N.Y. Comp. Codes R. & Regs. Tit. 18 §§ 360-7.4

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

Section 360-7.4 - Liability of third parties

(a)

(1) When care and services are or may be provided to an applicant/recipient for treatment of injury, disease or disability, the State or social services district will take all reasonable measures to ascertain the legal liability of third parties (including health insurers) to pay for such care and services.

(2) The social services district, when determining or redetermining eligibility, must collect sufficient information to enable the State to pursue claims against such third parties, including all information specifically required by the department.

(3) As a condition of eligibility, an applicant/recipient must cooperate with the State or social services district in identifying third parties who may be liable to pay for care. The applicant/recipient must provide information to assist the State in pursuing such third parties. An applicant/recipient may refuse to cooperate only for good cause.

(4) As a condition of eligibility, an applicant/recipient with the legal capacity to execute an assignment, must assign to the State and social services district any rights against any third party for support (specified as support for medical care by a court or administrative order) and for payment of medical care. The requirement extends to any person with the legal authority to execute an assignment on behalf of an applicant/recipient.

(5) The State or social services district will seek reimbursement for MA when there is a third party legal liability and the expected amount of reimbursement is more than the costs of making the recovery.

(6) Upon furnishing MA to a recipient, the social services district or the department will be subrogated, to the extent of the expenditures by such district or the department, to any rights the recipient may have to medical support or third party reimbursement. For purposes of this section, the term medical support means the right to support for purposes of medical care as specified by court or administrative order. The social services district or the department will issue a written notice of the exercise of subrogation rights to the appropriate party or parties.

(b) A recipient is eligible to receive MA even if he/she has a right of action, suit, claim, counterclaim or demand against a third party for personal injuries suffered, if all other eligibility requirements are met. If the social services district finds that the third party has paid or will pay within a reasonable time, the district will pay only the amount by which the allowable MA claim exceeds the third party liability. If payment will not be made within a reasonable time, the social services district must file a lien covering the cost of such assistance in accordance with section 104-b of the Social Services Law. The recipient will be required to assign to the district the proceeds of such right or demand.

(c) Whenever a social services district authorizes hospital care for the treatment of recipient's personal injuries, it must obtain a satisfaction or discharge of any hospital lien covering such care before or at the time payment to the hospital is made. The district must file the satisfaction or discharge in accordance with the Lien Law.

N.Y. Comp. Codes R. & Regs. Tit. 18 §§ 360-7.4