N.Y. Comp. Codes R. & Regs. Tit. 18 §§ 360-2.4

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

Section 360-2.4 - Decision

(a) Time frames.

(1) Except as provided in paragraphs (2) and (3) of this subdivision, the social services district must determine an applicant's eligibility for MA within 45 days of the date of the MA application.

(2) If an applicant's MA eligibility is dependent on disability status, the social services district will determine MA eligibility within 90 days of application. If a decision is not reached within 90 days, the applicant must be sent a statement explaining why.

(3) The district will determine eligibility within 30 days of the date of the MA application if an applicant is:

(i) a pregnant woman or an infant younger than one year of age whose household income does not exceed 200 percent of the applicable Federal poverty level.

(ii) a child at least one year of age but younger than 19 years of age whose household income does not exceed 133 percent of the applicable Federal poverty level.

(b) The social services district must determine MA eligibility within the time frames in subdivision (a) of this section except in unusual circumstances including:

(1) when the district cannot reach a decision because the applicant or an examining physician has delayed taking or has not taken a required action, or because medical records have not been received; or

(2) where there is an administrative or other emergency beyond the district's control.

(c) When a social services district determines that an applicant or recipient is eligible for MA, MA will be authorized. Such authorization will be effective back to the first day of the first month for which eligibility is established, except as otherwise provided in this Part. A retroactive authorization will be issued for medical expenses incurred during the three months prior to the month of application for MA, provided the applicant was eligible in the month in which the medical care and services were received. Direct payment to the recipient for paid medical bills will be limited to the MA rate or fee in effect at the time the services were rendered.

N.Y. Comp. Codes R. & Regs. Tit. 18 §§ 360-2.4