New York Codes, Rules and Regulations
Title 18 - DEPARTMENT OF SOCIAL SERVICES
Chapter II - Regulations of the Department of Social Services
Subchapter E - Medical Care
Article 4 - Fees and Reimbursement
Part 527 - State Reimbursement For Payment To Out-of-state Providers Of Medical Care And Services
Section 527.1 - Maximum reimbursable fee schedule
Universal Citation: 18 NY Comp Codes Rules and Regs ยง 527.1
Current through Register Vol. 46, No. 39, September 25, 2024
(a) Maximum reimbursable rates for payments made to out-of-state providers of medical care and services shall be as foliows:
(1) Effective January 1, 1984, for
inpatient hospital care, the lowest of the following charges:
(i) the title XIX payment established for the
hospital under the Medical Assistance Program in that state;
(ii) the title XVIII Medicare payment
established for the hospital;
(iii)
the hospital's customary charge for public beneficiaries; or
(iv) the maximum New York State title XIX
payment for similar inpatient care.
(2) For care in a nursing facility, charges
in accordance with rates negotiated by the commissioner which will not, with
the exception of ancillary services not included in that state's medical
assistance rate, exceed the rate established for the facility under that
state's medical assistance program. A nursing facility may arrange for the
provision of ancillary services through contractual agreements or may use
providers who are enrolled in the State's medical assistance program and bill
the State directly on a fee for service basis. Ancillary services are those
services which are required to be provided to medical assistance recipients
receiving nursing facility care but which the nursing facility is not required
to provide directly.
(3) For all
other medical care and services:
(i) rates
applicable to New York State providers for similar services when the care was
rendered by an out-of-state provider of services who is located within the
usual medical marketing area of the community where the patient resides;
or
(ii) charges as billed by the
out-of-state provider of services when such provider of service is located
outside the usual medical marketing area of the community where the patient
resides.
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