N.Y. Comp. Codes R. & Regs. Tit. 14 §§ 635-12.4

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

Section 635-12.4 - Provider obligations for preexisting services

(a) This section applies only to preexisting services.

(b)Disclosure of personal and financial information.

(1) Prior to the notice date (see section 635-12.1 of this Subpart) the provider shall take such steps to obtain personal and financial information concerning individuals without full Medicaid coverage as may be reasonably required to identify liable parties and to ascertain the individual's and any other liable parties' ability to pay for services or the individual's ability to obtain and maintain full Medicaid coverage.

(2) However, when individuals or other liable parties have agreed to pay the full fee for the services, the provider is not required to obtain the information specified in paragraph (1) of this subdivision. In these situations, the provider may obtain such information at its discretion.

(3) The provider may require that, during the period that an individual receives preexisting services, the individual or liable party supply personal and financial information as may be reasonably required to identify liable parties and to ascertain the individual's and any other liable parties' ability to pay for services or the individual's ability to obtain and maintain full Medicaid coverage.

(4) The provider shall require that, during the period an individual receives preexisting services, the individual and other liable parties notify the provider about any changes in liable parties, any changes in the individual's Medicaid coverage and any changes that may affect the individual's eligibility for full Medicaid coverage and/or the individual's and other liable parties' ability to pay for services.

(c) Notice and schedule of fees.

On or before the notice date, the provider shall give all individuals receiving preexisting services and any known other liable parties copies of the fee schedule for preexisting services which the individual is receiving, together with a notice including a description of the obligations of the provider, the individual and liable parties under the law and this regulation in the form and format specified by the commissioner.

(d)Reduction or waiver of fees.

(1) The provider may reduce or waive fees with prior OPWDD approval subject to the following conditions:

(i) OPWDD approval for a reduction or waiver of fees for an individual will be based on consideration of the individual's or other liable parties' available income and resources, the individual's living situation, and the individual's ability to meet Medicaid eligibility requirements.

(ii) OPWDD approval for a reduction or waiver of fees is only available when the individual has taken all necessary steps to obtain and maintain full Medicaid coverage. However, OPWDD may approve a reduction or waiver of fees for Medicaid service coordination (MSC) for up to three months if an individual does not have full Medicaid coverage and MSC is necessary to assist the individual in obtaining full Medicaid coverage.

(iii) OPWDD approval for a reduction or waiver of fees is only available when OPWDD was paying the full fee or part of the fee for the preexisting services on the preexisting compliance date (see section 635-12.1 of this Subpart), or when the individual had full Medicaid coverage on the preexisting compliance date.

(iv) The provider shall give the individual and all liable parties 30 days' written notice of any changes in the reduction or waiver of fees granted with prior OPWDD approval and shall require the individual and/or liable parties to agree to the full fee or new reduced fee or acknowledge the waiver of the fee.

(2) The provider may also waive or reduce fees at their discretion without the prior approval of OPWDD. However, OPWDD payments are not available when such waivers or reduced fees are granted.

(e) Application for HCBS waiver services.

If the preexisting services are HCBS waiver services and the individual is not already enrolled in the HCBS waiver, the provider shall require that the individual take all necessary steps to enroll in the HCBS waiver by the payment start date (see section 635-12.1 of this Subpart), and take all necessary steps to maintain HCBS waiver enrollment.

N.Y. Comp. Codes R. & Regs. Tit. 14 §§ 635-12.4

Amended New York State Register July 1, 2015/Volume XXXVII, Issue 26, eff. 7/1/2015

Amended New York State Register October 28, 2015/Volume XXXVII, Issue 43, eff. 11/1/2015

Amended New York State Register April 20, 2016/Volume XXXVIII, Issue 16, eff. 4/20/2016

Amended New York State Register September 21, 2016/Volume XXXVIII, Issue 38, eff. 9/21/2016