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 360-6 - Entitlement To Medical Assistance
Section 360-6.5 - Fair hearing requirements in utilization review cases
Universal Citation: 18 NY Comp Codes Rules and Regs ยง 360-6.5
Current through Register Vol. 46, No. 39, September 25, 2024
When a utilization review committee determines that MA payments should be reduced or discontinued, the following steps must be taken:
(a) If the recipient is in a long-term care facility (a skilled nursing facility, intermediate care facility or mental hospital) or is a chronic care patient in a general hospital facility:
(1) The recipient, his/her
representative, or an appropriate relative must be notified of the action in
writing by the utilization review committee. The notice must be notified of the
action in writing by the utilization review committee. The notice must be both
timely and adequate as defined in Part 358 of this Title. The notice and action
must be consistent with both State and Federal requirements on utilization
review.
(2) If the recipient
requests a fair hearing before the effective date of the action, payment for
the recipient's care in a long-term care facility or for long-term care in a
general hospital will be continued until the fair hearing decision is
rendered.
(b) If the recipient is in a general hospital, but not receiving chronic care services:
(1) The recipient, his/her representative, or
an appropriate relative must be notified of the action in writing by the
utilization review committee. The notice must be adequate, as defined in Part
358 of this Title. The notice and action must be consistent with both State and
Federal requirements on utilization review.
(2) MA payments on behalf of the recipient
will be terminated on the effective date of the utilization review committee
determination.
(3) MA payments will
not be continued on behalf of the recipient if the recipient requests a fair
hearing to contest a determination that hospitalization is no longer
necessary.
(c) All provisions of Part 358 of this Title which are not inconsistent with subdivisions (a) and (b) of this section apply to utilization review committee determinations.
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