Current through Register Vol. 47, No. 12, March 26, 2025
(a)
(1)
Except as provided in paragraphs (2) through (4) of this subdivision, payment
by the MA program for services covered under the program which are medically
necessary in amount, duration, and scope, will be made to the enrolled MA
provider which furnished the services, at the MA rate or fee in effect at the
time the services were provided.
(2) Payment may be made to:
(i) a practitioner's employer if the
practitioner would be required to do so as a condition of employment;
(ii) the facility in which such services were
provided if the facility submits the claim under a contract between a
practitioner and the facility; or
(iii) an organization, including a health
maintenance organization, which furnishes health care through an organized
health care delivery system, if there is a contract between the organization
and the practitioner under which the organization bills or receives payment for
the services.
(3)
(i) Payment may be made to a recipient or the
recipient's representative for paid medical bills if:
(a) an erroneous MA eligibility determination
is reversed (whether the reversal is due to the social services district
discovering its own error or is the result of a fair hearing decision or court
order), or the social services district fails to determine MA eligibility
within the time periods set forth in section
360-2.4 of this Part;
and
(b) the erroneous eligibility
determination or the delay in determining eligibility caused the recipient or
the recipient's representative to pay for medically necessary services which
otherwise would have been paid for by the MA program.
(ii) Payment under this paragraph is not
limited to the MA rate or fee in effect at the time the services were provided,
but may be made to reimburse the recipient's or the recipient's
representative's reasonable out-of-pocket expenditures. In addition, payment
under this paragraph may be made with respect to services furnished by a
provider who is not enrolled in the MA program, if such provider is otherwise
lawfully qualified to provide the services, and had not been excluded or
otherwise sanctioned from the MA program under Part 515 of this
Title.
(iii) For purposes of
subparagraph (ii) of this paragraph, an out-of-pocket expenditure will be
considered reasonable if it does not exceed 110 percent of the MA payment rate
for the service. If an out-of-pocket expenditure exceeds 110 percent of the MA
payment rate, the social services district will determine whether the
expenditure is reasonable. In making this determination, the district may
consider the prevailing private pay rate in the community at the time services
were rendered, and any special circumstances demonstrated by the
recipient.
(4) Payment
may be made to a recipient or the recipient's representative for paid medical
bills for services received during the recipient's retroactive eligibility
period, provided that the recipient was eligible in the month in which the
services were received, in accordance with the provisions of this paragraph.
(i) For services received during the period
beginning on the first day of the third month prior to the month of the MA
application and ending on the date the recipient applied for MA, payment can be
made without regard to whether the provider of services was enrolled in the MA
program. However, if the services were furnished by a provider not enrolled in
the MA program, the provider must have been otherwise lawfully qualified to
provide such services, and must not have been excluded or otherwise sanctioned
from the MA program under Part 515 of this Title. If services were provided
when the recipient was temporarily absent from the State, payment will be made
if: MA recipients customarily use medical facilities in the other state; or the
services were obtained to treat an emergency medical condition resulting from
an accident or sudden illness.
(ii)
For services received during the period beginning after the date the recipient
applied for MA and ending on the date the recipient received his or her MA
identification card, payment may be made only if the services were furnished by
a provider enrolled in the MA program.
(b) The claim of any provider of medical
care, services, or supplies assigned under a power of attorney or otherwise, is
invalid and cannot be enforced against a social services district. However, an
assignment from a supplier to a governmental agency or entity or an assignment
established under a court order is valid.
(c) A provider of medical care, services, or
supplies may employ a business agent, such as a billing service or an
accounting firm. Such agent may prepare and send bills and receive MA payments
in the name of the provider only if the compensation paid to the agent is:
(1) reasonably related to the cost of the
services;
(2) unrelated, directly
or indirectly, to the dollar amounts billed and collected; and
(3) not dependent on actual collection of
payments.
(d) A social
services district may use any appropriate organization as a fiscal intermediary
to audit and pay for the district's share of the cost of medical care, services
and supplies provided to recipients. An appropriate organization is any
insurance carrier authorized to conduct audits and make payments to providers
who furnish services under Medicare. A social services district must enter into
an agreement with the organization that meets the requirements of this
provision and other appropriate Federal authorities. The department must
approve the agreement before the organization can be used as a fiscal
intermediary.
(e) Payment for a
recipient's transportation costs will be made to the vendor. If payment cannot
be made directly to the vendor, it will be made to the recipient as an
administrative expense. When the services of an attendant are essential,
payment for the attendant's transportation costs will be made to the vendor. If
payment cannot be made directly to the vendor, payment will be made to the
attendant as an administrative expense.
(f) Payment for home health aide services
will be made in the same manner as payment for any other medical care provided
under the MA program.
(g) Payment
or part-payment of the premium for personal health insurance covering care and
other medical benefits which are authorized under the MA program may be made to
the insurance carrier or to another appropriate third party:
(1) on behalf of MA households eligible for
ADC, HR or extended MA coverage pursuant to paragraphs (1) and (2) of section
360-3.3(c) of
this Part, for cost-effective, employer-sponsored group health insurance
benefits. Such premiums will be paid for the benefit of the recipient's spouse
and dependent children. Non-employer health insurance will be paid, in part or
in full, when it would reduce the expense of providing MA services;
(2) on behalf of a recipient if the recipient
is receiving MA as a patient in a medical facility and all the recipient's
nonexempt income except that expended for the cost of such insurance, is
applied to the cost of his/her care; or
(3) on behalf of a recipient or household
which is eligible for MA if the full cost of such insurance premiums was not
used in calculating financial eligibility and if full or partial payment would
reduce the expense of providing MA services.
(h) Payment of the COBRA premiums for COBRA
continuation coverage, as defined in paragraph (1) of this subdivision, will be
made by the MA program on behalf of a person described in paragraph (2) of this
subdivision.
(1)
(i) COBRA continuation coverage means health
insurance coverage required by section 10002 of the Consolidated Omnibus Budget
Reconciliation Act of 1985 (P.L. No. 99-272) and provided under a group health
plan that meets the following requirements:
(a) the group health plan is provided by an
employer of 75 or more employees; and
(b) the group health plan is provided
pursuant to title XXII of the Public Health Service Act, section
4980B of the Internal Revenue Code of
1986, or title VI of the Employee Retirement Income Security Act of
1974.
(ii) COBRA
premiums means the applicable premiums imposed with respect to COBRA
continuation coverage.
(2) The MA program will pay the COBRA
premiums for a person who meets the following requirements:
(i) he or she is entitled to elect COBRA
continuation coverage;
(ii) his or
her income does not exceed 100 percent of the poverty line, as defined in
section 360-1.4(r) of
this Part, applicable to a household of the same size as the person's
household;
(iii) his or her
resources do not exceed twice the maximum amount of resources that a person may
have to be eligible for Federal Supplemental Security Income (SSI) benefits;
and
(iv) the social services
district has determined that the savings in MA expenditures resulting from
enrolling the person for COBRA continuation coverage are likely to exceed the
amount of payments made for the COBRA premiums.
(3) When determining the eligibility of a
person for payment of the COBRA premiums under this subdivision, the social
services district must:
(i) use the Federal
SSI eligibility requirements relating to income and resources; and
(ii) not consider costs that the person or
the person's household has incurred for medical or remedial care.
(4)
(i) The MA program will pay the COBRA
premiums on behalf of a person who has applied to have the program pay for such
premiums and who the social services district reasonably expects will meet the
eligibility requirements of paragraph (2) of this subdivision but for whom the
social services district has not yet received documentation verifying whether
the person is eligible for MA payment of his or her COBRA premiums.
(ii) When the social services district
receives such documentation and determines that such person does not meet the
eligibility requirements of paragraph (2) of this subdivision:
(a) the MA program's payment of the person's
COBRA premiums will terminate;
(b)
the person may request a fair hearing pursuant to Part 358 of this Title to
review the social services district's determination that he or she is
ineligible for the MA program's payment of his or her COBRA premiums; however,
the person will not be entitled to aid continuing; and
(c) the social services district may request
that the person repay the amount of the MA program's payments for his or her
COBRA premiums unless a fair hearing decision has held that the social services
district's determination was incorrect.
(5) The social services district must notify
the person, in writing and on forms required by the department, of its
determination whether the person is eligible, or continues to be eligible, to
have the MA program pay for his or her COBRA premiums. The notice must advise
the person of his or her right to request a fair hearing and of any aid
continuing rights in accordance with Part 358 of this Title.
(i) Payment of health insurance
premiums will be made by the MA program on behalf of a person described in
paragraph (1) of this subdivision.
(1) The MA
program will pay the health insurance premiums for a person who:
(i) has Acquired Immune Deficiency Syndrome
(AIDS) or an Human Immuno-Deficiency Virus (HIV) related illness, as defined by
the AIDS Institute of the Department of Health;
(ii) resides in a household whose income does
not exceed 185 percent of the poverty line, as defined in section
360-1.4(r) of
this Part, applicable to a household of the same size as the person's
household;
(iii)
(a)
is unemployed; participated in the health insurance plan his or her prior
employer provided; and is eligible to continue his or her participation in such
plan or convert his or her coverage to individual coverage;
(b) is employed; participated in the health
insurance plan his or her prior employer provided; is eligible to continue his
or her participation in such plan or convert his or her coverage to individual
coverage; and is ineligible to participate in the health insurance plan that
his or her current employer provides or such employer does not offer a health
insurance plan; or
(c) is or was
self-employed; maintained health insurance coverage while self-employed; and is
eligible to continue his or her participation in such plan or convert his or
her coverage to individual coverage; and
(iv) is ineligible for MA.
(2) When determining the
eligibility of a person for the payment of his or her health insurance premiums
under this subdivision, a social services district must:
(i) use the Federal Supplemental Security
Income eligibility requirements relating to income; and
(ii) not consider the following:
(a) costs that the person or the person's
household has incurred for medical or remedial care; or
(b) resources available to the person or the
person's household.
(3)
(i) The
MA program will pay the health insurance premiums on behalf of a person who has
applied to have the program pay for such premiums and who the social services
district reasonably expects will meet the eligibility requirements of paragraph
(1) of this subdivision but for whom the social services district has not yet
received documentation verifying whether the person is eligible for MA payment
of his or her health insurance premiums.
(ii) When the social services district
receives such documentation and determines that the person does not meet the
eligibility requirements of paragraph (1) of this subdivision:
(a) the MA program's payment under this
subdivision of the person's health insurance premiums will terminate;
(b) the person may request a fair hearing
pursuant to Part 358 of this Title to review the social services district's
determination that he or she is ineligible for the MA program's payment under
this subdivision of his or her health insurance premiums; however, the person
will not be entitled to aid continuing; and
(c) the social services district may request
that the person repay the amount of the MA program's payments for his or her
health insurance premiums unless a fair hearing decision has held that the
social services district's determination was incorrect.
(4) The social services district
must notify the person, in writing and on forms required by the department, of
its determination whether the person is eligible, or continues to be eligible,
to have the MA program pay for his or her health insurance premiums. The notice
must advise the person of his or her right to request a fair hearing and of any
aid continuing rights in accordance with Part 358 of this Title.
(j) Payments will be
made to the facility, agency or person who provided medical services under the
physically handicapped children's program when prior authorization was obtained
from the social services district. Services under this program include
inpatient hospital care, prosthetic appliance costing more than $40 and
prescribed by someone other than a qualified specialist, multiple extractions
and dental prosthesis, and other dental care and services. If, during a period
for which such care and services have been authorized, the recipient or
household becomes ineligible for MA, arrangements must be made with the
recipient or household to pay the social services district for the cost of care
and services provided during the period of MA ineligibility. In such instances,
the social services district will limit accounting division authorization to
the care and services for which prior authorization was obtained. If the
recipient or household remains ineligible for MA when such care and services
are completed, the case will be closed.
