360-7.5 Method of payment for medical care.
(a) Payment for medical care provided under the MA program will be made
to the person or institution supplying the care. However, payment for services or care may
be made, at the MA rate or fee in effect at the time such services or care were provided,
to the following:
(1) a recipient or his/her representative when
an erroneous determination by the social services district of ineligibility is reversed.
The erroneous decision must have caused the recipient or his/her representative to pay for
medical services which should have been paid under MA. Direct reimbursement to the
recipient or recipient's representative will be made whether the decision to reverse is
due to the district discovering its own error, or the result of a fair hearing decision or
court order;
(2) a practitioner's employer if the
practitioner would be required to do so as a condition of employment;
(3) the facility in which such care and
services were provided if the facility submits the claim under a contract between a
practitioner and the facility;
(4) an organization, including a health
maintenance organization, which furnishes health care through an organized health care
delivery system if there is a contract between the organization and the practitioner
providing the service under which the organization bills or receives payment for the
services; and
(5) a recipient or his/her representative for
paid medical bills for medical expenses incurred during the period beginning three months
prior to the month of application for MA and ending with the recipient's receipt of
his/her MA identification card, provided that the recipient was eligible in the month in
which the medical care and services were received and that the medical care and services
were furnished by a provider enrolled in the MA Program.
(b) The claim of any provider of medical care, services, or supplies
assigned under a power of attorney or otherwise, is invalid and cannot be enforced against
a social services district. However, an assignment from a supplier to a governmental
agency or entity or an assignment established under a court order is valid.
(c) A provider of medical care, services, or supplies may employ a
business agent, such as a billing service or an accounting firm. Such agent may prepare
and send bills and receive MA payments in the name of the provider only if the
compensation paid to the agent is:
(1) reasonably related to the cost of the
services;
(2) unrelated, directly or indirectly, to the
dollar amounts billed and collected; and
(3) not dependent on actual collection of
payments.
(d) A social services district may use any appropriate organization as
a fiscal intermediary to audit and pay for the district's share of the cost of medical
care, services and supplies provided to recipients. An appropriate organization is any
insurance carrier authorized to conduct audits and make payments to providers who furnish
services under Medicare. A social services district must enter into an agreement with the
organization that meets the requirements of this provision and other appropriate federal
authorities. The department must approve the agreement before the organization can be used
as a fiscal intermediary.
(e) Payment for a recipient's transportation costs will be made to the
vendor. If payment cannot be made directly to the vendor, it will be made to the recipient
as an administrative expense. When the services of an attendant are essential, payment for
the attendant's transportation costs will be made to the vendor. If payment cannot be made
directly to the vendor, payment will be made to the attendant as an administrative
expense.
(f) Payment for home health aide services will be made in the same
manner as payment for any other medical care provided under the MA program.
(g) Payment or part-payment of the premium for personal health
insurance covering care and other medical benefits which are authorized under the MA
program may be made to the insurance carrier or to another appropriate third party:
(1) on behalf of MA households eligible for
ADC, HR or extended MA coverage pursuant to paragraphs (1) and (2) of section 360-3.3(c)
of this Part, for cost-effective, employer-sponsored group health insurance benefits. Such
premiums will be paid for the benefit of the recipient's spouse and dependent children.
Non-employer health insurance will be paid, in part or in full, when it would reduce the
expense of providing MA services;
(2) on behalf of a recipient if the recipient
is receiving MA as a patient in a medical facility and all the recipient's non-exempt
income except that expended for the cost of such insurance, is applied to the cost of
his/his care; or
(3) on behalf of a recipient or household which
is eligible for MA if the full cost of such insurance premiums was not used in calculating
financial eligibility and if full or partial payment would reduce the expense of providing
MA services.
(h) Payment of the COBRA premiums for COBRA continuation coverage, as
defined in paragraph (1) of this subdivision, will be made by the MA program on behalf of
a person described in paragraph (2) of this subdivision.
(1) (i) COBRA continuation
coverage means health insurance coverage required by Section 10002 of the Consolidated
Omnibus Budget Reconciliation Act of 1985 (Pub. L. No. 99-272) and provided under a group
health plan that meets the following requirements:
(a) the group health plan is provided by an employer of 75 or more employees; and
(b) the group health plan is provided pursuant to title XXII of the Public Health Service
Act, section 4980B of the Internal Revenue Code of 1986, or title VI of the Employee
Retirement Income Security Act of 1974.
(ii) COBRA premiums
means the applicable premiums imposed with respect to COBRA continuation coverage.
(2) The MA program will pay the COBRA premiums
for a person who meets the following requirements:
(i) he or she is
entitled to elect COBRA continuation coverage;
(ii) his or her income
does not exceed 100 percent of the poverty line, as defined in section 360-1.4(r) of this
Part, applicable to a household of the same size as the person's household;
(iii) his or her
resources do not exceed twice the maximum amount of resources that a person may have to be
eligible for federal Supplemental Security Income (SSI) benefits; and
(iv) the social
services district has determined that the savings in MA expenditures resulting from
enrolling the person for COBRA continuation coverage are likely to exceed the amount of
payments made for the COBRA premiums.
(3) When determining the eligibility of a
person for payment of the COBRA premiums under this subdivision, the social services
district must:
(i) use the federal SSI
eligibility requirements relating to income and resources; and
(ii) not consider costs
that the person or the person's household has incurred for medical or remedial care.
(4) (i) The MA program will
pay the COBRA premiums on behalf of a person who has applied to have the program pay for
such premiums and who the social services district reasonably expects will meet the
eligibility requirements of paragraph (2) of this subdivision but for whom the social
services district has not yet received documentation verifying whether the person is
eligible for MA payment of his or her COBRA premiums.
(ii) When the social
services district receives such documentation and determines that such person does not
meet the eligibility requirements of paragraph (2) of this subdivision:
(a) the MA program's payment of the person's COBRA premiums will terminate;
(b) the person may request a fair hearing pursuant to Part 358 of this Title to review the
social services district's determination that he or she is ineligible for the MA program's
payment of his or her COBRA premiums; however, the person will not be entitled to aid
continuing; and
(c) the social services district may request that the person repay the amount of the MA
program's payments for his or her COBRA premiums unless a fair hearing decision has held
that the social services district's determination was incorrect.
(5) The social services district must notify
the person, in writing and on forms required by the department, of its determination
whether the person is eligible, or continues to be eligible, to have the MA program pay
for his or her COBRA premiums. The notice must advise the person of his or her right to
request a fair hearing and of any aid continuing rights in accordance with Part 358 of
this Title.
(i) Payment of health insurance premiums will be made by the MA program
on behalf of a person described in paragraph (1) of this subdivision.
(1) The MA program will pay the health
insurance premiums for a person who:
(i) has Acquired Immune
Deficiency Syndrome (AIDS) or an Human Immuno-Deficiency Virus (HIV) related illness, as
defined by the AIDS Institute of the Department of Health;
(ii) resides in a
household whose income does not exceed 185 percent of the poverty line, as defined in
section 360-1.4(r) of this Part, applicable to a household of the same size as the
person's household;
(iii) (a) is
unemployed; participated in the health insurance plan his or her prior employer provided;
and is eligible to continue his or her participation in such plan or convert his or her
coverage to individual coverage;
(b) is employed; participated in the health insurance plan his or her prior employer
provided; is eligible to continue his or her participation in such plan or convert his or
her coverage to individual coverage; and is ineligible to participate in the health
insurance plan that his or her current employer provides or such employer does not offer a
health insurance plan; or
(c) is or was self-employed; maintained health insurance coverage while self-employed; and
is eligible to continue his or her participation in such plan or convert his or her
coverage to individual coverage; and
(iv) is ineligible for
MA.
(2) When determining the eligibility of a
person for the payment of his or her health insurance premiums under this subdivision, a
social services district must:
(i) use the federal
Supplemental Security Income eligibility requirements relating to income; and
(ii) not consider the
following:
(a) costs that the person or the person's household has incurred for medical or remedial
care; or
(b) resources available to the person or the person's household.
(3) (i) The MA program will pay the health
insurance premiums on behalf of a person who has applied to have the program pay for such
premiums and who the social services district reasonably expects will meet the eligibility
requirements of paragraph (1) of this subdivision but for whom the social services
district has not yet received documentation verifying whether the person is eligible for
MA payment of his or her health insurance premiums.
(ii) When the social
services district receives such documentation and determines that the person does not meet
the eligibility requirements of paragraph (1) of this subdivision:
(a) the MA program's payment under this subdivision of the person's health insurance
premiums will terminate;
(b) the person may request a fair hearing pursuant to Part 358 of this Title to review the
social services district's determination that he or she is ineligible for the MA program's
payment under this subdivision of his or her health insurance premiums; however, the
person will not be entitled to aid continuing; and
(c) the social services district may request that the person repay the amount of the MA
program's payments for his or her health insurance premiums unless a fair hearing decision
has held that the social services district's determination was incorrect.
(4) The social services district must notify
the person, in writing and on forms required by the department, of its determination
whether the person is eligible, or continues to be eligible, to have the MA program pay
for his or her health insurance premiums. The notice must advise the person of his or her
right to request a fair hearing and of any aid continuing rights in accordance with Part
358 of this Title.
(j) Payments will be made to the facility, agency or person who
provided medical services under the physically handicapped children's program when prior
authorization was obtained from the social services district. Services under this program
include inpatient hospital care, prosthetic appliances costing more than $40 and
prescribed by someone other than a qualified specialist, multiple extractions and dental
prosthesis, and other dental care and services. If, during a period for which such care
and services have been authorized, the recipient or household becomes ineligible for MA,
arrangements must be made with the recipient or household to pay the social services
district for the cost of care and services provided during the period of MA ineligibility.
In such instances, the social services district will limit accounting division
authorization to the care and services for which prior authorization was obtained. If the
recipient or household remains ineligible for MA when such care and services are
completed, the case will be closed.