S T A T E   O F   N E W   Y O R K
________________________________________________________________________

                                  4793

                       2015-2016 Regular Sessions

                          I N  A S S E M B L Y

                            February 6, 2015
                               ___________

Introduced  by  M.  of  A.  BRENNAN, DINOWITZ, GOTTFRIED, ORTIZ, RIVERA,
  PEOPLES-STOKES, CAHILL, JAFFEE --  Multi-Sponsored  by  --  M.  of  A.
  GALEF,  LUPARDO  --  read once and referred to the Committee on Social
  Services

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:

  Section 1. Subdivisions 1, 2 and 3 of  section  364-i  of  the  social
services law, as amended by chapter 693 of the laws of 1996, are amended
to read as follows:
  1.  (A)  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)] (I) the applicant is receiving acute care in such hospi-
tal;  [(b)]  (II)    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)]  (III)
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)] (IV) it reasonably appears that the  applicant
is  otherwise  eligible  to  receive  medical  assistance;  [(e)] (V) it
reasonably appears that the amount expended by the state and  the  local

 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                      [ ] is old law to be omitted.
                                                           LBD08831-01-5
              

A. 4793                             2

social  services  district  for  medical  assistance in a certified home
health agency, long term home health care program, hospice  or  residen-
tial  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)] (VI) such other determinative criteria as the commissioner  OF
HEALTH  shall provide by rule or regulation. If a person has been deter-
mined to be presumptively eligible for medical assistance,  pursuant  to
this  subdivision,  and  is subsequently determined to be ineligible for
such assistance, the commissioner OF HEALTH, 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.
  (B)  AN  INDIVIDUAL, UPON APPLICATION FOR MEDICAL ASSISTANCE, SHALL BE
PRESUMED ELIGIBLE FOR SUCH ASSISTANCE FOR CARE,  SERVICES  AND  SUPPLIES
RELATED TO THE TREATMENT OF A MENTAL ILLNESS FOR A PERIOD OF NINETY DAYS
FROM  THE  DATE OF DISCHARGE FROM A HOSPITAL, AS DEFINED IN SECTION 1.03
OF THE MENTAL HYGIENE LAW, A CORRECTIONAL FACILITY AS DEFINED  IN  PARA-
GRAPH  (A) OF SUBDIVISION FOUR OF SECTION TWO OF THE CORRECTION LAW OR A
LOCAL CORRECTIONAL FACILITY AS DEFINED IN PARAGRAPH (A)  OF  SUBDIVISION
SIXTEEN OF SECTION TWO OF THE CORRECTION LAW, IF THE LOCAL DEPARTMENT OF
SOCIAL  SERVICES DETERMINES THAT THE APPLICANT MEETS EACH OF THE FOLLOW-
ING CRITERIA: (I) THE APPLICANT IS SEVERELY  AND  PERSISTENTLY  MENTALLY
ILL;  (II)  A  PHYSICIAN  CERTIFIES THAT SUCH APPLICANT REQUIRES MEDICAL
CARE TO TREAT SUCH MENTAL ILLNESS; (III) THE APPLICANT OR HIS  REPRESEN-
TATIVE  STATES  THAT  THE APPLICANT DOES NOT HAVE INSURANCE COVERAGE FOR
THE REQUIRED MEDICAL CARE AND THAT SUCH CARE CANNOT BE AFFORDED; (IV) IT
REASONABLY APPEARS THAT THE APPLICANT IS OTHERWISE ELIGIBLE  TO  RECEIVE
MEDICAL  ASSISTANCE;  (V) IT REASONABLY APPEARS THAT THE AMOUNT EXPENDED
BY THE STATE AND THE LOCAL SOCIAL SERVICES DISTRICT FOR MEDICAL  ASSIST-
ANCE  FOR  TREATMENT  OF  A MENTAL ILLNESS DURING THE PERIOD OF PRESUMED
ELIGIBILITY, WOULD BE LESS THAN THE  AMOUNT  THE  STATE  AND  THE  LOCAL
SOCIAL  SERVICES  DISTRICT  WOULD  EXPEND  FOR CONTINUED OR FUTURE ACUTE
HOSPITAL CARE FOR SUCH PERSON; AND (VI) SUCH OTHER DETERMINATIVE  CRITE-
RIA  AS  THE COMMISSIONER OF HEALTH 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  OF  HEALTH,  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.  (A)  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 PARAGRAPH (A) OF
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.
  (B) PAYMENT FOR UP TO NINETY DAYS OF CARE FOR SERVICES PROVIDED  UNDER
THE  MEDICAL  ASSISTANCE PROGRAM SHALL BE MADE FOR AN APPLICANT PRESUMED
ELIGIBLE FOR MEDICAL ASSISTANCE FOR CARE, SERVICES AND SUPPLIES  RELATED
TO THE TREATMENT OF A MENTAL ILLNESS PURSUANT TO PARAGRAPH (B) OF SUBDI-
VISION  ONE  OF  THIS SECTION, PROVIDED HOWEVER, THAT SUCH PAYMENT SHALL
NOT EXCEED ONE HUNDRED PERCENT OF THE RATE PAYABLE UNDER THIS TITLE  FOR
SUCH CARE, SERVICES AND SUPPLIES.

A. 4793                             3

  (C)  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] (I)
IN THE CASE OF COSTS INCURRED FOR A PERSON  PRESUMPTIVELY  ELIGIBLE  FOR
MEDICAL  ASSISTANCE  UNDER  PARAGRAPH  (A)  OF  SUBDIVISION  ONE OF THIS
SECTION, 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
OF HEALTH 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 determi-
nation 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] TITLE. Provided, however, if upon audit the department OF
HEALTH  determines  that there are subsequent determinations of ineligi-
bility 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.
  (II) IN THE CASE OF COSTS INCURRED FOR A PERSON PRESUMPTIVELY ELIGIBLE
FOR MEDICAL ASSISTANCE UNDER PARAGRAPH (B) OF SUBDIVISION  ONE  OF  THIS
SECTION  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
OF HEALTH TO APPROPRIATELY REFLECT FEDERAL FINANCIAL  PARTICIPATION  AND
THE  LOCAL SHARE OF COSTS FOR THE SERVICES PROVIDED DURING THE PERIOD OF
PRESUMPTIVE ELIGIBILITY. SUCH FEDERAL 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.
THERE SHALL BE NO LOCAL SHARE IN THE COSTS OF SUCH ASSISTANCE DURING THE
PRESUMPTIVE ELIGIBILITY PERIOD; PROVIDED HOWEVER THAT IF UPON AUDIT  THE
DEPARTMENT OF HEALTH 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  REIMBURSED  IN  ACCORDANCE WITH THE PROVISIONS OF
SECTION THREE HUNDRED SIXTY-EIGHT-A OF THIS TITLE.
  3. On or before March thirty-first,  [nineteen  hundred  ninety-seven]
TWO  THOUSAND  EIGHTEEN,  the  department  OF HEALTH 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 recommen-
dations for future modifications to improve the program.

A. 4793                             4

  S  2.  Subdivision  1  of  section 368-a of the social services law is
amended by adding a new paragraph (aa) to read as follows:
  (AA)  NOTWITHSTANDING ANY INCONSISTENT PROVISION OF LAW, REIMBURSEMENT
BY THE STATE FOR PAYMENTS MADE, WHETHER BY THE DEPARTMENT OF  HEALTH  ON
BEHALF  OF  A  LOCAL  SOCIAL SERVICES DISTRICT PURSUANT TO SECTION THREE
HUNDRED SIXTY-SEVEN-B OF THIS  TITLE  OR  BY  A  LOCAL  SOCIAL  SERVICES
DISTRICT  DIRECTLY,  FOR  MEDICAL  ASSISTANCE FURNISHED TO AN INDIVIDUAL
PRESUMED ELIGIBLE FOR MEDICAL ASSISTANCE UNDER PARAGRAPH (B) OF SUBDIVI-
SION ONE OF SECTION THREE HUNDRED SIXTY-FOUR-I OF THIS TITLE, DURING THE
PRESUMPTIVE ELIGIBILITY PERIOD,  SHALL  BE  MADE  FOR  THE  FULL  AMOUNT
EXPENDED FOR SUCH ASSISTANCE, AFTER FIRST DEDUCTING THEREFROM ANY FEDER-
AL FUNDS PROPERLY RECEIVED OR TO BE RECEIVED ON ACCOUNT OF SUCH EXPENDI-
TURE;  PROVIDED  THAT  IF UPON AUDIT THE DEPARTMENT OF HEALTH 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 REIM-
BURSED IN ACCORDANCE WITH PARAGRAPH (D) OF THIS SUBDIVISION.
  S 3. This act shall take effect April 1, 2017.