9 NYCRR Part 9610 - Executive Department

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Source versions current through May 15, 2022 - Oct 31, 2022 across sections

Sections in this Part carry different compiled dates; each section shows its own.

9 NYCRR 9610.1 - Application for coverage

Source version current through May 15, 2022

Later State Register activity may affect this section.

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Dates and status

NYCRR title agency: Executive Department
Section status: Section source receipt
Source version current through: May 15, 2022

(a)Any person who believes that he/she is eligible for coverage has the right to make application for coverage. The applicant himself/herself or an authorized representative shall have the right to make application on his/her behalf.

(b)Applications may be submitted by mail or by other means authorized by the contractor and approved by the State.

(c)Home visits shall be available where the physical or mental inability of the applicant makes it impracticable for him/her to submit a written application by mail.

(d)Applications and program information may be obtained from the contractor by calling the designated toll-free telephone number, by writing the contractor or contacting a designated outreach agency.

(e)Local in-person assistance shall be available for assisting applicants to apply and to answer questions.

9 NYCRR 9610.2 - Use of the application form

Source version current through May 15, 2022

Later State Register activity may affect this section.

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Dates and status

NYCRR title agency: Executive Department
Section status: Section source receipt
Source version current through: May 15, 2022

(a)The State-approved form must be completed:

(1)for each applicant upon initial application and recertification;

(2)when there is a change in status affecting eligibility; and

(3)in the event of a reapplication more than 30 days following the end of any eligibility period.

(b)Signatures on State-approved forms are required, as follows:

(1)For married applicants, both the husband and wife shall sign.

(2)Where the case involves a single individual, such individual shall sign.

(3)In any case where the applicant or spouse, whose signature is required, is incapable of signing the application because of physical incapability, mental incompetency or not residing in the household, the application shall be signed on behalf of such person by his authorized representative.

(c)The State-approved form shall contain the following information in addition to any other information which the contractor may require for the proper administration of the program:

(1)full name(s) of the applicant(s);

(2)date(s) of birth of the applicant(s);

(3)income amount and source(s) of the applicant(s);

(4)permanent address of the applicant(s);

(5)marital status of the applicant(s) and spouse's full name;

(6)county of residence of the applicant(s);

(7)other public or private insurance coverage(s), including medical assistance; and

(8)legal status of New York State residency.

9 NYCRR 9610.3 - Eligibility for coverage

Source version current through Oct 31, 2022

Later State Register activity may affect this section.

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Dates and status

NYCRR title agency: Executive Department
Section status: Section source receipt
Source version current through: Oct 31, 2022

(a)Residents of the State who are at least 65 years of age, who have incomes within the limitations prescribed by statute and who are not in receipt of medical assistance shall be eligible for coverage upon meeting the required registration fee, premium or deductible requirements of the program.

(b)Each applicant and participant shall furnish evidence, and when requested provide verification of, those factors which affect eligibilty and the amount of registration fee, premium or deductible, including:

(1)Age.

The applicant or participant shall furnish evidence that he/she is at least 65 years of age.

(2)Receiving medical assistance.

The applicant or participant shall furnish current and accurate information concerning the availability of his/her receipt of medical assistance.

(3)Residence.

Information shall be provided sufficient to establish that the applicant or participant is residing within the State.

(4)Spouse.

For each married applicant the following information shall be furnished concerning his/her spouse: full name and date of birth.

(5)[Reserved]

(6)Income.

The applicant or participant shall furnish sufficient information in order to permit calculation of his/her income.

(7)Insurance coverage.

The applicant or participant shall furnish current and accurate information concerning the availability of coverage of prescription drug expenses under a third-party assistance or insurance plan.

(c)An applicant or participant is not eligible to receive coverage if he/she has equivalent or better coverage from any other public or private third-party payment source or plan or program of insurance.

9 NYCRR 9610.4 - Decision on eligibility

Source version current through May 15, 2022

Later State Register activity may affect this section.

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Dates and status

NYCRR title agency: Executive Department
Section status: Section source receipt
Source version current through: May 15, 2022

(a)Decision on eligibility is the conclusion or determination reached in the application process. Such decision shall constitute the decision of the contractor. The decision shall be one of the following:

(1)Accepted for coverage.

This means that eligibility has been established through review and verification to the satisfaction of the contractor.

(2)Not accepted for coverage.

Applications are denied when:

(i)in the course of the application process the information given by the applicant establishes, without the need for further review and verification, that he/she is ineligible;

(ii)ineligibility is determined in the course of or upon completion of a review and verification, or if the applicant refuses to comply with any requirement essential to the determination of eligibility; or

(iii)the application is incomplete.

(3)No decision is required when:

(i)an application is withdrawn by the applicant; or

(ii)the contractor documents that the applicant has died, cannot be located, or has left the State prior to the completion of the review and verification.

(b)The applicant shall be notified in writing of the decision in accordance with these regulations.

9 NYCRR 9610.5 - Responsibility for prompt determination of eligibility

Source version current through May 15, 2022

Later State Register activity may affect this section.

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Dates and status

NYCRR title agency: Executive Department
Section status: Section source receipt
Source version current through: May 15, 2022

(a)Upon receipt of an application for coverage, the contractor shall conduct an appropriate review and verification and secure, record and evaluate its findings in order to promptly determine eligibility or ineligibility.

(b)The decision to accept or deny the application shall be made as soon as the facts to support it have been established, but not later than 30 days from the date of application, except where the applicant requests additional time or where difficulties in verification lead to unusual delay.

9 NYCRR 9610.6 - Notification

Source version current through May 15, 2022

Later State Register activity may affect this section.

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Dates and status

NYCRR title agency: Executive Department
Section status: Section source receipt
Source version current through: May 15, 2022

(a)Applicants have the right to adequate notice of their determination of eligibility.

(1)Notification shall be given within three days of the decision to accept or deny an application (except during the 120-day period beginning July 1, 1987, when notification of denial shall be given within 10 days of a decision to deny.)

(2)Notification of denial shall clearly set forth the decision of the contractor and the specific reason why the application was denied. Notification of acceptance shall clearly set forth the decision and the cost-sharing responsibilities of the applicant.

(b)Participants are entitled to timely and adequate notice of any change affecting their coverage, except for mass changes.

(c)Participants are entitled to adequate notice of any adjustment to the copayment schedule 30 days prior to the effective date of the change.

(d)Participants also have the right to adequate notice 30 days prior to the due date of any quarterly or annual registration fee or premium. The notice shall state the amount due, the date on which payment is to be received and that his/her coverage shall expire 30 days after the due date if payment is not received.

9 NYCRR 9610.7 - Issuance of identification cards

Source version current through May 15, 2022

Later State Register activity may affect this section.

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Dates and status

NYCRR title agency: Executive Department
Section status: Section source receipt
Source version current through: May 15, 2022

(a)The contractor shall issue an identification card to each person determined eligible for benefits within three days of the applicant's meeting his/her registration fee or premium or deductible requirements.

(b)The card shall include on its face the following information:

(1)participant's full name;

(2)participant's identification number;

(3)participant's annual coverage period; and

(4)any restriction on use.

(c)Upon a participant's meeting the annual limits on point-of-sale copayments, a new card shall be issued or an adjustment made to the eligibility file to reflect the waiver of the copayment requirement.

(d)Upon receipt of notification from a participant that his/her card has been lost or stolen, the contractor shall take necessary action to invalidate the original card and issue a replacement within three working days.

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