N.Y. Comp. Codes R. & Regs. Tit. 18 §§ 360-2.3

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

Section 360-2.3 - Investigation of eligibility

(a) Generally.

(1) The social services district has a continuing obligation to collect, verify, record and evaluate factual information concerning an MA applicant's/recipient's eligibility for MA.

(2) The MA applicant/recipient has a continuing obligation to provide accurate and complete information on his/her income, resources, and other factors that affect eligibility. The applicant/recipient must also provide information on the income and resources of a nonapplying legally responsible relative, even if the relative is not living with the applicant/recipient; if the applicant/recipient does not possess this information, he/she must cooperate with the social services district in obtaining it. An applicant/recipient will not have eligibility denied or discontinued solely because he/she does not possess and cannot obtain information about the income or resources of a nonapplying legally responsible relative who is not living with him/her.

(3) The applicant/recipient is the primary source of eligibility information. When an applicant/recipient is unable to document the information provided, the social services district must conduct an investigation to verify such information. The social services district must also conduct such an investigation if it believes that information provided by an applicant/recipient is inaccurate. The district may examine records, other than public records, only with the applicant's/recipient's permission. If the applicant/recipient refuses such permission and the social services district is unable to verify information through public records, the applicant/recipient will be informed that the district is unable to determine MA eligibility. The application then will be denied, or eligibility will be discontinued.

(4) Part 351 of this Title sets forth additional requirements which must be met in the investigation process.

(b) Nonfinancial eligibility requirements. The social services district must verify that applicants and recipients meet the nonfinancial eligibility requirements contained in Subpart 360-3 of this Part.

(c) Financial eligibility requirements.

(1) Evaluation of financial circumstances. In determining whether an applicant/recipient is financially eligible for MA under section 360-3.3(b) or 360-3.3(c) of this Part, the social services district must review all sources of income and resources available or potentially available to the applicant/recipient. The district must consider the income and resources of all legally responsible relatives. The review will be based on information in the application and from a personal interview with the applicant/recipient or the person applying on his/her behalf. The district must consider only available income and resources, as defined in Subpart 360-4 of this Part. To be eligible for MA, the applicant must pursue any potential income and resources that may be available. As soon as income or resources become available, the applicant must report them to the district. The district must reevaluate the applicant's eligibility for MA based on the new financial information.

(2) Verification of income. The applicant must submit with his/her application documentation of wages received by all employed family members who are included in the application and by all legally responsible relatives living with the applicant. Acceptable forms of documentation are pay envelopes, wage stubs, or an employer's statement of wages. If the applicant's income varies, the documentation must show all wages earned in the past four weeks. If the applicant cannot supply such documentation, the social services district can accept other forms of information which it determines will verify the wages earned. All other income also must be documented and a determination made as to its availability. The social services district must record the type of information used to verify other available income.

(3) Verification of resources.

(i) The applicant may attest to the amount of his or her resources, unless the applicant is seeking coverage for long-term care services. For purposes of this paragraph, long-term care services shall include those services defined in subparagraph (ii) of this paragraph, with the exception of short-term rehabilitation as defined in subparagraph (iii) of this paragraph. The applicant must provide documentation of all available or potentially available resources when applying for long-term care services. The social services district must record the documentation provided and determine the availability of such resources.

(ii) Long-term care services shall include, but not be limited to care, treatment, maintenance, and services: provided in a nursing facility licensed under article 28 of the Public Health Law; provided in an intermediate care facility certified under article 16 of the Mental Hygiene Law; provided in a residential treatment facility certified by the Commissioner of Mental Health pursuant to section 31.02 (a)(4) of the Mental Hygiene Law; provided in a developmental center operated by the Office of Mental Retardation and Developmental Disabilities; provided by a home care services agency, certified home health agency or long-term home health care program as defined in section 3602 of the Public Health Law; provided by an adult day health care program in accordance with regulations of the Department of Health; provided by a personal care provider licensed or regulated by any other State or local agency; provided in a hospital that is equivalent to the level of care provided in a nursing facility; and provided by an assisted living program in accordance with regulations of the Department of Health. Long-term care services also shall include: private duty nursing; limited licensed home care services; hospice services including services provided by the Hospice Residence Program in accordance with the regulations of the Department of Health; services provided in accordance with the consumer directed Personal Assistance Program; services provided by the Managed Long-Term Care Program; personal emergency response services; and care, services or supplies provided by the Care at Home Waiver Program, Traumatic Brain Injury Waiver Program, or Office of Mental Retardation and Developmental Disabilities Home and Community-Based Waiver Program.

(iii) Short-term rehabilitation means one period of certified home health care, up to a maximum of 29 consecutive days, and/or one period of nursing home care, up to a maximum of 29 consecutive days, commenced within a 12-month period.

(4) If any income or resources are unavailable, the applicant/recipient must submit documentation establishing the unavailability.

(5) The applicant/recipient must satisfactorily explain and/or document how current living expenses are being met.

N.Y. Comp. Codes R. & Regs. Tit. 18 §§ 360-2.3