New York Codes, Rules and Regulations
Title 18 - DEPARTMENT OF SOCIAL SERVICES
Chapter II - Regulations of the Department of Social Services
Subchapter B - Public Assistance
Article 2 - Determination of Eligibility-Categorical
Part 360 - MEDICAL ASSISTANCE
Subpart 360-10 - MEDICAID MANAGED CARE PROGRAMS
Section 360-10.5 - Individuals exempt or excluded from enrollment in an MMCO
Universal Citation: 18 NY Comp Codes Rules and Regs ยง 360-10.5
Current through Register Vol. 46, No. 39, September 25, 2024
(a) A Medicaid recipient is exempt from enrollment in an MMCO if the recipient meets one of the criteria for exemption identified in section 364-j (3)(b) of the Social Services Law.
(b) A Medicaid recipient identified in section 364-j (3)(e) of the Social Services Law is exempt from enrollment unless the commissioner has established program features for that population.
(c) A Medicaid recipient shall be excluded from enrollment in an MMCO if the recipient meets one of the criteria identified in section 364-j (3)(c) of the Social Services Law.
(d) Determination of a Medicaid recipient's eligibility for an exemption or exclusion shall be the responsibility of the social services district.
(1) Determinations made prior to enrollment.
Determinations made prior to enrollment.
(i)
If a Medicaid recipient requests an exemption or exclusion from enrollment in
an MMCO, the Medicaid recipient or the Medicaid recipient's representative must
file a written request with the appropriate social services district. The
social services district shall require the Medicaid recipient to provide
documentation to support the request for an exemption or exclusion where
appropriate.
(ii) The social
services district must make a determination within 10 days after receipt of all
necessary information and notify the Medicaid recipient in writing whether the
request for an exemption or exclusion is granted or denied.
(iii) When a request for an exemption or
exclusion is denied, the social services district must provide a written notice
that explains the reason for the denial, states the facts upon which the denial
is based, cites the relevant statutory or regulatory authority for the denial,
and advises the Medicaid recipient of his or her right to a fair hearing. The
notice must comply with section
358-2.2(a)
of this Title.
(2)
Determinations of a Medicaid recipient's eligibility for an exemption or
exclusion from enrollment in a managed care program after enrollment has
occurred. Determinations of a Medicaid recipient's eligibility for an exemption
or exclusion from enrollment in a managed care program after enrollment has
occurred.
(i) When the social services
district becomes aware that an enrollee is excluded from participating in
accordance with subdivision (c) of this section, the social services district
will initiate disenrollment of the enrollee.
(ii) A Medicaid recipient may apply for an
exemption or an exclusion by filing a written request with the appropriate
social services district. The social services district shall require the
Medicaid recipient to provide documentation to support the request for an
exemption or exclusion where appropriate.
(a)
The social services district must make a determination in sufficient time to
ensure that the disenrollment will be effective no later than the first day of
the second month following the month in which the social services district
received the request, unless the recipient requests expedited disenrollment
pursuant to paragraph (iii) of this subdivision.
(b) The social services district must notify
the recipient in writing of its determination to approve or deny the request
for an exemption or exclusion.
(c)
When a request is denied, the social services district must provide a written
notice that explains the reason for the denial, states the facts upon which the
denial is based, cites the relevant statutory or regulatory authority for the
denial, and advises the Medicaid recipient of his or her right to a fair
hearing. The notice must comply with section
358-2.2(a)
of this Title.
(iii) An
enrollee may request an expedited disenrollment or change if: an immediate risk
to the enrollee's health exists; the enrollment was non-consensual; or for
other reasons as set forth in the contract between the MMCO and the State. The
social services district may request documentation to substantiate the request.
The effective date of the expedited disenrollment or change must comply with
the timeframes found in the contract between the MMCO and the State.
(a) The social services district must notify
the recipient in writing of its determination to approve or deny the request
for an expedited disenrollment.
(b)
When a request is denied, the social services district must provide a written
notice that explains the reason for the denial, states the facts upon which the
denial is based, cites the relevant statutory or regulatory authority for the
denial, and advises the Medicaid recipient of his or her right to a fair
hearing. The notice must comply with section
358-2.2(a)
of this Title.
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