New York Codes, Rules and Regulations
Title 14 - DEPARTMENT OF MENTAL HYGIENE
Chapter XIV - Office for People With Developmental Disabilities
Part 635 - General Quality Control and Administrative Requirements Applicable to Programs, services or Facilities Funded or Certified by the Office for People With Developmental Disabilities
Subpart 635-12 - Liability for Services
Section 635-12.3 - Provider obligations for services other than preexisting services

Universal Citation: 14 NY Comp Codes Rules and Regs § 635-12.3

Current through Register Vol. 47, No. 12, March 26, 2025

(a) This section applies only to services which are not preexisting services.

(b) Disclosure of personal and financial information.

(1) Prior to the individual receiving services, the provider shall take such steps to obtain personal and financial information as may be reasonably required to identify liable parties and to ascertain the individual's and any other liable parties' ability to pay for services or the individual's ability to obtain and maintain full Medicaid coverage.

(2) However, when individuals and/or other liable parties agree to pay the full fee for the services, the provider is not required to obtain the information specified in paragraph (1) of this subdivision. In these situations, the provider may obtain such information at its discretion.

(3) The provider shall require that, during the period that services are received, the individual and all other liable parties notify the provider about any changes in liable parties, any changes in the individual's Medicaid coverage and any changes that may affect the individual's eligibility for full Medicaid coverage and/or the individual's and other liable parties' ability to pay for services.

(c) Notice and schedule of fees.

Prior to the receipt of services, the provider shall give the individual and any known other liable parties copies of the fee schedule for those services, together with a notice including a description of the obligations of the provider, the individual and liable parties under the law and this regulation in the form and format specified by the commissioner.

(d) Reduction or waiver of fees.

(1) The provider may reduce or waive fees with prior OPWDD approval subject to the following conditions:
(i) OPWDD approval for a reduction or waiver of fees for an individual will be based on consideration of the individual's or other liable parties' available income and resources, the individual's living situation, and the individual's ability to meet Medicaid eligibility requirements.

(ii) OPWDD approval for a reduction or waiver of fees is only available when the individual has taken all necessary steps to obtain and maintain full Medicaid coverage. However, OPWDD may approve a reduction or waiver of fees for Medicaid service coordination (MSC) for up to three months if an individual does not have full Medicaid coverage and MSC is necessary to assist the individual in obtaining full Medicaid coverage.

(iii) The provider shall give the individual and all liable parties 30 days' written notice of any changes in the reduction or waiver of fees granted with prior OPWDD approval and shall require the individual and/or liable parties to agree to the full fee or new reduced fee or acknowledge the waiver of the fee.

(2) The provider may also waive or reduce fees at their discretion without the prior approval of OPWDD. However, OPWDD payments are not available when such waivers or reduced fees are granted.

(e) Application for HCBS waiver services.

If the services are HCBS waiver services, the provider shall require that the individual take all necessary steps to enroll in the HCBS waiver and take all necessary steps to maintain HCBS waiver enrollment.

(f) The provider shall inquire whether an individual applying for services is already enrolled in supported employment services or applying for or enrolled in respite services. If the individual is enrolled in supported employment services or applying for or enrolled in respite services, the provider shall comply with its obligations as specified in section 635-12.12(c) and/or (d) of this Subpart, as applicable.

(g) Community habilitation phase II services are "other than preexisting services."

Disclaimer: These regulations may not be the most recent version. New York may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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