N.Y. Comp. Codes R. & Regs. Tit. 14 §§ 635-12.8

Current through Register Vol. 46, No. 51, December 18, 2024

Section 635-12.8 - OPWDD payments

(a)Services other than preexisting services.

(1) OPWDD may, subject to the availability of State funds, pay a provider for services given to an individual if:

(i) the individual is not now paying, and has not paid in the past, the full fee for the services, and no one else is now paying or has paid in the past the full fee for the services for the individual; and

(ii) the individual took all necessary steps to obtain and maintain full Medicaid coverage and was denied full Medicaid coverage; and

(iii) the provider is meeting its obligations under this Subpart; and

(iv) the individual has an immediate need for services and delaying the start of the services would endanger the individual's health or safety.

(2) OPWDD may also, subject to the availability of State funds, pay a provider for services given to an individual if:

(i) the individual is not now paying the full fee for the services, no one else is now paying the full fee for the services for the individual, and the individual does not now have full Medicaid coverage; and

(ii) the provider is meeting its obligations under this Subpart; and

(iii) the provider is legally prohibited from denying services to the individual, discharging the individual or discontinuing services to the individual.

(3) OPWDD may also, subject to the availability of State funds, pay a provider for services given to an individual if:

(i) either:

(a) the individual was paying the full fee for the services, or someone else was paying the full fee for the services for the individual, and the individual or the other party stopped paying the full fee for the services; or

(b) the individual had full Medicaid coverage and then lost full Medicaid coverage; and

(ii) the provider is meeting its obligations under this Subpart and section 633.12 of this Title; and

(iii) the individual has a continuing need for services and ending the services would endanger the individual's health or safety.

(4) OPWDD may also, subject to the availability of State funds and if the provider is meeting its obligations under this Subpart, pay a provider the full fee if it has approved a waiver of the fee, or pay the difference between the reduced fee and the full fee if it has approved the reduced fee.

(5) Medicaid service coordination (MSC). OPWDD may, subject to the availability of State funds, pay a provider for up to three months of MSC if:

(i) the individual does not have full Medicaid coverage and MSC is necessary to assist the individual in obtaining full Medicaid coverage;

(ii) the individual is not paying for MSC and no one else is paying for MSC; and

(iii) the provider is meeting its obligations under this Subpart.

(b)Preexisting services.

(1) OPWDD may, subject to the availability of State funds, pay a provider for preexisting services given to an individual if:

(i) the individual is not paying for the preexisting services and no one else is paying for the services for the individual; and

(ii) the individual does not have full Medicaid coverage; and

(iii) the provider is meeting its obligations under this Subpart; and

(iv) OPWDD was paying the provider for the preexisting services immediately prior to the preexisting compliance date, or the individual had full Medicaid coverage immediately prior to the preexisting compliance date.

(2) OPWDD may, subject to the availability of State funds and if the provider is meeting its obligations under this Subpart, pay a provider the full fee if it has approved a waiver of the fee, or the difference between the reduced fee and the full fee if it has approved the reduced fee.

(c) The amount of OPWDD payment to a provider under this section shall be reduced by:

(1) any payments the provider receives on behalf of the individual for services; and

(2) any payments the individual receives to pay for services; and

(3) any income and resources OPWDD determines the individual or a liable party has available to pay for services.

(d) If a provider receives OPWDD payments under this section for services, and also receives monies for services from another source, the provider shall owe OPWDD the amount by which the total payment exceeds the fees for the services.

(e) Any payment by OPWDD shall not constitute nor be construed as a release from liability for services. (See section 635-12.11 of this Subpart.)

N.Y. Comp. Codes R. & Regs. Tit. 14 §§ 635-12.8

Amended New York State Register July 1, 2015/Volume XXXVII, Issue 26, eff. 7/1/2015

Amended New York State Register October 28, 2015/Volume XXXVII, Issue 43, eff. 11/1/2015

Amended New York State Register April 20, 2016/Volume XXXVIII, Issue 16, eff. 4/20/2016

Amended New York State Register September 21, 2016/Volume XXXVIII, Issue 38, eff. 9/21/2016