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 531 - Reimbursement For Ma Provided To Presumptively Eligible Applicants
Section 531.1 - Basic policy

(a) Medical assistance payments for care and services provided during a period of presumptive eligibility, as described in section 360.24(d) of this Title, will be made from State funds. Payment for services provided by a certified home health agency or a long-term home health care program during the period of presumptive eligibility will not exceed 65 percent of the established medical assistance rate for such services. After the applicant is determined to be eligible for medical assistance, payment will be made for the remaining 35 percent of the cost of such services, and a retroactive adjustment will be made to reflect Federal financial participation and the local share of costs for all medical assistance provided during the period of presumptive eligibility.

(b) Except as provided in subdivision (c) of this section, if an applicant presumed eligible for medical assistance is subsequently determined to be ineligible, the cost for services provided during the period of presumptive eligibility will be reimbursed in accordance with the provisions of section 368-a(1)(g) of the Social Services Law.

(c) If, after an audit, the department determines that subsequent determinations of ineligibility have occurred in at least 15 percent of the cases in which presumptive eligibility has been granted by a particular social services district, payments for care and services provided to all persons presumed eligible pursuant to section 360.24(d) of this Title, and subsequently determined ineligible, will be divided equally between the State and the district.

(d) The payment policy described in this Part applies to care and services provided on or after May 1, 1988.