360-7.3 Use of health, hospital or accident insurance.
(a) Definitions used in this section.
(1) Insurance providing full coverage. A
recipient's insurance is providing full coverage when the recipient's care is paid for
under the insurance contract without the payment of any coinsurance amount, deductible, or
Medicare.
(2) Insurance providing partial coverage. A
recipient's insurance is providing partial coverage when payment for his/her care under
the insurance contract is subject to payment of a coinsurance amount, deductible, or
Medicare.
(3) Indemnity insurance coverage. Indemnity
insurance coverage is any insurance benefit a recipient receives because of accident or
injury. Examples of this type of insurance are automobile and liability insurance and
workers' compensation benefits.
(4) Coinsurance amount or deductible are
amounts an insurance beneficiary must pay when he/she receives care or services.
(b) A recipient must use health, hospital or accident insurance
benefits to the fullest extent in meeting his/her medical needs.
(1) Using insurance benefits to pay for care
provided to a recipient by a medical institution:
(i) Blue Cross,
Government Health Insurance and other types of insurance (other than indemnity insurance).
(a) When a recipient's care in a medical institution is covered in full by insurance, the
social services district will only make payments for items of care not covered by the
insurance contract that are the recipient's responsibility to pay. Payments which the
social services district makes for a recipient in this way will be at rates set by the
appropriate official. The total payment by the social services district for any item of
service must be limited to the amount by which the rate of payment approved by the State
Director of the Budget, according to section 2807 of the Public Health Law, exceeds the
amount paid by the insurance carrier.
(b) When a recipient's care in a medical institution is partially covered by insurance,
the payment by the social services district must be no more than the amount by which the
rate of payment for the institution approved by the State Director of the Budget, in
accordance with section 2807 of the Public Health Law, exceeds the amount paid by the
insurance carrier. The term "partially covered" for the purpose of this clause
includes specific and fixed benefits for maternity care.
(ii) Assignment of a
recipient's indemnity insurance coverage. The social services district must establish
procedures for the proper use of a recipient's indemnity insurance benefits. These
procedures must provide for an MA applicant or recipient to assign these benefits to the
medical institution providing his/her care or to the social services district. If the
procedures provide for assignment of benefits to the social services district, they must
include a method for obtaining payment of the benefits to the social services district.
(iii) Situations where
the social services district pays the difference between the amount of assigned benefits
and the established rate. If a recipient assigns his/her indemnity insurance benefits to
the medical institution, the social services district must pay the medical institution the
amount by which the rate of payment for the institution approved by the State Director of
the Budget, in accordance with section 2807 of the Public Health Law, exceeds the amount
paid by the insurance carrier.
(2) Using insurance benefits to pay for care
provided to recipients by persons and agencies other than medical institutions.
(i) Blue Shield,
Government Health Insurance and other insurance (except indemnity coverage). The social
services district must pay the provider of a recipient's medical services the amount by
which the fee for the care and services that is set by the social services district
exceeds the amount paid by the insurance carrier.
(ii) Assignment of
indemnity insurance coverage. The social services district must establish procedures for
the proper use of indemnity insurance benefits. These procedures must provide for an
applicant or recipient to assign his/her indemnity insurance benefits to the provider of
medical services, if the provider will accept such assignment, or to the social services
district. If the social services district's procedures provide for assignment of these
benefits to the district, they must include the methods for obtaining payment by the
social services district.
(iii) If a recipient
assigns indemnity insurance benefits to the provider of medical services, the social
services district must pay the provider the amount by which the fee established by the
district for the service rendered exceeds the amount paid by the insurance carrier. If the
indemnity insurance benefit is assigned to the social services district, the provider must
be paid the district's established fee for the services the recipient receives.
(3) The social services district staff must
obtain from applicants/recipients information about their private health coverage. This
information includes insurance coverage which may be available to the applicant/recipient
through an absent parent or spouse. If the applicant/recipient is unaware of what coverage
is available through an absent parent or spouse, the social services district is
responsible for getting the information from either the absent parent or spouse or their
employers. The applicant/recipient must provide the social services district with the name
of the insurance carrier, type of coverage, policy number, and amount of the premium
payment.
(c) Applicants/recipients must make full use of available medical
resources which will provide or pay for medical care, services and supplies.
(1) Children under 21 years of age may be
eligible for medical services under the children with physical disabilities program
(formerly the physically handicapped children's program) provided for under Title V of
Article 25 of the Public Health Law. The social services district must promptly refer the
case of a child who may be eligible for this program to the local program medical
director. If the local program medical director determines that the child is medically
eligible, MA-covered services must be provided in accordance with the plan of care
approved by the local program medical director. Once the social services district official
has been notified that the child is medically eligible, the child's financial eligibility
for MA must be determined, in accordance with the agreement between the State Department
of Health and the State Department of Social Services. If the child is eligible for MA
with no parental liability, the medical services must be authorized by the social services
district and paid for from MA funds. If the child's parents are required to contribute
toward the cost of his/her care under MA eligibility standards, the child's case must be
referred to the children with physical disabilities program for payment for the cost of
medical services up to the amount of the child's excess income.
(2) The social services district must review
any existing support order which has been entered for a recipient's benefit against a
spouse or parent. The social services district must petition to amend orders of support to
provide that the parent or spouse participate in a family medical insurance plan if one is
available through the parent's or spouse's employer.