Current through Register Vol. 46, No. 39, September 25, 2024
(a) The CHCEP is available to a family which:
is ineligible for MA and PA; meets the residency requirements of section 369-c
of the Social Services Law; and has eligible catastrophic health care
expenses.
(b)
(1) The CHCEP assistance with cost sharing of
eligible catastrophic health care expenses is available to a family if its
health care expenses, after deducting health insurance benefits, are in excess
of 50 percent, but are no more than 75 percent, of the difference between the
adjusted or projected annual family income and the maximum PA grant it would
receive if it were eligible for PA.
(2) For a family which is eligible for the
CHCEP assistance with cost sharing under paragraph (1) of this subdivision, the
CHCEP will pay a percentage of the expenses for covered services and the family
must pay the remainder. The Commissioner of Health has established a schedule
setting forth the cost-sharing percentages which will be used to allocate costs
between families and the CHCEP for the various CHCEP services (10 NYCRR 85.42).
The CHCEP share of the expenses will be determined by multiplying the cost
sharing percentage by the MA rate for the service or the rate charged by the
provider of the service, whichever is less.
(3) A family in receipt of the CHCEP
assistance with cost sharing may be reimbursed only for paid bills for health
care services incurred during the previous calendar year, unless the family
demonstrates hardship as defined in section
360-9.3 of
this Subpart. If hardship is demonstrated, the family in receipt of the CHCEP
may be reimbursed up to the MA rate for the current year's expenses. When the
social services district determines that hardship exists, payments may be made
directly to the provider of the health care services. The social services
district may determine that hardship exists at the time a family applies for an
interim authorization or assistance with or without cost sharing under this
Subpart.
(c)
(1) The CHCEP assistance without cost sharing
of eligible catastrophic health care expenses is available to a family if its
health care expenses, after deducting health insurance benefits and the
benefits available pursuant to section 360-9.4(b) of this Subpart, are in
excess of 75 percent of the difference between the adjusted or projected annual
family income and the maximum PA grant it would receive if it were eligible for
PA.
(2) For a family which is
eligible for the CHCEP assistance without cost sharing under paragraph (1) of
this subdivision, the CHCEP will reimburse a family for the bills it has paid
for covered services and directly pay the provider of service for unpaid bills.
The CHCEP will reimburse or pay for such bills at the MA rate for the service
or the rate charged by the provider of the service, whichever is
less.
(d) A family may
apply to the social services district for an interim authorization which would
enable the family, on a prospective basis, to have any medical expenses covered
under the MA program reduced to the MA rate or fee. To be eligible for an
interim authorization, a family must be eligible for the CHCEP pursuant to
subdivision (b) or (c) of this section. The social services district must use
projected income and allowable deductions to compute the current year's
adjusted income for purposes of determining eligibility for interim
authorization. The interim authorization may not extend beyond the final day of
the calendar year in which the services were rendered and in which eligibility
for the CHCEP assistance was based.
