360-7.6 Payment for services or supplies.
(a) For most services, rates of payment are established pursuant to
section 367-a of the Social Services Law. They are contained in Subchapter E of this Title
and the department's Medicaid Management Information System (MMIS) Provider Manuals.
Copies of the manuals may be obtained by writing Computer Sciences Corporation, Health and
Administrative Services Division, 800 North Pearl St., Albany, New York 12204. Copies may
also be obtained from the Department of Social Services, 40 North Pearl St., Albany, New
York 12243. The manuals are provided free of charge to every provider at the time of
enrollment in the MA program. Where rates of payment are not otherwise established, each
social services district must set a schedule of rates of payment for services and supplies
provided under the MA program. These rates of payment must be set to assure that adequate
services and supplies will be provided. Each social services district must require that
payment of rates made according to established schedules, including any portion to be paid
by the recipient, will constitute full payment for the services or supplies provided to
the MA recipient.
(b) (1) Payment for the following medical care, services and supplies
provided to a recipient who is eligible for medical assistance (MA) solely as a result of
being eligible for or in receipt of Home Relief (HR) and who is at least 21 years of age
but under the age of 65 is available only if the recipient is enrolled in a health
maintenance organization or other entity which provides comprehensive health services, a
managed care program, a primary provider program, or a voluntary medical care coordinator
program (MCCP):
(i) home health
services;
(ii) personal care;
(iii) physical, speech
and occupational therapy;
(iv) transportation;
(v) private duty
nursing;
(vi) optometric care;
(vii) audiology
services;
(viii) clinical
psychology;
(ix) orthotic devices;
(x) sick room supplies;
and
(xi) nursing home
in-patient care unless the recipient was an in-patient nursing home resident on July 1,
1992.
(2) Payment for in-patient hospital services
provided to a recipient who is eligible for MA solely as a result of being eligible for or
in receipt of HR and who is at least 21 years of age but under the age of 65 will be
limited to 32 days in any consecutive 12-month period unless such services are provided
through a program which receives full capitation payments.