S T A T E O F N E W Y O R K
________________________________________________________________________
5227
2013-2014 Regular Sessions
I N A S S E M B L Y
February 21, 2013
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Introduced by M. of A. BRENNAN, DINOWITZ, GOTTFRIED, ORTIZ, RIVERA,
PEOPLES-STOKES, CASTRO, CAHILL, JAFFEE -- Multi-Sponsored by -- M. of
A. GALEF, JACOBS, LUPARDO, SWEENEY -- read once and referred to the
Committee on Social Services
AN ACT to amend the social services law, in relation to the medical
assistance presumptive eligibility program
THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM-
BLY, DO ENACT AS FOLLOWS:
Section 1. Subdivisions 1, 2 and 3 of section 364-i of the social
services law, as amended by chapter 693 of the laws of 1996, are amended
to read as follows:
1. (A) An individual, upon application for medical assistance, shall
be presumed eligible for such assistance for a period of sixty days from
the date of transfer from a general hospital, as defined in section
twenty-eight hundred one of the public health law to a certified home
health agency or long term home health care program, as defined in
section thirty-six hundred two of the public health law, or to a hospice
as defined in section four thousand two of the public health law, or to
a residential health care facility as defined in section twenty-eight
hundred one of the public health law, if the local department of social
services determines that the applicant meets each of the following
criteria: [(a)] (I) the applicant is receiving acute care in such hospi-
tal; [(b)] (II) a physician certifies that such applicant no longer
requires acute hospital care, but still requires medical care which can
be provided by a certified home health agency, long term home health
care program, hospice or residential health care facility; [(c)] (III)
the applicant or his representative states that the applicant does not
have insurance coverage for the required medical care and that such care
cannot be afforded; [(d)] (IV) it reasonably appears that the applicant
is otherwise eligible to receive medical assistance; [(e)] (V) it
reasonably appears that the amount expended by the state and the local
EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
[ ] is old law to be omitted.
LBD03988-01-3
A. 5227 2
social services district for medical assistance in a certified home
health agency, long term home health care program, hospice or residen-
tial health care facility, during the period of presumed eligibility,
would be less than the amount the state and the local social services
district would expend for continued acute hospital care for such person;
and [(f)] (VI) such other determinative criteria as the commissioner OF
HEALTH shall provide by rule or regulation. If a person has been deter-
mined to be presumptively eligible for medical assistance, pursuant to
this subdivision, and is subsequently determined to be ineligible for
such assistance, the commissioner OF HEALTH, on behalf of the state and
the local social services district shall have the authority to recoup
from the individual the sums expended for such assistance during the
period of presumed eligibility.
(B) AN INDIVIDUAL, UPON APPLICATION FOR MEDICAL ASSISTANCE, SHALL BE
PRESUMED ELIGIBLE FOR SUCH ASSISTANCE FOR CARE, SERVICES AND SUPPLIES
RELATED TO THE TREATMENT OF A MENTAL ILLNESS FOR A PERIOD OF NINETY DAYS
FROM THE DATE OF DISCHARGE FROM A HOSPITAL, AS DEFINED IN SECTION 1.03
OF THE MENTAL HYGIENE LAW, A CORRECTIONAL FACILITY AS DEFINED IN PARA-
GRAPH (A) OF SUBDIVISION FOUR OF SECTION TWO OF THE CORRECTION LAW OR A
LOCAL CORRECTIONAL FACILITY AS DEFINED IN PARAGRAPH (A) OF SUBDIVISION
SIXTEEN OF SECTION TWO OF THE CORRECTION LAW, IF THE LOCAL DEPARTMENT OF
SOCIAL SERVICES DETERMINES THAT THE APPLICANT MEETS EACH OF THE FOLLOW-
ING CRITERIA: (I) THE APPLICANT IS SEVERELY AND PERSISTENTLY MENTALLY
ILL; (II) A PHYSICIAN CERTIFIES THAT SUCH APPLICANT REQUIRES MEDICAL
CARE TO TREAT SUCH MENTAL ILLNESS; (III) THE APPLICANT OR HIS REPRESEN-
TATIVE STATES THAT THE APPLICANT DOES NOT HAVE INSURANCE COVERAGE FOR
THE REQUIRED MEDICAL CARE AND THAT SUCH CARE CANNOT BE AFFORDED; (IV) IT
REASONABLY APPEARS THAT THE APPLICANT IS OTHERWISE ELIGIBLE TO RECEIVE
MEDICAL ASSISTANCE; (V) IT REASONABLY APPEARS THAT THE AMOUNT EXPENDED
BY THE STATE AND THE LOCAL SOCIAL SERVICES DISTRICT FOR MEDICAL ASSIST-
ANCE FOR TREATMENT OF A MENTAL ILLNESS DURING THE PERIOD OF PRESUMED
ELIGIBILITY, WOULD BE LESS THAN THE AMOUNT THE STATE AND THE LOCAL
SOCIAL SERVICES DISTRICT WOULD EXPEND FOR CONTINUED OR FUTURE ACUTE
HOSPITAL CARE FOR SUCH PERSON; AND (VI) SUCH OTHER DETERMINATIVE CRITE-
RIA AS THE COMMISSIONER OF HEALTH SHALL PROVIDE BY RULE OR REGULATION.
IF A PERSON HAS BEEN DETERMINED TO BE PRESUMPTIVELY ELIGIBLE FOR MEDICAL
ASSISTANCE, PURSUANT TO THIS SUBDIVISION, AND IS SUBSEQUENTLY DETERMINED
TO BE INELIGIBLE FOR SUCH ASSISTANCE, THE COMMISSIONER OF HEALTH, ON
BEHALF OF THE STATE AND THE LOCAL SOCIAL SERVICES DISTRICT SHALL HAVE
THE AUTHORITY TO RECOUP FROM THE INDIVIDUAL THE SUMS EXPENDED FOR SUCH
ASSISTANCE DURING THE PERIOD OF PRESUMED ELIGIBILITY.
2. (A) Payment for up to sixty days of care for services provided
under the medical assistance program shall be made for an applicant
presumed eligible for medical assistance pursuant to PARAGRAPH (A) OF
subdivision one of this section provided, however, that such payment
shall not exceed sixty-five percent of the rate payable under this title
for services provided by a certified home health agency, long term home
health care program, hospice or residential health care facility.
(B) PAYMENT FOR UP TO NINETY DAYS OF CARE FOR SERVICES PROVIDED UNDER
THE MEDICAL ASSISTANCE PROGRAM SHALL BE MADE FOR AN APPLICANT PRESUMED
ELIGIBLE FOR MEDICAL ASSISTANCE FOR CARE, SERVICES AND SUPPLIES RELATED
TO THE TREATMENT OF A MENTAL ILLNESS PURSUANT TO PARAGRAPH (B) OF SUBDI-
VISION ONE OF THIS SECTION, PROVIDED HOWEVER, THAT SUCH PAYMENT SHALL
NOT EXCEED ONE HUNDRED PERCENT OF THE RATE PAYABLE UNDER THIS TITLE FOR
SUCH CARE, SERVICES AND SUPPLIES.
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(C) Notwithstanding any other provision of law, no federal financial
participation shall be claimed for services provided to a person while
presumed eligible for medical assistance under this program until such
person has been determined to be eligible for medical assistance by the
local social services district. During the period of presumed medical
assistance eligibility, payment for services provided persons presumed
eligible under this program shall be made from state funds. [Upon] (I)
IN THE CASE OF COSTS INCURRED FOR A PERSON PRESUMPTIVELY ELIGIBLE FOR
MEDICAL ASSISTANCE UNDER PARAGRAPH (A) OF SUBDIVISION ONE OF THIS
SECTION, UPON the final determination of eligibility by the local social
services district, payment shall be made for the balance of the cost of
such care and services provided to such applicant for such period of
eligibility and a retroactive adjustment shall be made by the department
OF HEALTH to appropriately reflect federal financial participation and
the local share of costs for the services provided during the period of
presumptive eligibility. Such federal and local financial participation
shall be the same as that which would have occurred if a final determi-
nation of eligibility for medical assistance had been made prior to the
provision of the services provided during the period of presumptive
eligibility. In instances where an individual who is presumed eligible
for medical assistance is subsequently determined to be ineligible, the
cost for services provided to such individual shall be reimbursed in
accordance with the provisions of section three hundred sixty-eight-a of
this [article] TITLE. Provided, however, if upon audit the department OF
HEALTH determines that there are subsequent determinations of ineligi-
bility for medical assistance in at least fifteen percent of the cases
in which presumptive eligibility has been granted in a local social
services district, payments for services provided to all persons
presumed eligible and subsequently determined ineligible for medical
assistance shall be divided equally by the state and the district.
(II) IN THE CASE OF COSTS INCURRED FOR A PERSON PRESUMPTIVELY ELIGIBLE
FOR MEDICAL ASSISTANCE UNDER PARAGRAPH (B) OF SUBDIVISION ONE OF THIS
SECTION UPON THE FINAL DETERMINATION OF ELIGIBILITY BY THE LOCAL SOCIAL
SERVICES DISTRICT, PAYMENT SHALL BE MADE FOR THE BALANCE OF THE COST OF
SUCH CARE AND SERVICES PROVIDED TO SUCH APPLICANT FOR SUCH PERIOD OF
ELIGIBILITY AND A RETROACTIVE ADJUSTMENT SHALL BE MADE BY THE DEPARTMENT
OF HEALTH TO APPROPRIATELY REFLECT FEDERAL FINANCIAL PARTICIPATION AND
THE LOCAL SHARE OF COSTS FOR THE SERVICES PROVIDED DURING THE PERIOD OF
PRESUMPTIVE ELIGIBILITY. SUCH FEDERAL FINANCIAL PARTICIPATION SHALL BE
THE SAME AS THAT WHICH WOULD HAVE OCCURRED IF A FINAL DETERMINATION OF
ELIGIBILITY FOR MEDICAL ASSISTANCE HAD BEEN MADE PRIOR TO THE PROVISION
OF THE SERVICES PROVIDED DURING THE PERIOD OF PRESUMPTIVE ELIGIBILITY.
THERE SHALL BE NO LOCAL SHARE IN THE COSTS OF SUCH ASSISTANCE DURING THE
PRESUMPTIVE ELIGIBILITY PERIOD; PROVIDED HOWEVER THAT IF UPON AUDIT THE
DEPARTMENT OF HEALTH DETERMINES THAT THERE ARE SUBSEQUENT DETERMINATIONS
OF INELIGIBILITY FOR MEDICAL ASSISTANCE IN AT LEAST FIFTEEN PERCENT OF
THE CASES IN WHICH PRESUMPTIVE ELIGIBILITY HAS BEEN GRANTED IN A LOCAL
SOCIAL SERVICES DISTRICT, PAYMENTS FOR SERVICES PROVIDED TO ALL PERSONS
PRESUMED ELIGIBLE AND SUBSEQUENTLY DETERMINED INELIGIBLE FOR MEDICAL
ASSISTANCE SHALL BE REIMBURSED IN ACCORDANCE WITH THE PROVISIONS OF
SECTION THREE HUNDRED SIXTY-EIGHT-A OF THIS TITLE.
3. On or before March thirty-first, [nineteen hundred ninety-seven]
TWO THOUSAND SIXTEEN, the department OF HEALTH shall submit to the
governor and legislature an evaluation of the program, including the
program's effects on access, quality and cost of care, and any recommen-
dations for future modifications to improve the program.
A. 5227 4
S 2. Subdivision 1 of section 368-a of the social services law is
amended by adding a new paragraph (aa) to read as follows:
(AA) NOTWITHSTANDING ANY INCONSISTENT PROVISION OF LAW, REIMBURSEMENT
BY THE STATE FOR PAYMENTS MADE, WHETHER BY THE DEPARTMENT OF HEALTH ON
BEHALF OF A LOCAL SOCIAL SERVICES DISTRICT PURSUANT TO SECTION THREE
HUNDRED SIXTY-SEVEN-B OF THIS TITLE OR BY A LOCAL SOCIAL SERVICES
DISTRICT DIRECTLY, FOR MEDICAL ASSISTANCE FURNISHED TO AN INDIVIDUAL
PRESUMED ELIGIBLE FOR MEDICAL ASSISTANCE UNDER PARAGRAPH (B) OF SUBDIVI-
SION ONE OF SECTION THREE HUNDRED SIXTY-FOUR-I OF THIS TITLE, DURING THE
PRESUMPTIVE ELIGIBILITY PERIOD, SHALL BE MADE FOR THE FULL AMOUNT
EXPENDED FOR SUCH ASSISTANCE, AFTER FIRST DEDUCTING THEREFROM ANY FEDER-
AL FUNDS PROPERLY RECEIVED OR TO BE RECEIVED ON ACCOUNT OF SUCH EXPENDI-
TURE; PROVIDED THAT IF UPON AUDIT THE DEPARTMENT OF HEALTH DETERMINES
THAT THERE ARE SUBSEQUENT DETERMINATIONS OF INELIGIBILITY FOR MEDICAL
ASSISTANCE IN AT LEAST FIFTEEN PERCENT OF THE CASES IN WHICH PRESUMPTIVE
ELIGIBILITY HAS BEEN GRANTED IN A LOCAL SOCIAL SERVICES DISTRICT,
PAYMENTS FOR SERVICES PROVIDED TO ALL PERSONS PRESUMED ELIGIBLE AND
SUBSEQUENTLY DETERMINED INELIGIBLE FOR MEDICAL ASSISTANCE SHALL BE REIM-
BURSED IN ACCORDANCE WITH PARAGRAPH (D) OF THIS SUBDIVISION.
S 3. This act shall take effect April 1, 2015.