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SECTION 364-I
Medical assistance presumptive eligibility program
Social Services (SOS) CHAPTER 55, ARTICLE 5, TITLE 11
§ 364-i. Medical assistance presumptive eligibility program. 1. 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)
the applicant is receiving acute care in such hospital; (b) 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) 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) it reasonably appears that the applicant is otherwise
eligible to receive medical assistance; (e) it reasonably appears that
the amount expended by the state and the local social services district
for medical assistance in a certified home health agency, long term home
health care program, hospice or residential 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) such other determinative
criteria as the commissioner 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, 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. 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 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. 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 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 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 determination 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. Provided, however, if upon audit
the department 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 divided equally by the state and the district.

3. On or before March thirty-first, nineteen hundred ninety-seven, the
department 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 recommendations for future modifications to improve the
program.

4. (a) Notwithstanding any inconsistent provision of law to the
contrary, a child shall be presumed to be eligible for medical
assistance under this title beginning on the date that a qualified
entity, as defined in paragraph (c) of this subdivision, determine, on
the basis of preliminary information, that the MAGI household income of
the child does not exceed the applicable level for eligibility as
provided for pursuant to subparagraph two or three of paragraph (b) of
subdivision one of section three hundred sixty-six of this title.

(b) Such presumptive eligibility shall continue through the earlier of
the day on which eligibility is determined pursuant to this title, or in
the case of a child on whose behalf an application is not filed by the
last day of the month following the month during which the qualified
entity makes a preliminary determination, the last day of the month
following the month in which the qualified entity makes a determination
in paragraph (a) of this subdivision.

(c) For the purposes of this subdivision, and consistent with the
applicable provisions of section 1920A of the federal social security
act, "qualified entity" means an entity determined by the department of
health to be capable of making presumptive eligibility determinations.

(d) Notwithstanding any inconsistent provision of law to the contrary,
care, services and supplies, as set forth in section three hundred
sixty-five-a of this title, that are furnished to a child during a
presumptive eligibility period by an entity that is eligible for
payments under this title shall be deemed to be medical assistance for
purposes of payment and state and federal reimbursement.

(e) Presumptive eligibility pursuant to this subdivision shall be
implemented effective December first, two thousand seven contingent upon
a determination by the commissioner of health that all necessary systems
and processes are in place to enroll children appropriately in
accordance with the requirements set forth in this title; provided,
however, presumptive eligibility pursuant to this subdivision shall be
implemented no later than April first, two thousand eight.

5. Persons in need of treatment for breast, cervical, colon or
prostate cancer; presumptive eligibility. (a) An individual shall be
presumed to be eligible for medical assistance under this title
beginning on the date that a qualified entity, as defined in paragraph
(c) of this subdivision, determines, on the basis of preliminary
information, that the individual meets the requirements of paragraph (d)
or (e) of subdivision four of section three hundred sixty-six of this
title.

(b) Such presumptive eligibility shall continue through the earlier of
the day on which a determination is made with respect to the eligibility
of such individual for services, or in the case of such an individual
who does not file an application by the last day of the month following
the month during which the qualified entity makes the determination of
presumptive eligibility, such last day.

(c) For the purposes of this subdivision, "qualified entity" means an
entity that provides medical assistance approved under this title, and
is determined by the department of health to be capable of making
determinations of presumptive eligibility under this subdivision.

(d) Care, services and supplies, as set forth in section three hundred
sixty-five-a of this title, that are furnished to an individual during a
presumptive eligibility period under this subdivision by an entity that
is eligible for payments under this title shall be deemed to be medical
assistance for purposes of payment and state reimbursement.

6. (a) A pregnant woman shall be presumed to be eligible for medical
assistance under this title, excluding inpatient services and
institutional long term care, beginning on the date that a prenatal care
provider, licensed under article twenty-eight of the public health law
or other prenatal care provider approved by the department of health
determines, on the basis of preliminary information, that the pregnant
woman's MAGI household income does not exceed the MAGI-equivalent of two
hundred percent of the federal poverty line for the applicable family
size.

(a-2) At the time of application for presumptive eligibility pursuant
to this subdivision, a pregnant woman who resides in a social services
district that has implemented the state's managed care program pursuant
to section three hundred sixty-four-j of this title must choose a
managed care provider. If a managed care provider is not chosen at the
time of application, the pregnant woman will be assigned to a managed
care provider in accordance with subparagraphs (ii), (iii), (iv) and (v)
of paragraph (f) of subdivision four of section three hundred
sixty-four-j of this title.

(b) Such presumptive eligibility shall continue through the earlier
of: the day on which eligibility is determined pursuant to this title;
or the last day of the month following the month in which the provider
makes preliminary determination, in the case of a pregnant woman who
does not file an application for medical assistance on or before such
day.

(c) The department of health shall provide prenatal care providers
licensed under article twenty-eight of the public health law and other
approved prenatal care providers with such forms as are necessary for a
pregnant woman to apply and information on how to assist such women in
completing and filing such forms. A qualified provider which determines
that a pregnant woman is presumptively eligible shall notify the social
services district in which the pregnant woman resides of the
determination within five working days after the date on which such
determination is made and shall inform the woman at the time the
determination is made that she is required to make application by the
last day of the month following the month in which the determination is
made.

(d) Notwithstanding any other provision of law, care that is furnished
to a pregnant woman pursuant to this subdivision during a presumptive
eligibility period shall be deemed as medical assistance for purposes of
payment and state reimbursement.

(e) Facilities licensed under article twenty-eight of the public
health law providing prenatal care services shall perform presumptive
eligibility determinations and assist women in submitting appropriate
documentation to the social services district as required by the
commissioner; provided, however, that a facility may apply to the
commissioner for exemption from this requirement on the basis of undue
hardship.

(f) All prenatal care providers enrolled in the medicaid program must
provide prenatal care services to eligible service recipients determined
presumptively eligible for medical assistance but not yet enrolled in
the medical assistance program, and assist women in submitting
appropriate documentation to the social services district as required by
the commissioner.

7. Notwithstanding any other section of law, where care, services, or
supplies are received prior to the date an individual is determined
eligible for assistance under this title, medical assistance
reimbursement, regardless of funding source, shall be available for such
care, services, or supplies only (a) if the care, services, or supplies
are received during the three month period preceding the month of
application for medical assistance and the recipient is determined to
have been eligible in the month in which the care, service, or supply
was received, or (b) if provided during a period of presumptive
eligibility pursuant to this section.

8. (a) The following individuals shall be presumed to be eligible for
medical assistance under this title beginning on the date that a
qualified hospital, as defined in paragraph (b) of this subdivision,
determines, on the basis of preliminary information, that:

(1) a child has MAGI household income that does not exceed the
applicable level for eligibility as provided for pursuant to
subparagraph two or three of paragraph (b) of subdivision one of section
three hundred sixty-six of this title;

(2) a pregnant woman has MAGI household income that does not exceed
the MAGI-equivalent of two hundred percent of the federal poverty line
for the applicable family size;

(3) a parent or caretaker relative has MAGI household income that does
not exceed the MAGI-equivalent of one hundred thirty percent of the
highest amount that ordinarily would have been paid to a person without
any income or resources under the family assistance program as it
existed on the first day of November, nineteen hundred ninety-seven, or
has net available income, including available support from responsible
relatives, that does not exceed the amounts set forth in paragraph (a)
of subdivision two of section three hundred sixty-six of this title;

(4) an individual in need of treatment of breast, cervical, colon, or
prostate cancer meets the requirements of paragraph (d) or (e) of
subdivision four of section three hundred sixty-six of this title;

(5) an individual age nineteen or older and under age sixty-five meets
the requirements of subparagraph one of paragraph (b) of subdivision one
of section three hundred sixty-six of this title;

(6) an individual under twenty-six years of age meets the requirements
of subparagraph nine of paragraph (c) of subdivision one of section
three hundred sixty-six of this title; and

(7) an individual has income that does not exceed the MAGI-equivalent
of two hundred percent of the federal poverty line for the applicable
family size, and the individual meets the requirements of subparagraph
six of paragraph (b) of subdivision one of section three hundred
sixty-six of this title; coverage pursuant to this subparagraph shall be
limited to family planning services reimbursed by the federal government
at a rate of ninety percent.

(b) For the purposes of this subdivision, "qualified hospital" means a
hospital that:

(1) is licensed as a general hospital under article twenty-eight of
the public health law;

(2) is enrolled as a provider in the program of medical assistance
under this title;

(3) has notified the department of health of its election to make
presumptive eligibility determinations under this subdivision, and
agrees to make such determinations in accordance with policies and
procedures established by the department;

(4) has been designated by the department of health as a certified
application counselor to provide information to individuals concerning
qualified health plans offered through a health insurance exchange and
other insurance affordability programs, assist individuals to apply for
coverage through a qualified health plan or insurance affordability
program, and help facilitate the enrollment of eligible individuals in
such plans or programs; and

(5) has not been disqualified by the department of health pursuant to
paragraph (c) of this subdivision.

(c) The department of health may disqualify a hospital as a qualified
hospital if the department determines that the hospital is not:

(1) making, or is not capable of making, presumptive eligibility
determinations in accordance with the policies and procedures
established by the department; or

(2) meeting such standards as may be established by the department
with respect to the proportion of individuals determined presumptively
eligible by the hospital who are found by the medical assistance program
to be eligible for ongoing medical assistance after the end of the
presumptive eligibility period.

(d) Care, services and supplies, as set forth in section three hundred
sixty-five-a of this title, that are furnished to an individual during a
presumptive eligibility period under this subdivision by an entity that
is eligible for payments under this title shall be deemed to be medical
assistance for purposes of payment and state reimbursement.