N.Y. Comp. Codes R. & Regs. Tit. 14 §§ 635-12.7

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

Section 635-12.7 - Obligations of individuals receiving or requesting services and liable parties-preexisting services

(a) This section applies only to preexisting services.

(b)Responsibility to provide information.

(1) Individuals receiving preexisting services and other liable parties shall, by the payment start date, provide information upon the provider's request regarding 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 the information required in paragraph (1) of this subdivision and throughout the period that preexisting services are received, the individual and other liable parties shall notify the provider of 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) Prior to the payment start date, each individual receiving preexisting services must:

(i) present evidence of full Medicaid coverage; or

(ii) take all necessary steps to obtain 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 to apply on behalf of the individual; 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 an individual not already enrolled in the HCBS waiver is receiving preexisting services that are offered through the HCBS waiver, the individual must take all necessary steps to enroll in the HCBS waiver by the payment start date and must take all necessary steps to maintain enrollment in the HCBS waiver.

(5) Unless the fee is waived by the provider, if the individual does not obtain full Medicaid coverage by the payment start date, or if the individual loses full Medicaid coverage on or after the payment start date, the individual and/or liable parties must either:

(i) pay for the preexisting services delivered on or after the payment start date in accordance with the applicable fee schedule in section 635-12.9 of this Subpart; or

(ii) pay for the preexisting services delivered on or after the payment start date with the reduced fees established by the provider.

(6) For Medicaid service coordination; day treatment services; the following HCBS waiver services: at home residential habilitation services, prevocational services, supported employment services, respite services; and blended and comprehensive services: If a notice from the Medicaid district has been received prior to March 15, 2010, which states that the individual is losing full Medicaid coverage on or after March 15, 2010, the individual or other party receiving the notice shall notify the provider about such notice by March 22, 2010.

(7) On or after the preexisting compliance date, 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.

N.Y. Comp. Codes R. & Regs. Tit. 14 §§ 635-12.7

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