360-2.4 Decision.
(a) Time frames.
(1) Except as provided in paragraphs (2), (3)
and (4) 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) If an applicant for ADC or HR is determined
ineligible for such benefits, the social services district will make a separate
determination of MA eligibility within 30 days of the date the application for ADC or HR
was denied. If timely action was not taken on the ADC or HR application, the district will
determine eligibility within 30 days of the date when action should have been taken.
(4) 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 185 percent
of the applicable Federal poverty level;
(ii) a child at least
one year of age but younger than six years of age whose household income does not exceed
133 percent of the applicable Federal poverty level; or
(iii) a child born
after September 30, 1983 who is at least six years of age but younger than 19 years of age
whose income does not exceed 100 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.