S T A T E O F N E W Y O R K ________________________________________________________________________ 1606 2011-2012 Regular Sessions I N S E N A T E January 10, 2011 ___________ Introduced by Sen. MONTGOMERY -- read twice and ordered printed, and when printed to be committed to the Committee on Health 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: 1 Section 1. Subdivisions 1, 2 and 3 of section 364-i of the social 2 services law, as amended by chapter 693 of the laws of 1996, are amended 3 to read as follows: 4 1. (A) An individual, upon application for medical assistance, shall 5 be presumed eligible for such assistance for a period of sixty days from 6 the date of transfer from a general hospital, as defined in section 7 twenty-eight hundred one of the public health law to a certified home 8 health agency or long term home health care program, as defined in 9 section thirty-six hundred two of the public health law, or to a hospice 10 as defined in section four thousand two of the public health law, or to 11 a residential health care facility as defined in section twenty-eight 12 hundred one of the public health law, if the local department of social 13 services determines that the applicant meets each of the following 14 criteria: [(a)] (I) the applicant is receiving acute care in such hospi- 15 tal; [(b)] (II) a physician certifies that such applicant no longer 16 requires acute hospital care, but still requires medical care which can 17 be provided by a certified home health agency, long term home health 18 care program, hospice or residential health care facility; [(c)] (III) 19 the applicant or his representative states that the applicant does not 20 have insurance coverage for the required medical care and that such care 21 cannot be afforded; [(d)] (IV) it reasonably appears that the applicant 22 is otherwise eligible to receive medical assistance; [(e)] (V) it 23 reasonably appears that the amount expended by the state and the local 24 social services district for medical assistance in a certified home 25 health agency, long term home health care program, hospice or residen- EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets [ ] is old law to be omitted. LBD06135-01-1 S. 1606 2 1 tial health care facility, during the period of presumed eligibility, 2 would be less than the amount the state and the local social services 3 district would expend for continued acute hospital care for such person; 4 and [(f)] (VI) such other determinative criteria as the commissioner OF 5 HEALTH shall provide by rule or regulation. If a person has been deter- 6 mined to be presumptively eligible for medical assistance, pursuant to 7 this subdivision, and is subsequently determined to be ineligible for 8 such assistance, the commissioner OF HEALTH, on behalf of the state and 9 the local social services district shall have the authority to recoup 10 from the individual the sums expended for such assistance during the 11 period of presumed eligibility. 12 (B) AN INDIVIDUAL, UPON APPLICATION FOR MEDICAL ASSISTANCE, SHALL BE 13 PRESUMED ELIGIBLE FOR SUCH ASSISTANCE FOR CARE, SERVICES AND SUPPLIES 14 RELATED TO THE TREATMENT OF A MENTAL ILLNESS FOR A PERIOD OF NINETY DAYS 15 FROM THE DATE OF DISCHARGE FROM A HOSPITAL, AS DEFINED IN SECTION 1.03 16 OF THE MENTAL HYGIENE LAW, A CORRECTIONAL FACILITY AS DEFINED IN PARA- 17 GRAPH (A) OF SUBDIVISION FOUR OF SECTION TWO OF THE CORRECTION LAW OR A 18 LOCAL CORRECTIONAL FACILITY AS DEFINED IN PARAGRAPH (A) OF SUBDIVISION 19 SIXTEEN OF SECTION TWO OF THE CORRECTION LAW, IF THE LOCAL DEPARTMENT OF 20 SOCIAL SERVICES DETERMINES THAT THE APPLICANT MEETS EACH OF THE FOLLOW- 21 ING CRITERIA: (I) THE APPLICANT IS SEVERELY AND PERSISTENTLY MENTALLY 22 ILL; (II) A PHYSICIAN CERTIFIES THAT SUCH APPLICANT REQUIRES MEDICAL 23 CARE TO TREAT SUCH MENTAL ILLNESS; (III) THE APPLICANT OR HIS REPRESEN- 24 TATIVE STATES THAT THE APPLICANT DOES NOT HAVE INSURANCE COVERAGE FOR 25 THE REQUIRED MEDICAL CARE AND THAT SUCH CARE CANNOT BE AFFORDED; (IV) IT 26 REASONABLY APPEARS THAT THE APPLICANT IS OTHERWISE ELIGIBLE TO RECEIVE 27 MEDICAL ASSISTANCE; (V) IT REASONABLY APPEARS THAT THE AMOUNT EXPENDED 28 BY THE STATE AND THE LOCAL SOCIAL SERVICES DISTRICT FOR MEDICAL ASSIST- 29 ANCE FOR TREATMENT OF A MENTAL ILLNESS DURING THE PERIOD OF PRESUMED 30 ELIGIBILITY, WOULD BE LESS THAN THE AMOUNT THE STATE AND THE LOCAL 31 SOCIAL SERVICES DISTRICT WOULD EXPEND FOR CONTINUED OR FUTURE ACUTE 32 HOSPITAL CARE FOR SUCH PERSON; AND (VI) SUCH OTHER DETERMINATIVE CRITE- 33 RIA AS THE COMMISSIONER OF HEALTH SHALL PROVIDE BY RULE OR REGULATION. 34 IF A PERSON HAS BEEN DETERMINED TO BE PRESUMPTIVELY ELIGIBLE FOR MEDICAL 35 ASSISTANCE, PURSUANT TO THIS SUBDIVISION, AND IS SUBSEQUENTLY DETERMINED 36 TO BE INELIGIBLE FOR SUCH ASSISTANCE, THE COMMISSIONER OF HEALTH, ON 37 BEHALF OF THE STATE AND THE LOCAL SOCIAL SERVICES DISTRICT SHALL HAVE 38 THE AUTHORITY TO RECOUP FROM THE INDIVIDUAL THE SUMS EXPENDED FOR SUCH 39 ASSISTANCE DURING THE PERIOD OF PRESUMED ELIGIBILITY. 40 2. (A) Payment for up to sixty days of care for services provided 41 under the medical assistance program shall be made for an applicant 42 presumed eligible for medical assistance pursuant to PARAGRAPH (A) OF 43 subdivision one of this section provided, however, that such payment 44 shall not exceed sixty-five percent of the rate payable under this title 45 for services provided by a certified home health agency, long term home 46 health care program, hospice or residential health care facility. 47 (B) PAYMENT FOR UP TO NINETY DAYS OF CARE FOR SERVICES PROVIDED UNDER 48 THE MEDICAL ASSISTANCE PROGRAM SHALL BE MADE FOR AN APPLICANT PRESUMED 49 ELIGIBLE FOR MEDICAL ASSISTANCE FOR CARE, SERVICES AND SUPPLIES RELATED 50 TO THE TREATMENT OF A MENTAL ILLNESS PURSUANT TO PARAGRAPH (B) OF SUBDI- 51 VISION ONE OF THIS SECTION, PROVIDED HOWEVER, THAT SUCH PAYMENT SHALL 52 NOT EXCEED ONE HUNDRED PERCENT OF THE RATE PAYABLE UNDER THIS TITLE FOR 53 SUCH CARE, SERVICES AND SUPPLIES. 54 (C) Notwithstanding any other provision of law, no federal financial 55 participation shall be claimed for services provided to a person while 56 presumed eligible for medical assistance under this program until such S. 1606 3 1 person has been determined to be eligible for medical assistance by the 2 local social services district. During the period of presumed medical 3 assistance eligibility, payment for services provided persons presumed 4 eligible under this program shall be made from state funds. [Upon] (I) 5 IN THE CASE OF COSTS INCURRED FOR A PERSON PRESUMPTIVELY ELIGIBLE FOR 6 MEDICAL ASSISTANCE UNDER PARAGRAPH (A) OF SUBDIVISION ONE OF THIS 7 SECTION, UPON the final determination of eligibility by the local social 8 services district, payment shall be made for the balance of the cost of 9 such care and services provided to such applicant for such period of 10 eligibility and a retroactive adjustment shall be made by the department 11 OF HEALTH to appropriately reflect federal financial participation and 12 the local share of costs for the services provided during the period of 13 presumptive eligibility. Such federal and local financial participation 14 shall be the same as that which would have occurred if a final determi- 15 nation of eligibility for medical assistance had been made prior to the 16 provision of the services provided during the period of presumptive 17 eligibility. In instances where an individual who is presumed eligible 18 for medical assistance is subsequently determined to be ineligible, the 19 cost for services provided to such individual shall be reimbursed in 20 accordance with the provisions of section three hundred sixty-eight-a of 21 this article. Provided, however, if upon audit the department OF HEALTH 22 determines that there are subsequent determinations of ineligibility for 23 medical assistance in at least fifteen percent of the cases in which 24 presumptive eligibility has been granted in a local social services 25 district, payments for services provided to all persons presumed eligi- 26 ble and subsequently determined ineligible for medical assistance shall 27 be divided equally by the state and the district. 28 (II) IN THE CASE OF COSTS INCURRED FOR A PERSON PRESUMPTIVELY ELIGIBLE 29 FOR MEDICAL ASSISTANCE UNDER PARAGRAPH (B) OF SUBDIVISION ONE OF THIS 30 SECTION UPON THE FINAL DETERMINATION OF ELIGIBILITY BY THE LOCAL SOCIAL 31 SERVICES DISTRICT, PAYMENT SHALL BE MADE FOR THE BALANCE OF THE COST OF 32 SUCH CARE AND SERVICES PROVIDED TO SUCH APPLICANT FOR SUCH PERIOD OF 33 ELIGIBILITY AND A RETROACTIVE ADJUSTMENT SHALL BE MADE BY THE DEPARTMENT 34 OF HEALTH TO APPROPRIATELY REFLECT FEDERAL FINANCIAL PARTICIPATION AND 35 THE LOCAL SHARE OF COSTS FOR THE SERVICES PROVIDED DURING THE PERIOD OF 36 PRESUMPTIVE ELIGIBILITY. SUCH FEDERAL FINANCIAL PARTICIPATION SHALL BE 37 THE SAME AS THAT WHICH WOULD HAVE OCCURRED IF A FINAL DETERMINATION OF 38 ELIGIBILITY FOR MEDICAL ASSISTANCE HAD BEEN MADE PRIOR TO THE PROVISION 39 OF THE SERVICES PROVIDED DURING THE PERIOD OF PRESUMPTIVE ELIGIBILITY. 40 THERE SHALL BE NO LOCAL SHARE IN THE COSTS OF SUCH ASSISTANCE DURING THE 41 PRESUMPTIVE ELIGIBILITY PERIOD; PROVIDED HOWEVER THAT IF UPON AUDIT THE 42 DEPARTMENT OF HEALTH DETERMINES THAT THERE ARE SUBSEQUENT DETERMINATIONS 43 OF INELIGIBILITY FOR MEDICAL ASSISTANCE IN AT LEAST FIFTEEN PERCENT OF 44 THE CASES IN WHICH PRESUMPTIVE ELIGIBILITY HAS BEEN GRANTED IN A LOCAL 45 SOCIAL SERVICES DISTRICT, PAYMENTS FOR SERVICES PROVIDED TO ALL PERSONS 46 PRESUMED ELIGIBLE AND SUBSEQUENTLY DETERMINED INELIGIBLE FOR MEDICAL 47 ASSISTANCE SHALL BE REIMBURSED IN ACCORDANCE WITH THE PROVISIONS OF 48 SECTION THREE HUNDRED SIXTY-EIGHT-A OF THIS ARTICLE. 49 3. On or before March thirty-first, [nineteen hundred ninety-seven] 50 TWO THOUSAND THIRTEEN, the department OF HEALTH shall submit to the 51 governor and legislature an evaluation of the program, including the 52 program's effects on access, quality and cost of care, and any recommen- 53 dations for future modifications to improve the program. 54 S 2. Subdivision 1 of section 368-a of the social services law is 55 amended by adding a new paragraph (aa) to read as follows: S. 1606 4 1 (AA) NOTWITHSTANDING ANY INCONSISTENT PROVISION OF LAW, REIMBURSEMENT 2 BY THE STATE FOR PAYMENTS MADE, WHETHER BY THE DEPARTMENT OF HEALTH ON 3 BEHALF OF A LOCAL SOCIAL SERVICES DISTRICT PURSUANT TO SECTION THREE 4 HUNDRED SIXTY-SEVEN-B OF THIS TITLE OR BY A LOCAL SOCIAL SERVICES 5 DISTRICT DIRECTLY, FOR MEDICAL ASSISTANCE FURNISHED TO AN INDIVIDUAL 6 PRESUMED ELIGIBLE FOR MEDICAL ASSISTANCE UNDER PARAGRAPH (B) OF SUBDIVI- 7 SION ONE OF SECTION THREE HUNDRED SIXTY-FOUR-I OF THIS TITLE, DURING THE 8 PRESUMPTIVE ELIGIBILITY PERIOD, SHALL BE MADE FOR THE FULL AMOUNT 9 EXPENDED FOR SUCH ASSISTANCE, AFTER FIRST DEDUCTING THEREFROM ANY FEDER- 10 AL FUNDS PROPERLY RECEIVED OR TO BE RECEIVED ON ACCOUNT OF SUCH EXPENDI- 11 TURE; PROVIDED THAT IF UPON AUDIT THE DEPARTMENT OF HEALTH DETERMINES 12 THAT THERE ARE SUBSEQUENT DETERMINATIONS OF INELIGIBILITY FOR MEDICAL 13 ASSISTANCE IN AT LEAST FIFTEEN PERCENT OF THE CASES IN WHICH PRESUMPTIVE 14 ELIGIBILITY HAS BEEN GRANTED IN A LOCAL SOCIAL SERVICES DISTRICT, 15 PAYMENTS FOR SERVICES PROVIDED TO ALL PERSONS PRESUMED ELIGIBLE AND 16 SUBSEQUENTLY DETERMINED INELIGIBLE FOR MEDICAL ASSISTANCE SHALL BE REIM- 17 BURSED IN ACCORDANCE WITH PARAGRAPH (D) OF THIS SUBDIVISION. 18 S 3. This act shall take effect April 1, 2012.