360-3.7 Presumptive eligibility.
(a) Any person applying for MA will be presumed eligible for such
assistance for a period of up to 60 days from the date of transfer from a general hospital
to a certified home health agency or long term home health care program if:
(1) the applicant is receiving acute care in
such hospital;
(2) a physician certifies that the 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;
(3) the applicant or his/her representative
states that the applicant does not have insurance coverage for the required medical care
and that such care cannot be afforded;
(4) it reasonably appears that the applicant is
eligible for MA; and
(5) it reasonably appears that the amount
expended by the department and the social services district for care and services provided
by a certified home health agency or long term home health care program during the period
of presumed eligibility would be less than the amount which would be expended for
continued acute hospital care.
(b) An applicant determined to be presumptively eligible for MA under
subdivision (a) of this section will not be eligible, during the period of presumptive
eligibility, for MA coverage of inpatient care in a hospital or residential health care
facility, hospital emergency room treatment, and hospital-based clinic care. If the
applicant is subsequently determined to be eligible for MA, he/she will be eligible for
all care and services available under the MA program retroactively to the effective date
of presumptive eligibility. If a presumptively eligible applicant is subsequently
determined to be ineligible for MA, any sums expended for such assistance during the
period of presumptive eligibility will be recouped from the applicant. The social services
district will have the authority to recoup such sums on behalf of the department.
(c) A period of presumptive eligibility pursuant to subdivision (a) of
this section will end automatically after 60 days from the date of transfer from the
general hospital or upon a determination by the social services district as to the
applicant's eligibility for MA, whichever occurs first. If a presumptively eligible
applicant is subsequently determined to be ineligible for MA, the applicant may request a
fair hearing pursuant to Part 358 of this Title to dispute the denial of MA but the period
of presumptive eligibility will not be extended by such request.
(d) Presumptive eligibility for pregnant women.
(1) A pregnant woman will be presumed eligible
to receive the MA care, services and supplies listed in paragraph (9) of this subdivision
when a qualified provider determines, on the basis of preliminary information, that the
pregnant woman's family income does not exceed 185 percent of the applicable poverty line
listed in subdivision (b) of section 360-4.7 of this Part.
(2) For purposes of this subdivision, the
pregnant woman's family income will be determined according to section 360-4.6 of this
Part relating to financial eligibility for MA. The resources of the pregnant woman's
family will not be considered in determining the pregnant woman's presumptive eligibility
for MA.
(3) For purposes of this subdivision, a
pregnant woman's family includes the pregnant woman, any legally responsible relatives and
any legally dependent relatives with whom she resides.
(4) As used in this subdivision, the term
"qualified provider" means a provider who:
(i) is eligible to
receive payment under the MA program;
(ii) provides one or
more of the following types of services:
(a) outpatient hospital services;
(b) rural health clinic services, or
(c) clinic services furnished by or under the direction of a physician, without regard to
whether the clinic itself is administered by a physician;
(iii) has been found by
the department to be capable of making presumptive eligibility determinations based on
family income; and
(iv) meets at least one
of the following additional criteria:
(a) receives funds under the federal Migrant Health Centers or Community Health Centers
programs pursuant to the federal Public Health Service Act;
(b) receives funds under the federal Maternal and Child Health Services Block Grant
programs pursuant to Title V of the federal Social Security Act;
(c) participates in the program established under the federal Special Supplemental Food
Program for Women, Infants, and Children pursuant to the federal Child Nutrition Act of
1966;
(d) participates in the program established under the federal Commodity Supplemental Food
Program pursuant to the federal Agriculture and Consumer Protection Act of 1973; or
(e) participates in the New York State Department of Health's Prenatal Care Assistance
Program (PCAP), established pursuant to Article 25 of the Public Health Law (PHL).
(5) A pregnant woman who has been determined
presumptively eligible for MA must submit an MA application to the social services
district in which she resides by the last day of the month following the month in which a
qualified provider determined her to bepresumptively eligible.
(6) A qualified provider that has determined a
pregnant woman to be presumptively eligible for MA must:
(i) On the day the
qualified provider determines the pregnant woman to be presumptively eligible, inform her
that she must submit an MA application to the social services district in which she
resides by the last day of the following month in order to continue her presumptive
eligibility until the day the social services district determines her eligibility;
(ii) assist her to
complete the MA application and submit the application on her behalf;
(iii) within five
business days after the day the qualified provider determines the pregnant woman to be
presumptively eligible, notify the social services district in which the pregnant woman
resides of its presumptive eligibility determination on forms the department develops or
approves; and
(iv) if the qualified
provider participates in PCAP, offer to represent the presumptively eligible pregnant
woman during the remainder of the MA eligibility process, including acting as her
representative at the personal interview the social services district conducts pursuant to
section 360-2.2 of this Part.
(7) The period of presumptive eligibility for
MA begins on the day a qualified provider determines the pregnant woman to be
presumptively eligible. If the pregnant woman submits an MA application to the social
services district in which she resides by the last day of the following month, the period
of presumptive eligibility continues through the day the social services distict
determines whether the pregnant woman is eligible for MA; if the pregnant woman fails to
submit such an application, the period of presumptive eligibility continues through the
last day of the following month.
(8) A pregnant woman is eligible for only one
period of presumptive eligibility during each pregnancy.
(9) A presumptively eligible pregnant woman is
eligible for medical care, services and supplies as follows:
(i) a presumptively
eligible pregnant woman whose family income does not exceed 100 percent of the applicable
poverty line, as listed in subdivision (b) of section 360-4.7 of this Part, is eligible
for all medical care, services and supplies available under the MA program, excluding
inpatient and institutional long- term care; and
(ii) a presumptively
eligible pregnant woman whose family income exceeds 100 percent of the applicable poverty
line but does not exceed 185 percent of such line, as listed in subdivision (b) of section
360-4.7 of this Part, is eligible for comprehensive prenatal care services available under
PCAP, as described in Section 2522 of the Public Health Law, excluding inpatient care.
(10) If a presumptively eligible pregnant woman
is subsequently determined to be ineligible for MA, she may request a fair hearing
pursuant to Part 358 of this Title to dispute the denial of MA, but her presumptive
eligibility period will not be extended by such request.