is equivalent to the level of care provided in a nursing facility; and
provided by an assisted living program in accordance with regulations of the department of
health. Long-term care services also shall include: private duty nursing; limited licensed
home care services; hospice services including services provided by the hospice residence
program in accordance with the regulations of the department of health; services provided
in accordance with the consumer directed personal assistance program; services provided by
the managed long-term care program; personal emergency response services; and care,
services or supplies provided by the Care at Home Waiver program, Traumatic Brain Injury
Waiver program, or Office of Mental Retardation and Developmental Disabilities Home and
Community-Based Waiver program.
(iii) Short-term
rehabilitation means one period of certified home health care, up to a maximum of 29
consecutive days, and/or one period of nursing home care, up to a maximum of 29
consecutive days, commenced within a twelve-month period.
(4) If any income or resources are
unavailable, the applicant/recipient must submit documentation establishing the
unavailability.
(5) The applicant/recipient must satisfactorily
explain and/or document how current living expenses are being met.