New York Codes, Rules and Regulations
Title 9 - EXECUTIVE DEPARTMENT
Subtitle KK - Program for Elderly Pharmaceutical Insurance Coverage
Part 9720 - Rights And Obligations Of The Applicant/participant
Section 9720.2 - Right to a fair hearing

Universal Citation: 9 NY Comp Codes Rules and Regs ยง 9720.2

Current through Register Vol. 46, No. 12, March 20, 2024

(a) Applicants and participants shall be entitled to a fair hearing to have a contractor's determination after reconsideration reviewed on the following grounds:

(1) denial of benefits;

(2) failure to determine the applicant's eligibility or, if found eligible, failure to issue a card or authorize services within three days from the date the applicant met his/her registration fee, premium or deductible requirement;

(3) discontinuance or suspension of coverage, in whole or in part;

(4) computation of his/her cost-sharing responsibilities;

(5) any other grounds affecting the applicant or participant's coverage, including a determination of the receipt of medical assistance or equivalent or better public or private insurance benefits.

(b) Notwithstanding the above, participants have no right to a hearing when the contractor discontinues payment to a provider or the panel authorizes a mass change.

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