New York State Medicaid State Plan

Table of Contents

Section 1 – SINGLE STATE AGENCY ORGANIZATION

Section 1.1 - Designation and Authority

Section 1.2 - Organization for Administration

Section 2 – COVERAGE AND ELIGIBILITY

Section 2.1 - Application, Determination of Eligibility & Furnishing Medicaid

Section 2.2 – Coverage and Conditions of Eligibility

  • Attachment 2.2-A – Groups Covered and Agencies Responsible for Eligibility Determinations
  • Attachment 2.2-A Supplement 1 – Reasonable Classification of Individuals Under the Age of 21, 20, 19, and 18
  • Attachment 2.2-A Supplement 3 – Method for Determining cost Effectiveness of Care for Certain Disabled Children at Home

Section 2.6 – Financial Eligibility

Section 3 – Services: GENERAL PROVISIONS

Section 3.1 - Amount, Duration, and Scope of Services

  • Attachment 3.1-A – Amount, Duration and Scope of Medical and Remedial Care and Services Provided to the Categorically Needy
  • Attachment 3.1-A Supplement – Prior Approval - Medical and Remedial Care Services Provided to the Categorically Needy (Prior Approval) (Must be in Accordance with Regulations of the Department of Health)
  • Attachment 3.1-A Supplement 1 – Case Management Services
  • Attachment 3.1-A Supplement 3 – PACE Services
  • Attachment 3.1-B – Amount, Duration and Scope of Services Provided to Medically Needy Group(s)
  • Attachment 3.1-B Supplement – Prior Approval - Medical and Remedial Care Services Provided to the Medically Needy (Prior Approval) (Must be in Accordance with Regulations of the Department of Health)
  • Attachment 3.1-C – Standards and Methods of Assuring High Quality Care
  • Attachment 3.1-D – Provisions for Providing Medical Assistance Transportation
  • Attachment 3.1-E – Standards for the Coverage of Organ Transplant Services
  • Attachment 3.1-F – Enrollment into Managed Care Entities, and Chronic Illness Demonstration Project
  • Attachment 3.1-H – Health Homes for Individuals with Chronic Conditions (This Attachment is Broken Down by SPA Numbers)
  • Attachment 3.1-K – Amount, Duration, and Scope of Medical and Remedial Care and Services Provided to The Categorically Needy
  • Attachment 3.1-L – Alternative Benefit Plans

Section 3.2 - Coordination of Medicaid with Medicare Other Insurances

  • Attachment 3.2-A – Medicare –Part A and B – Dual Eligibles (Coordination of Title XIX with Part A and Part B of Title XVIII)

Section 4 – GENERAL PROGRAM ADMINISTRATION

Section 4.11 - Relations with Standard Setting and Survey Agencies (DOH, OMH)

Section 4.14 - Utilization/Quality Control

Section 4.16 - Relations with State Health and Vocational Rehabilitation Agencies and Title V Grantees

  • Attachment 4.16-A – Summary of Cooperative Arrangements with State Health and State Vocational Rehabilitation Agencies and with Title V Grantees

Section 4.17 - Liens and Adjustments or Recoveries

Section 4.18 - Recipient Cost Sharing and Similar Charges (Deductibles, Coinsurance Rates, and Copayments)

Section 4.19 - Payment for Services

Section 4.22 - Third Party Liability

Section 4.30 - Exclusion of Providers and Suspension of Practitioners and Other Individuals

Section 4.32 - Income and Eligibility Verification System

  • Attachment 4.32-A – Income & Eligibility Verification System Procedures Requests to Other State Agencies

Section 4.33 - Medicaid Eligibility Cards to Homeless Individuals
  • Attachment 4.33-A – Method for Issuance of Medicaid Eligibility Cards to Homeless Individuals

Section 4.34 - Requirements for Advance Directives Under State Plans for Medicaid Assistance

  • Attachment 4.34-A – Requirements for Advance Directives Under State Plans for Medical Assistance

Section 4.35 - Enforcement of Compliance for Nursing Facilities

  • Attachment 4.35-A – Enforcement of Compliance for Nursing Facilities – Seriousness of Deficiencies
  • Attachment 4.35-B – Enforcement of Compliance for Nursing Facilities – Termination of Provider Agreement
  • Attachment 4.35-C – Enforcement of Compliance for Nursing Facilities – Temporary Management
  • Attachment 4.35-D – Enforcement of Compliance for Nursing Facilities – Denial of Payment for New Admissions
  • Attachment 4.35-E – Enforcement of Compliance for Nursing Facilities – Civil Money Penalty
  • Attachment 4.35-F – Enforcement of Compliance for Nursing Facilities – State Monitoring
  • Attachment 4.35-G – Enforcement of Compliance for Nursing Facilities – Transfer of Residents with Closure of Facility, Emergency Cases
  • Attachment 4.35-H – Enforcement of Compliance for Nursing Facilities – Directed Plan of Correction
  • Attachment 4.35-I – Enforcement of Compliance for Nursing Facilities – Directed In-service Training
  • Attachment 4.35-J – Enforcement of Compliance for Nursing Facilities – Additional Remedies – State Civil Money Penalties Imposed as a Category 2 Enforcement Remedy

Section 4.38 - Nurse Aide Training and Competency Evaluation for Nursing Facilities

Section 4.39 - Preadmission Screening and Annual Resident Review in Nursing Facilities

Section 4.40 - Survey and Certification Process

  • Attachment 4.40-A – Eligibility Conditions and Requirements – Survey and Certification Education Program
  • Attachment 4.40-B – Eligibility Conditions and Requirements – Process for Investigations of Allegations of Resident Neglect and Abuse and Misappropriation of Resident Property
  • Attachment 4.40-B Supplement 1A – Complaint Program Overview
  • Attachment 4.40-C – Eligibility Conditions and Requirements – Procedures for Scheduling and Conduct of Standard Surveys
  • Attachment 4.40-D – Eligibility Conditions and Requirements – Programs to Measure and Reduce Inconsistency
  • Attachment 4.40-E – Eligibility Conditions and Requirements – Process for Investigations of Complaints and Monitoring

Section 4.42 – Employee Education about False Claims Recoveries

Section 7 – GENERAL PROVISIONS

Section 7.2 - Nondiscrimination

  • Attachment 7.2-A – Methods of Administration – Civil Rights Act (Title VI)
  • Attachment 7.2-B – Non-Discrimination on the Basis of Handicap – Methods of Administration