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 360-7 - Payment For Services
Section 360-7.3 - Use of health, hospital or accident insurance

(1) Insurance providing full coverage. A recipient's insurance is providing full coverage when the recipient's care is paid for under the insurance contract without the payment of any coinsurance amount, deductible, or Medicare.

(2) Insurance providing partial coverage. A recipient's insurance is providing partial coverage when payment for his/her care under the insurance contract is subject to payment of a coinsurance amount, deductible, or Medicare.

(3) Indemnity insurance coverage is any insurance benefit a recipient receives because of accident or injury. Examples of this type of insurance are automobile and liability insurance and workers' compensation benefits.

(4) Coinsurance amount or deductible are amounts an insurance beneficiary must pay when he/she receives care or services.

(1) Using insurance benefits to pay for care provided to a recipient by a medical institution:

(2) Using insurance benefits to pay for care provided to recipients by persons and agencies other than medical institutions.

(3) The social services district staff must obtain from applicants/recipients information about their private health coverage. This information includes insurance coverage which may be available to the applicant/recipient through an absent parent or spouse. If the applicant/recipient is unaware of what coverage is available through an absent parent or spouse, the social services district is responsible for getting the information from either the absent parent or spouse or their employers. The applicant/recipient must provide the social services district with the name of the insurance carrier, type of coverage, policy number, and amount of the premium payment.

(1) Children under 21 years of age may be eligible for medical services under the children with physical disabilities program (formerly the physically handicapped children's program) provided for under title V of article 25 of the Public Health Law. The social services district must promptly refer the case of a child who may be eligible for this program to the local program medical director. If the local program medical director determines that the child is medically eligible, MA-covered services must be provided in accordance with the plan of care approved by the local program medical director. Once the social services district official has been notified that the child is medically eligible, the child's financial eligibility for MA must be determined, in accordance with the agreement between the State Department of Health and the State Department of Social Services. If the child is eligible for MA with no parental liability, the medical services must be authorized by the social services district and paid for from MA funds. If the child's parents are required to contribute toward the cost of his/her care under MA eligibility standards, the child's case must be referred to the children with physical disabilities program for payment of the cost of medical services up to the amount of the child's excess income.

(2) The social services district must review any existing support order which has been entered for a recipient's benefit against a spouse or parent. The social services district must petition to amend orders of support to provide that the parent or spouse participate in a family medical insurance plan if one is available through the parent's or spouse's employer.