N.Y. Comp. Codes R. & Regs. Tit. 18 §§ 360-9.4

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

Section 360-9.4 - Eligibility for the CHCEP services

(a) The CHCEP is available to a family which: is ineligible for MA and PA; meets the residency requirements of section 369-c of the Social Services Law; and has eligible catastrophic health care expenses.

(b)

(1) The CHCEP assistance with cost sharing of eligible catastrophic health care expenses is available to a family if its health care expenses, after deducting health insurance benefits, are in excess of 50 percent, but are no more than 75 percent, of the difference between the adjusted or projected annual family income and the maximum PA grant it would receive if it were eligible for PA.

(2) For a family which is eligible for the CHCEP assistance with cost sharing under paragraph (1) of this subdivision, the CHCEP will pay a percentage of the expenses for covered services and the family must pay the remainder. The Commissioner of Health has established a schedule setting forth the cost-sharing percentages which will be used to allocate costs between families and the CHCEP for the various CHCEP services (10 NYCRR 85.42). The CHCEP share of the expenses will be determined by multiplying the cost sharing percentage by the MA rate for the service or the rate charged by the provider of the service, whichever is less.

(3) A family in receipt of the CHCEP assistance with cost sharing may be reimbursed only for paid bills for health care services incurred during the previous calendar year, unless the family demonstrates hardship as defined in section 360-9.3 of this Subpart. If hardship is demonstrated, the family in receipt of the CHCEP may be reimbursed up to the MA rate for the current year's expenses. When the social services district determines that hardship exists, payments may be made directly to the provider of the health care services. The social services district may determine that hardship exists at the time a family applies for an interim authorization or assistance with or without cost sharing under this Subpart.

(c)

(1) The CHCEP assistance without cost sharing of eligible catastrophic health care expenses is available to a family if its health care expenses, after deducting health insurance benefits and the benefits available pursuant to section 360-9.4(b) of this Subpart, are in excess of 75 percent of the difference between the adjusted or projected annual family income and the maximum PA grant it would receive if it were eligible for PA.

(2) For a family which is eligible for the CHCEP assistance without cost sharing under paragraph (1) of this subdivision, the CHCEP will reimburse a family for the bills it has paid for covered services and directly pay the provider of service for unpaid bills. The CHCEP will reimburse or pay for such bills at the MA rate for the service or the rate charged by the provider of the service, whichever is less.

(d) A family may apply to the social services district for an interim authorization which would enable the family, on a prospective basis, to have any medical expenses covered under the MA program reduced to the MA rate or fee. To be eligible for an interim authorization, a family must be eligible for the CHCEP pursuant to subdivision (b) or (c) of this section. The social services district must use projected income and allowable deductions to compute the current year's adjusted income for purposes of determining eligibility for interim authorization. The interim authorization may not extend beyond the final day of the calendar year in which the services were rendered and in which eligibility for the CHCEP assistance was based.

N.Y. Comp. Codes R. & Regs. Tit. 18 §§ 360-9.4