N.Y. Comp. Codes R. & Regs. tit. 14 § 635-12.6

Current through Register Vol. 46, No. 25, June 18, 2024

Section 635-12.6 - Obligations of individuals receiving or requesting services and liable parties - services other than Preexisting services

(a) This section applies only to services which are not preexisting services.

(b)Responsibility for provision of information.

(1) Prior to the receipt of services, and upon request of the provider, individuals requesting or receiving services, and other liable parties, shall provide 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.

(2) Subsequent to the provision of information required in paragraph (1) of this subdivision and throughout the period that services are received, the individual and other liable parties shall 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. If the individual or any other party receives a notice from the Medicaid district that the individual is losing full Medicaid coverage, the individual or party must inform the provider within five days of receipt of the notice.

(3) Each individual requesting or receiving services must:

(i) present evidence of and maintain full Medicaid coverage; or

(ii) take all necessary steps to obtain and maintain full Medicaid coverage; or

(iii) disclose to the provider such information as may be reasonably required to obtain and maintain full Medicaid coverage, and allow the provider to assist the individual to take all necessary steps to obtain and maintain full Medicaid coverage or apply on the individual's behalf; or

(iv) agree to pay for the services in accordance with the applicable fee schedule in section 635-12.9 of this Subpart. Liable parties may agree in lieu of the individual; or

(v) agree to pay for the services in accordance with the reduced fee established by the provider and acknowledge that any reduction of the fee shall not constitute nor be construed as a release of the individual or any liable party from liability for payment of the full fee. Other liable parties may agree and acknowledge same in lieu of the individual; or

(vi) acknowledge that the fee has been waived by the provider and that any waiver of the fee shall not constitute nor be construed as a release of the individual or any liable party from liability for payment of the full fee. Other liable parties may acknowledge same in lieu of the individual.

(4) In addition, if HCBS waiver services are requested, the individual must take all necessary steps to enroll in the HCBS waiver and take all necessary steps to maintain enrollment in the HCBS waiver.

(5) Unless the individual has full Medicaid coverage or the fee is waived by the provider, the individual and/or liable parties must either:

(i) pay for the services in accordance with the applicable fee schedule in section 635-12.9 of this Subpart; or

(ii) pay for the services with the reduced fees established by the provider.

N.Y. Comp. Codes R. & Regs. Tit. 14 § 635-12.6

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