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 360-3 - ELIGIBILITY REQUIREMENTS
Section 360-3.7 - Presumptive eligibility
Universal Citation: 18 NY Comp Codes Rules and Regs § 360-3.7
Current through Register Vol. 47, No. 12, March 26, 2025
(a) Any person applying for MA will be presumed eligible for such assistance for a period of up to 60 days from the date of transfer from a general hospital to a certified home health agency or long term home health care program if:
(1)
the applicant is receiving acute care in such hospital;
(2) a physician certifies that the applicant
no longer requires acute hospital care, but still requires medical care which
can be provided by a certified home health agency or a long term home health
care program;
(3) the applicant or
his/her representative states that the applicant does not have insurance
coverage for the required medical care and that such care cannot be
afforded;
(4) it reasonably appears
that the applicant is eligible for MA; and
(5) it reasonably appears that the amount
expended by the department and the social services district for care and
services provided by a certified home health agency or long term home health
care program during the period of presumed eligibility would be less than the
amount which would be expended for continued acute hospital care.
(b) An applicant determined to be presumptively eligible for MA under subdivision (a) of this section will not be eligible, during the period of presumptive eligibility, for MA coverage of inpatient care in a hospital or residential health care facility, hospital emergency room treatment, and hospital-based clinic care. If the applicant is subsequently determined to be eligible for MA, he/she will be eligible for all care and services available under the MA program retroactively to the effective date of presumptive eligibility. If a presumptively eligible applicant is subsequently determined to be ineligible for MA, any sums expended for such assistance during the period of presumptive eligibility will be recouped from the applicant. The social services district will have the authority to recoup such sums on behalf of the department.
(c) A period of presumptive eligibility pursuant to subdivision (a) of this section will end automatically after 60 days from the date of transfer from the general hospital or upon a determination by the social services district as to the applicant's eligibility for MA, whichever occurs first. If a presumptively eligible applicant is subsequently determined to be ineligible for MA, the applicant may request a fair hearing pursuant to Part 358 of this Title to dispute the denial of MA but the period of presumptive eligibility will not be extended by such request.
(d) Presumptive eligibility for pregnant women.
(1) A
pregnant woman will be presumed eligible to receive the MA care, services and
supplies listed in paragraph (9) of this subdivision when a qualified provider
determines, on the basis of preliminary information, that the pregnant woman's
family income does not exceed 185 percent of the applicable poverty line listed
in section
360-4.7(b) of
this Part.
(2) For purposes of this
subdivision, the pregnant woman's family income will be determined according to
section 360-4.6 of this Part relating to
financial eligibility for MA. The resources of the pregnant woman's family will
not be considered in determining the pregnant woman's presumptive eligibility
for MA.
(3) For purposes of this
subdivision, a pregnant woman's family includes the pregnant woman, any legally
responsible relatives and any legally dependent relatives with whom she
resides.
(4) As used in this
subdivision, the term qualified provider means a provider who:
(i) is eligible to receive payment under the
MA program;
(ii) provides one or
more of the following types of services:
(a)
outpatient hospital services;
(b)
rural health clinic services; or
(c) clinic services furnished by or under the
direction of a physician, without regard to whether the clinic itself is
administered by a physician;
(iii) has been found by the department to be
capable of making presumptive eligibility determinations based on family
income; and
(iv) meets at least one
of the following additional criteria:
(a)
receives funds under the Federal Migrant Health Centers or Community Health
Centers programs pursuant to the Federal Public Health Service Act;
(b) receives funds under the Federal Maternal
and Child Health Services Block Grant programs pursuant to title V of the
Federal Social Security Act;
(c)
participates in the program established under the Federal Special Supplemental
Food Program for Women, Infants, and Children pursuant to the Federal Child
Nutrition Act of 1966;
(d)
participates in the program established under the Federal Commodity
Supplemental Food Program pursuant to the Federal Agriculture and Consumer
Protection Act of 1973; or
(e)
participates in the New York State Department of Health's Prenatal Care
Assistance Program (PCAP), established pursuant to article 25 of the Public
Health Law (PHL).
(5) A pregnant woman who has been determined
presumptively eligible for MA must submit an MA application to the social
services district in which she resides by the last day of the month following
the month in which a qualified provider determined her to be presumptively
eligible.
(6) A qualified provider
that has determined a pregnant woman to be presumptively eligible for MA must:
(i) on the day the qualified provider
determines the pregnant woman to be presumptively eligible, inform her that she
must submit an MA application to the social services district in which she
resides by the last day of the following month in order to continue her
presumptive eligibility until the day the social services district determines
her eligibility;
(ii) assist her to
complete the MA application and submit the application on her behalf;
(iii) within five business days after the day
the qualified provider determines the pregnant woman to be presumptively
eligible, notify the social services district in which the pregnant woman
resides of its presumptive eligibility determination on forms the department
develops or approves; and
(iv) if
the qualified provider participates in PCAP, offer to represent the
presumptively eligible pregnant woman during the remainder of the MA
eligibility process, including acting as her representative at the personal
interview the social services district conducts pursuant to section
360-2.2 of this Part.
(7) The period of presumptive
eligibility for MA begins on the day a qualified provider determines the
pregnant woman to be presumptively eligible. If the pregnant woman submits an
MA application to the social services district in which she resides by the last
day of the following month, the period of presumptive eligibility continues
through the day the social services district determines whether the pregnant
woman is eligible for MA; if the pregnant woman fails to submit such an
application, the period of presumptive eligibility continues through the last
day of the following month.
(8) A
pregnant woman is eligible for only one period of presumptive eligibility
during each pregnancy.
(9) A
presumptively eligible pregnant woman is eligible for medical care, services
and supplies as follows:
(i) a presumptively
eligible pregnant woman whose family income does not exceed 100 percent of the
applicable poverty line, as listed in section
360-4.7(b) of
this Part, is eligible for all medical care, services and supplies available
under the MA program, excluding inpatient and institutional long-term care;
and
(ii) a presumptively eligible
pregnant woman whose family income exceeds 100 percent of the applicable
poverty line but does not exceed 185 percent of such line, as listed in section
360-4.7(b) of
this Part, is eligible for comprehensive prenatal care services available under
PCAP, as described in section
2522 of the
Public Health Law, excluding inpatient care.
(10) If a presumptively eligible pregnant
woman is subsequently determined to be ineligible for MA, she may request a
fair hearing pursuant to Part 358 of this Title to dispute the denial of MA,
but her presumptive eligibility period will not be extended by such
request.
(e) Presumptive eligibility for coverage of family planning benefit program (FPBP) services.
(1) An individual
will be presumed eligible to receive the MA care, services and supplies listed
in paragraph (8) of this subdivision when a qualified provider determines, on
the basis of preliminary information, that the individual's family income does
not exceed 200 percent of the Federal poverty line applicable to a family of
the same size.
(2) For purposes of
this subdivision, the individual's family income will be determined according
to section
360-4.6 of this Part relating to
financial eligibility for MA. The resources of the individual's family will not
be considered in determining the individual's presumptive eligibility for
coverage of FPBP services.
(3) For
purposes of this subdivision, an individual's family includes the individual,
any legally responsible relatives and any legally dependent relatives with whom
he or she resides. In determining eligibility for children under 21, parental
income is disregarded when the child requests confidentiality, has good cause
not to provide or is otherwise unable to obtain parental income
information.
(4) As used in this
subdivision, the term qualified provider means a provider who:
(i) is eligible to receive payment under the
MA program;
(ii) provides family
planning services, treatment and supplies; and
(iii) has been found by the department to be
capable of making presumptive eligibility determinations based on family
income.
(5) An
individual who has been determined presumptively eligible for coverage of FPBP
services must submit a FPBP application to the social services district in
which he or she resides, or to the department or its agent, by the last day of
the month following the month in which a qualified provider determined him or
her to be presumptively eligible.
(6) A qualified provider that has determined
an individual to be presumptively eligible for coverage of FPBP services must:
(i) on the day the qualified provider
determines the individual to be presumptively eligible, inform the individual
that a FPBP application must be submitted to the social services district in
which he or she resides, or to the department or its agent, by the last day of
the following month in order to continue presumptive eligibility until the day
his or her FPBP eligibility is determined;
(ii) assist the individual to complete the
FPBP application and submit the application on his or her behalf; and
(iii) within five business days after the day
the qualified provider determines the individual to be presumptively eligible,
notify the social services district in which the individual resides, or the
department or its agent, of its presumptive eligibility determination on forms
the department develops or approves.
(7) The period of presumptive eligibility for
coverage of FPBP services begins on the day a qualified provider determines the
individual to be presumptively eligible. If the individual submits a FPBP
application to the social services district in which he or she resides, or to
the department or its agent, by the last day of the following month, the period
of presumptive eligibility continues through the day the individual's
eligibility for FPBP is determined; if the individual fails to submit such an
application, the period of presumptive eligibility continues through the last
day of the following month.
(8) An
individual found presumptively eligible pursuant to this subdivision is
eligible for coverage of the following medically necessary FPBP services and
appropriate transportation to obtain such services:
(i) hospital based and free standing
clinics;
(ii) county health
department clinics;
(iii) federally
qualified health centers or rural health centers;
(iv) obstetricians and
gynecologists;
(v) family practice
physicians;
(vi) licensed midwives,
nurse practitioners; and
(vii)
family planning related services from pharmacies and laboratories.
(9) If a presumptively eligible
individual is subsequently determined to be ineligible for FPBP, he or she may
request a fair hearing pursuant to Part 358 of this Title to dispute the denial
of FPBP, but the presumptive eligibility period will not be extended by such
request.
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