360-4.8 Determination of financial eligibility; effect of excess income and resources
on eligibility.
(a) Financial eligibility.
(1) Except as provided in paragraphs (2), (3),
(4), and (5) of this subdivision, an applicant/recipient is financially eligible for MA if
his or her net available income and net available resources do not exceed the appropriate
standards. The standards are found in section 360-4.7 of this Subpart.
(2) (i) A pregnant woman is
financially eligible for MA if her net available income does not exceed the highest of the
following three items: the applicable MA standard; the applicable PA Standard of Need; or,
100 percent of the applicable poverty line listed in subdivision (b) of section 360-4.7 of
this Subpart.
(ii) A pregnant woman
is financially eligible for comprehensive prenatal care services available under the
Prenatal Care Assistance Program, as listed in Public Health Law Section 2522, if her net
available income exceeds the highest of the three items listed in subparagraph (i) of this
paragraph but does not exceed 185 percent of the applicable poverty line listed in
subdivision (b) of section 360-4.7 of this Subpart.
(3) An infant younger than one year of age is
financially eligible for MA if his or her net available household income does not exceed
185 percent of the applicable poverty line set forth in section 360-4.7(b) of this
Subpart.
(4) A child at least one year of age but
younger than six years of age is financially eligible for MA if his or her net available
household income does not exceed 133 percent of the applicable federal poverty line set
forth in section 360-4.7(b) of this Subpart.
(5) A child born after September 30, 1983 who
is at least six years of age but younger than 19 years of age is financially eligible for
MA if his or her net available household income does not exceed 100 percent of the
applicable federal poverty line set forth in section 360-4.7(b) of this Subpart.
(6) Applicants/recipients who are financially
eligible under paragraphs (1) thorugh (5) of this subdivision will be authorized to
receive MA if they also meet the non-financial eligibility requirements. The non-financial
eligibility requirements are found in Subpart 360-3 of this Part.
(b) Reduction of excess resources. An MA applicant/recipient whose net
available resources exceed the resource standards will be ineligible for MA until he/she
incurs medical expenses equal to or greater than the excess resources. However, non-exempt
resources transferred for less than their fair market value may still be considered
available, under subdivision 360-4.4(c) of this Subpart.
(c) Reduction of excess income.
(1) Except as provided in paragraphs (4) and
(5) of this subdivision, if an otherwise eligible MA applicant's or recipient's net
available income exceeds the appropriate income standard, he or she will be eligible for
MA only after incurring medical expenses equal to or greater than the amount of excess
income, provided such medical expenses are not subject to payment by a third party other
than another public program of the State or any of its political subdivisions. Once
deduction of incurred medical expenses reduces income to the income standard, the MA
applicant or recipient is eligible for MA; however, no MA payment will be made for those
incurred medical expenses used to establish eligibility. The social services district will
deduct from the MA applicant's income the following medical expenses incurred by the
applicant, by family members living with the applicant for whom the applicant is legally
responsible, and by legally responsible relatives living with the applicant, in the order
listed below and regardless of whether these expenses are subject to payment by another
public program of the State or any of its political subdivisions:
(i) expenses incurred
for Medicare and other health insurance premiums, deductibles, or coinsurance charges;
(ii) expenses incurred
for necessary medical and remedial services that are recognized under State law but are
not covered by MA; and
(iii) expenses incurred
for necessary medical and remedial services that are covered under the MA Program.
(2) Budgeting periods.
(i) To be eligible for
MA coverage for acute care in a medical facility, an applicant/recipient must incur
medical expenses equal to or greater than the amount of his/her excess income for a period
of six months. Once that amount of medical expenses has been incurred, the
applicant/recipient may receive full MA coverage for a period of six months.
(ii) To be eligible for
MA coverage of all medical care, services and supplies outside the medical facility, as
well as prosthetic appliances (including dentures), the applicant/recipient must incur
medical expenses in the month equal to or greater than the amount of his/her excess
monthly income. When that amount of medical expenses has been incurred, the
applicant/recipient will receive MA outpatient coverage for any additional medical
expenses incurred in that month.
(iii) If an MA
recipient regularly receives home care in the community but is temporarily absent from the
home to receive respite care for a fixed period of up to four weeks in an intermediate
care facility, skilled nursing facility, or residential health care facility, he/she will
be eligible for MA coverage of the respite care for each month in which incurred medical
expenses are at least equal to the amount of monthly excess income. Respite care is
infrequent and temporary substitute care or supervision provided to a person on behalf of
and in the absence of the caregiver, in order to relieve the caregiver from the stresses
or responsibilities of providing constant care and to enable the caregiver to maintain a
normal routine. Respite care must be provided in accordance with the terms of approved
federal waivers.
(3) For services regularly requiring prior
approval, after the social services district tells the recipient the amount of services
that are medically necessary for him/her, as determined by the district according to
applicable regulations, additional medical services over and above the amount which is
medically necessary cannot be used to reduce the amount of the recipient's excess income.
(4) Except as provided in paragraph (5) of this
subdivision, a social services district will authorize MA for an otherwise eligible MA
applicant or recipient who pays to the district the amount that his or her net available
income exceeds the appropriate income standard, provided that the district submit to the
department and receives approval of a plan for the pre- payment of excess income.
(i) A plan for the
pre-payment of excess income must provide that:
(a) the MA applicant or recipient has the option of participating in the pre-payment
program;
(b) the MA applicant or recipient must pay to the social services district the amount that
his or her net available income exceeds the appropriate income standard for the budgeting
period specified in paragraph (2) of this subdivision, minus the amount of any medical
expenses incurred during the budgeting period or credited pursuant to subparagraph (iii)
of this paragraph which are not payable by the MA program;
(c) the social services district must safeguard the amounts paid to it by an MA recipient
who participates in the pre-payment program by depositing such amounts in a special
pre-payment account;
(d) the social services district must periodically reconcile the amount in the MA
recipient's pre- payment account with the amount of MA payments made on his or her behalf
for the budgeting period specified in paragraph (2) of this subdivision to determine if a
refund to the MA recipient or credit to the MA recipient's pre- payment account for
subsequent spenddown period(s) is appropriate; and
(e) the social services district must report to the department the pre-payment amounts
collected minus any refunds made pursuant to subparagraph (iii) of this paragraph.
(ii) A plan for the
pre-payment of excess income must include a detailed description of how the social
services district will:
(a) administer the pre-payment program;
(b) enroll MA applicants and recipients; and
(c) meet the requirements of subparagraphs (i) and (iii) of this paragraph.
(iii) Refunds and
credits.
(a) If an MA recipient makes a payment pursuant to this paragraph and then incurs medical
expenses during the budgeting period that are not payable by MA, the social services
district must:
(1) refund to the MA recipient the amount of such medical expenses from the recipient's
pre-payment account for that budgeting period. If the amount of such medical expenses
exceeds the MA recipient's pre-payment account for that budgeting period, the district
must credit the remainder to the MA recipient's pre-payment account for the subsequent
spenddown period(s); or
(2) credit the amount of such medical expenses to the MA recipient's pre- payment account
for the subsequent spenddown period(s).
A plan for the pre-payment of excess income may provide for the social services district
to make this refund separately as described in this clause or as part of the periodic
refund described in clause (b) of this subparagraph.
(b) The social services district will periodically compare the amount in the MA
recipient's pre- payment account, minus any amount to be refunded for medical expenses
which are not payable by MA, to the amount of MA payments made on his or her behalf for
the budgeting period specified in paragraph (2) of this subdivision. If the former exceeds
the latter, the social services district must periodically refund the difference to the MA
recipient or credit the difference to the recipient's pre- payment account for the
subsequent spenddown period(s).
(iv) When a social
services district submits a pre-payment plan for excess income to the department for
approval, the department will approve, disapprove, or request the social services district
to modify such plan within 90 days of receipt of the plan.
(5) (i) Federally
non-participating persons described in paragraph 360-3.3(b)(7) of this Part whose net
available income exceeds the appropriate income standard cannot become eligible for MA by
incurring medical expenses equal to or greater than the amount of their excess income.
(ii)
(a) A pregnant woman whose net available income exceeds 185 percent of the applicable
poverty line listed in subdivision (b) of section 360- 4.7 of this Subpart:
(1) cannot become eligible for comprehensive prenatal care services listed in Section 2522
of the Public Health Law by incurring medical expenses equal to or greater than the amount
by which her net available income exceeds 185 percent of such line; and
(2) cannot become eligible for full MA coverage by incurring medical expenses equal to or
greater than the amount by which her net available income exceeds 100 percent of such
line.
(b) A pregnant woman whose net available income exceeds 100 percent of the applicable
poverty line listed in subdivision (b) of section 360-4.7 of this Subpart but does
notexceed 185 percent of such line cannot become eligible for full MA coverage by
incurring medical expenses equal to or greater than the amount by which her net available
income exceeds 100 percent of such line.
(c) An infant younger than one year of age whose net available income exceeds 185 percent
of the applicable poverty line listed in subdivision (b) of section 360-4.7 of this
Subpart cannot become eligible for MA by incurring medical expenses equal to or greater
than the amount by which his or her net available income exceeds 185 percent of such line.
(iii) A child at least
one year of age but younger than six years of age whose net available household income
exceeds 133 percent of the applicable federal poverty line set forth in section 360-4.7(b)
of this Subpart cannot become eligible for MA coverage by incurring medical expenses equal
to or greater than the amount by which his or her net available household income exceeds
133 percent of such poverty line.
(iv) A child born after
September 30, 1983 who is at least six years of age but younger than 19 years of age whose
net available household income exceeds 100 percent of the applicable federal poverty line
set forth in section 360-4.7(b) of this Subpart cannot become eligible for MA by incurring
medical expenses equal to or greater than the amount by which his or her net available
household income exceeds 100 percent of such poverty line.
(v) A pregnant woman or
child described in subparagraphs (ii), (iii), or
(iv) of this paragraph
can become eligible for full MA coverage only by incurring medical expenses equal to or
greater than the amount by which his or her net available household income exceeds the
higher of the applicable MA standard or PA standard of need.