N.Y. Comp. Codes R. & Regs. Tit. 9 § 6654.6 - EISEP cost-sharing

(a) EISEP clients shall pay cost-sharing for in-home, ancillary, and noninstitutional respite services received under the client's care plan according to a sliding scale, subject to adjustments pursuant to this section, reflecting the cost of such services and client income so that:

(1) no cost-sharing will be charged clients whose income is at or below 150 percent of poverty levels specified by the office (unless they are eligible for Medicaid);

(2) the full cost of services will be charged clients whose income is at or above 250 percent of poverty levels specified by the office and clients who are eligible for Medicaid;

(3) partial cost-sharing will be charged clients whose income is between 150 percent and 250 percent of poverty levels specified by the office; and

(4) no cost-sharing will be charged clients for durable items provided on a loan basis as an ancillary service.

(b) Adjusted monthly income:

(1) includes, to the extent available, income of the client's spouse if the client is living with his or her spouse; and

(2) equals monthly income minus the threshold and the housing adjustment;

(i) monthly income is the clients's income during the month in which the client's care plan is prepared, including a proportionate share of annual income received less frequently than monthly:

(a) consisting of money regularly received, after the payment of Federal, State, and local personal income taxes, from:

(1) wages or salary;

(2) net income (gross income minus expenses incurred in generating the income up to the amount of gross income) from:

(i) farm and nonfarm self-employment;

(ii) buying and selling real or personal property on a regular basis;

(iii) roomers or boarders and rental of property;

(3) social security old-age, survivors, and disability insurance benefits;

(4) pensions and annuities; and

(5) interest and dividends;

(b) excluding:

(1) income from participation in the Senior Community Services Employment Program under title V of the Older Americans Act, Job Training Partnership Act, Foster Grandparent Program, or other programs established to foster employment of lower income elderly or to support volunteer efforts by the elderly;

(2) unearned income from one-time lump sum payments such as insurance benefits, irregular gifts or contributions, the Real Property Tax Credit, and the Low-Income Home Energy Assistance Program;

(3) sums which the client is obligated to repay, such as proceeds from reverse mortgages and other home equity conversion plans; and

(4) goods, services, or benefits received in kind, such as food stamp coupon allotments;

(ii) the threshold is the amount of monthly income to be exempt from cost-sharing for all clients as specified by the office. (At the time these regulations were originally promulgated, the threshold was $905 for clients living with spouses whose income is available to meet their needs and $670 for all other clients.) Thresholds are adjusted regularly by the office to reflect changes in the consumer price index for all items, between the third quarters of the preceding two calendar years;

(iii) the housing adjustment is the amount by which the client's average monthly housing expenses exceed 40 percent of the threshold, except that the housing adjustment shall not exceed 40 percent of the threshold;

(a) housing expenses are costs incurred against the client's income for renting or owning the housing unit in which the client lives, including rent, property taxes, mortgage payments, heating, telephone installation and local service, and other utilities;

(b) average monthly housing expenses are housing expenses payable from the client's income during the month in which the client's care plan is prepared, including a proportionate share of annual heating and other costs which occur less frequently than monthly or are subject to seasonal variation.

(c) Cost-sharing charged a client equals the adjusted cost of in-home, ancillary, and noninstitutional respite services received by the client under the care plan, multiplied by the percentage of cost to be charged given the client's adjusted monthly income as specified in the current cost-share schedule specified by the office, except that total cost sharing charged a client living with a spouse who is also a client receiving in-home, ancillary, or noninstitutional respite services under a care plan shall not exceed one half the adjusted monthly income, and total cost-sharing charged any other client shall not exceed the client's adjusted monthly income.

(1) The adjusted cost of an in-home, ancillary, or noninstitutional respite service equals the number of units received by the client under the care plan multiplied by the unit cost for the service under the county's approved county home care plan for functionally impaired elderly (or, if no such cost is stated in the plan, the actual cost incurred in providing or purchasing the service for the client) or, for clients required to pay less than the full cost of the service, by the lesser of the unit cost specified in such approved plan (or, if none, the actual cost incurred) or the statewide average unit cost of the service, if any, as specified by the office.

(2) The percentage of cost to be charged a client shall be determined according to the client's adjusted monthly income in accordance with the current cost-share schedule specified by the office. The cost-share schedule is adjusted regularly by the office to reflect changes in the consumer price index for all items, between the third quarters of the preceding two calendar years. At the time these regulations were originally promulgated, the cost-share schedule for clients living with spouses whose income was available to meet their needs (designated as couples) and for all other clients (designated as individuals) was as follows:

COST-SHARE SCHEDULE

Couples		Individuals
Adjusted monthly income	Cost-sharing rate	Adjusted monthly income	Cost-shaing rate
$0	0%	$0	0%
$1 to $32	5	$1 to $24	5
33 to 63	10	25 to 47	10
64 to 95	15	48 to 71	15
96 to 127	20	72 to 94	20
128 to 159	25	95 to 118	25
160 to 190	30	119 to 141	30
191 to 222	35	142 to 165	35
223 to 254	40	166 to 188	40
255 to 286	45	189 to 212	45
287 to 317	50	213 to 235	50
318 to 349	55	236 to 259	55
350 to 381	60	260 to 282	60
382 to 413	65	283 to 306	65
414 to 444	70	307 to 329	70
445 to 476	75	330 to 353	75
477 to 508	80	354 to 376	80
509 to 540	85	377 to 400	85
541 to 571	90	401 to 423	90
572 to 603	95	424 to 447	95
More than 603*	100	More than 447*	100
* or eligible for Medicaid.

(d) A copy of all documents used in determining the extent of cost sharing required from a client, including forms specified by the office, shall be maintained in the client's case record.

(e) Unless the applicant voluntarily agrees to pay the full cost of EISEP in-home, noninstitutional respite and ancillary services received under the care plan, each applicant or his or her authorized representative shall:

(1) declare sources and amounts of income of the client and, for clients living with their spouse, of the spouse of which the client is aware or which are available to meet the needs of the client;

(2) provide information necessary for assessing potential Medicaid eligibility;

(3) sign a statement prescribed by the office attesting to the truthfulness of declarations and agreeing to provide supporting documentation upon request;

(4) sign a cost sharing agreement promising to pay the required cost sharing and to notify the case manager or designated case management staff of any changes in income or expenses that would affect the amount of cost sharing required of the client; and

(5) to receive a housing adjustment, declare the kind, amount, and recipient of housing expenses.

(f) The case manager:

(1) shall ensure that clients or their authorized representatives receive assistance as requested by clients or representatives in reviewing financial documents;

(2) shall sign the cost-sharing agreement attesting that the information contained therein is consistent with information provided by the client or his or her authorized representative and with any other available information;

(3) may require the client or his or her authorized representative to provide documentation to verify the accuracy of declarations;

(4) shall ensure the computation of cost sharing and the execution of a cost sharing agreement in accordance with this section and section 6654.16 of this Part;

(5) shall ensure that no cost sharing is required for services not received by a client or received prior to the cost sharing determination pursuant to this section; and

(6) shall ensure that the client's cost-sharing obligations are redetermined and a new cost-sharing agreement is developed if requested by the client or his or her authorized representative or if there is a change in in-home, ancillary, or noninstitutional respite services to be provided the client under the care plan; the client's adjusted monthly income; or the status of the client in a way that may affect the terms of the cost-sharing agreement, including new medical expenses that could make the client eligible for Medicaid. A redetermination shall not be required solely by reason of changes in the schedule of unit costs, cost share schedule, thresholds, of the client's monthly income resulting from cost of living adjustments in social security old-age, survivors, and disability insurance benefits or other income subject to periodic adjustments based on the cost of living, consumer price index, or similar measures.

(g) Cost-sharing agreements shall:

(1) clearly present the responsibilities of the client for payment of cost sharing, including payment schedules, billing practices and payment procedures;

(2) describe the client's liability for the payment of cost sharing, including:

(i) the maximum amount of cost sharing the client could be required to pay per month, regardless of the extent of services received under the care plan, based on the client's adjusted monthly income;

(ii) the cost-sharing rate for the client;

(iii) the time period covered by the agreement, which shall not exceed the period covered by the client's care plan;

(iv) the projected number of units of each in-home, noninstitutional respite, and ancillary service covered by the agreement, which shall be the same as in the client's care plan during the period covered by the agreement; and

(v) the estimated dollar amount of cost sharing the client will be required to pay if the units of service covered by the agreement are received by the client as planned;

(3) be modified or replaced when a redetermination of cost sharing is conducted; and

(4) not be presented to the client or his or her authorized representative for signature until such person has been informed in writing of policies and procedures governing payment, redetermination and nonpayment of cost sharing, including the right to a redetermination or a hearing regarding the extent of cost sharing required of the client.

(h) The area agency shall ensure the use of procedures for collection of cost sharing consistent with this section and with standards specified by the office:

(1)

(i) which may include the opportunity to pay equal amounts over the period covered by the cost-sharing agreement; and

(ii) which shall provide that no client shall be requested to pay a cost share for services for an amount in excess of the client's maximum monthly cost sharing as set forth in the cost-sharing agreement;

(2) designating authorized staff or agents to receive such cost sharing on behalf of the area agency;

(3) including the submission to the office for prior approval policies and procedures or actions for collecting cost sharing due but not paid by clients under cost-sharing agreements and for discharging clients due to nonpayment of cost sharing, providing that:

(i) clients who willfully fail to make payments shall be terminated from the program and shall be ineligible for any services under EISEP until payment of past cost sharing is received; and

(ii) clients will not be terminated from the program for reason of nonpayment without receiving:

(a) written notification of failure to make required cost sharing;

(b) an opportunity to be heard on whether such cost sharing was paid or why not;

(c) prior written notification of the proposed termination of services and the procedure for discharge from the program; and

(d) benefit of the procedures for discharge from the program.

Notes

N.Y. Comp. Codes R. & Regs. Tit. 9 § 6654.6