N.Y. Comp. Codes R. & Regs. Tit. 18 §§ 360-4.8

Current through Register Vol. 46, No. 45, November 2, 2024

Section 360-4.8 - Determination of financial eligibility; effect of excess income and resources on eligibility

(a) Financial eligibility.

(1) Except as provided in paragraphs (2), (3), (4) and (5) of this subdivision, an applicant/recipient is financially eligible for MA if his or her net available income and net available resources do not exceed the appropriate standards. The standards are found in section 360-4.7 of this Subpart.

(2)

(i) A pregnant woman is financially eligible for MA if her net available income does not exceed the highest of the following three items: the applicable MA standard; the applicable PA standard of need; or 100 percent of the applicable poverty line listed in section 360-4.7(b) of this Subpart.

(ii) A pregnant woman is financially eligible for comprehensive prenatal care services available under the Prenatal Care Assistance Program, as listed in Public Health Law, section 2522, if her net available income exceeds the highest of the three items listed in subparagraph (i) of this paragraph but does not exceed 185 percent of the applicable poverty line listed in section 360-4.7(b) of this Subpart.

(3) An infant younger than one year of age is financially eligible for MA if his or her net available household income does not exceed 185 percent of the applicable Federal poverty line set forth in section 360-4.7(b) of this Subpart.

(4) A child at least one year of age but younger than six years of age is financially eligible for MA if his or her net available household income does not exceed 133 percent of the applicable Federal poverty line set forth in section 360-47(b) of this Subpart.

(5) A child born after September 30, 1983 who is at least six years of age but younger than 19 years of age is financially eligible for MA if his or her net available household income does not exceed 100 percent of the applicable Federal poverty line set forth in section 360-4.7(b) of this Subpart.

(6) Applicants/recipients who are financially eligible under paragraphs (1) through (5) of this subdivision will be authorized to receive MA if they also meet the nonfinancial eligibility requirements. The nonfinancial eligibility requirements are found in Subpart 360-3 of this Part.

(b) Reduction of excess resources. An MA applicant/recipient whose net available resources exceed the resource standards will be ineligible for MA until he/she incurs medical expenses equal to or greater than the excess resources. However, nonexempt resources transferred for less than their fair market value may still be considered available, under section 360-4.4(c) of this Subpart.

(c) Reduction of excess income.

(1) Except as provided in paragraphs (4) and (5) of this subdivision, if an otherwise eligible MA applicant's or recipient's net available income exceeds the appropriate income standard, he or she will be eligible for MA only after incurring medical expenses equal to or greater than the amount of excess income, provided such medical expenses are not subject to payment by a third party other than another public program of the State or any of its political subdivisions. Once deduction of incurred medical expenses reduces income to the income standard, the MA applicant or recipient is eligible for MA; however, no MA payment will be made for those incurred medical expenses used to establish eligibility. The social services district will deduct from the MA applicant's income the following medical expenses incurred by the applicant, by family members living with the applicant for whom the applicant is legally responsible, and by legally responsible relatives living with the applicant, in the order listed below and regardless of whether these expenses are subject to payment by another public program of the State or any of its political subdivisions:

(i) expenses incurred for Medicare and other health insurance premiums, deductibles, or coinsurance charges;

(ii) expenses incurred for necessary medical and remedial services that are recognized under State law but are not covered by MA; and

(iii) expenses incurred for necessary medical and remedial services that are covered under the MA program.

(2) Budgeting periods.

(i) To be eligible for MA coverage for acute care in a medical facility, an applicant/recipient must incur medical expenses equal to or greater than the amount of his/her excess income for a period of six months. Once that amount of medical expenses has been incurred, the applicant/recipient may receive full MA coverage for a period of six months.

(ii) To be eligible for MA coverage of all medical care, services and supplies outside the medical facility, as well as prosthetic appliances (including dentures), the applicant/recipient must incur medical expenses in the month equal to or greater than the amount of his/her excess monthly income. When that amount of medical expenses has been incurred, the applicant/recipient will receive MA outpatient coverage for any additional medical expenses incurred in that month.

(iii) If an MA recipient regularly receives home care in the community but is temporarily absent from the home to receive respite care for a fixed period of up to four weeks in an intermediate care facility, skilled nursing facility, or residential health care facility, he/she will be eligible for MA coverage of the respite care for each month in which incurred medical expenses are at least equal to the amount of monthly excess income. Respite care is infrequent and temporary substitute care or supervision provided to a person on behalf of and in the absence of the caregiver, in order to relieve the caregiver from the stresses or responsibilities of providing constant care and to enable the caregiver to maintain a normal routine. Respite care must be provided in accordance with the terms of approved Federal waivers.

(3) For services regularly requiring prior approval, after the social services district tells the recipient the amount of services that are medically necessary for him/her, as determined by the district according to applicable regulations, additional medical services over and above the amount which is medically necessary cannot be used to reduce the amount of the recipient's excess income.

(4) Except as provided in paragraph (5) of this subdivision, a social services district will authorize MA for an otherwise eligible MA applicant or recipient who pays to the district the amount that his or her net available income exceeds the appropriate income standard, provided that the district submits to the department and receives approval of a plan for the pre-payment of excess income.

(i) A plan for the pre-payment of excess income must provide that:

(a) the MA applicant or recipient has the option of participating in the pre-payment program;

(b) the MA applicant or recipient must pay to the social services district the amount that his or her net available income exceeds the appropriate income standard for the budgeting period specified in paragraph (2) of this subdivision, minus the amount of any medical expenses incurred during the budgeting period or credited pursuant to subparagraph (iii) of this paragraph which are not payable by the MA program;

(c) the social services district must safeguard the amounts paid to it by an MA recipient who participates in the pre-payment program by depositing such amounts in a special pre-payment account.

(d) the social services district must periodically reconcile the amount in the MA recipient's pre-payment account with the amount of MA payments made on his or her behalf for the budgeting period specified in paragraph (2) of this subdivision to determine if a refund to the MA recipient or credit to the MA recipient's pre-payment account for subsequent spenddown period(s) is appropriate; and

(e) the social services district must report to the department the pre-payment amounts collected minus any refunds made pursuant to subparagraph (iii) of this paragraph.

(ii) A plan for the pre-payment of excess income must include a detailed description of how the social services district will:

(a) administer the pre-payment program;

(b) enroll MA applicants and recipients; and

(c) meet the requirements of subparagraphs (i) and (iii) of this paragraph.

(iii) Refunds and credits.

(a) If an MA recipient makes a payment pursuant to this paragraph and then incurs medical expenses during the budgeting period that are not payable by MA, the social services district must:

(1) prefund to the MA recipient the amount of such medical expenses from the recipient's pre-payment account for that budgeting period. If the amount of such medical expenses exceeds the MA recipient's pre-payment account for that budgeting period, the district must credit the remainder to the MA recipient's pre-payment account for the subsequent spenddown period(s); or

(2) credit the amount of such medical expenses to the MA recipient's pre-payment account for the subsequent spenddown period(s).

A plan for the pre-payment of excess income may provide for the social services district to make this refund separately as described in this clause or as part of the periodic refund described in clause (b) of this subparagraph.

(b) The social services district will periodically compare the amount in the MA recipient's pre-payment account, minus any amount to be refunded for medical expenses which are not payable by MA, to the amount of MA payments made on his or her behalf for the budgeting period specified in paragraph (2) of this subdivision. If the former exceeds the latter, the social services district must periodically refund the difference to the MA recipient or credit the difference to the recipient's pre-payment account for the subsequent spenddown period(s).

(iv) When a social services district submits a pre-payment plan for excess income to the department for approval, the department will approve, disapprove, or request the social services district to modify such plan within 90 days of receipt of the plan.

(5)

(i) Federally nonparticipating persons described in section 360-3.3(b)(7) of this Part whose net available income exceeds the appropriate income standard cannot become eligible for MA by incurring medical expenses equal to or greater than the amount of their excess income.

(ii)

(ii)

(a) A pregnant woman whose net available income exceeds 185 percent of the applicable poverty line listed in section 360-4.7(b) of this Subpart:

(1) cannot become eligible for comprehensive prenatal care services listed in section2522 of the Public Health Law by incurring medical expenses equal to or greater than the amount by which her net available income exceeds 185 percent of such line; and

(2) cannot become eligible for full MA coverage by incurring medical expenses equal to or greater than the amount by which her net available income exceeds 100 percent of such line.

(b) A pregnant woman whose net available income exceeds 100 percent of the applicable poverty line listed in section 360-4.7(b) of this Subpart but does not exceed 185 percent of such line cannot become eligible for full MA coverage by incurring medical expenses equal to or greater than the amount by which her net available income exceeds 100 percent of such line.

(c) An infant younger than one year of age whose net available income exceeds 185 percent of the applicable poverty line listed in section 360-4.7(b) of this Subpart cannot become eligible for MA by incurring medical expenses equal to or greater than the amount by which his or her net available income exceeds 185 percent of such line.

(iii) A child at least one year of age but younger than six years of age whose net available household income exceeds 133 percent of the applicable Federal poverty line set forth in section 360-4.7(b) of this Subpart cannot become eligible for MA coverage by incurring medical expenses equal to or greater than the amount by which his or her net available household income exceeds 133 percent of such poverty line.

(iv) A child born after September 30, 1983 who is at least six years of age but younger than 19 years of age whose net available household exceeds 100 percent of the applicable Federal poverty line set forth in section 360-4.7(b) of this Subpart cannot become eligible for MA by incurring medical expenses equal to or greater than the amount by which his or her net available household income exceeds 100 percent of such poverty line.

(v) A pregnant woman or child described in subparagraph (ii), (iii) or (iv) of this paragraph can become eligible for full MA coverage only by incurring medical expenses equal to or greater than the amount by which his or her net available household income exceeds the higher of the applicable MA standard or PA standard of need.

N.Y. Comp. Codes R. & Regs. Tit. 18 §§ 360-4.8