Current through Register Vol. 50, No. 9, September 20, 2024
The Department of Health and Human Resources (DHHR), Office
of Mental Health (OMH), has adopted uniform policies, rules, and fee scales for
outpatient centers and clinics of the Office of Mental Health. Fees will be
based on cost and adjusted according to the ability of the recipient to
pay.
A. Fee Policy
1. All persons seen for services at an OMH
center or clinic shall be assessed a fee for each chargeable service.
Chargeable services are those defined as chargeable under Medicaid, regardless
of the source of payment. These services are listed in Table 1. The unadjusted
fee for each service shall be equivalent to the cost of service computed for
reimbursement under Medicaid.
|
Table 1. Chargeable Services as Defined for
Medicaid Reimbursement
|
|
Code
|
Service
|
|
00071
|
Psychosocial evaluation
|
|
00072
|
Psychiatric evaluation
|
|
00073
|
Psychological evaluation
|
|
00074
|
Physical evaluation
|
|
00075
|
Other evaluation assessment service
|
|
00076
|
Individual counseling/therapy
|
|
00077
|
Group counseling/therapy
|
|
00078
|
Family/group counseling/therapy
|
|
00079
|
Medication management
|
|
00080
|
Medication injection
|
|
00081
|
Occupational therapy
|
|
00082
|
Recreational therapy
|
|
00083
|
Music therapy
|
|
00084
|
Art therapy
|
2.
All patients whose gross family income is above the minimum indicated on the
fee adjustment schedule shall pay a fee for each service provided. Fees and
adjustments to fees are to be established by the fee clerk at the time the
patient is first admitted to the facility. It is the responsibility of the
patient and/or his legally responsible family to justify any adjustment to the
full fee authorized under this policy. The patient or family will be asked to
present reasonable proof of income before any adjustment to the full fee will
be made by the fee clerk. Appropriate center or clinic staff will assist the
patient and family in verifying eligibility for a fee adjustment. There shall
be adequate documentation of the information used in adjusting any fee. Such
documentation shall be signed by the fee clerk who verifies the information and
sets the adjusted fee. The full fee, and/ or the adjusted fee, shall be posted
on the patient's ledger card and noted in the patient's permanent
record.
3. Patients shall be
charged a fee for each service, regardless of which service is provided, in the
same manner in which Medicaid is charged. No fee shall be charged for failed or
cancelled appointments.
4. All
patients shall be asked to pay their fees at the time of service delivery.
However, when patients do not pay at the time of the visit, they shall be
billed on a regular basis, preferably monthly, but no less frequently than
quarterly.
B. Fee
Adjustment Schedule
1. The fee adjustment
schedule is designed to provide for proportional payment for each service based
on the family's ability to pay. Three variable figures are utilized in
calculating the schedule:
a. state median
income as promulgated annually by the Secretary of the United States Department
of Health, Education and Welfare;
b. family size;
c. cost of service provided [for purposes of
this scale the cost of service provided will be that figure currently agreed
upon between OMH and the Office of Family Security (OFS) as the cost to be
reimbursed under the Medicaid program].
2. The fee adjustment schedule will be
calculated by OMH based on current state median income each time OMH and OFS
adjust the figure for cost reimbursement under the Medicaid program.
3. Persons whose gross family income is less
than one-half the current state median income adjusted for family size will not
be responsible for payment of services. Persons whose gross family income is
more than 150 percent of the current state median income adjusted for family
size will be charged the full cost of services provided. Between these two
levels, fees will be adjusted in accordance with the following formula.
|
Gross Family Income as a Percent of Median
Income
|
|
Adjusted for Family Size
|
Fee as a Percent of Cost
|
|
50-55%
|
4% of cost
|
|
55-60%
|
8%
|
|
60-65%
|
12%
|
|
65%
|
16%
|
|
70%
|
20%
|
|
75%
|
25%
|
|
80%
|
30%
|
|
85%
|
35%
|
|
90%
|
40%
|
|
95%
|
45%
|
|
100%
|
50%
|
|
105%
|
55%
|
|
115%
|
60%
|
|
120%
|
65%
|
|
125%
|
70%
|
|
130%
|
75%
|
|
135%
|
80%
|
|
140%
|
85%
|
|
145%
|
90%
|
|
150%
|
100%
|
4.
Adjustment of median income for family size shall be computed in accordance
with the following formula.
|
Family Size
|
% of Median Income for a Family of Four
|
|
1
|
52%
|
|
2
|
68%
|
|
3
|
84%
|
|
4
|
100%
|
|
5
|
116%
|
|
6
|
132%
|
|
7, or more
|
148%
|
5.
In computing each modification of the scale, the OMH will round actual fees to
the nearest quarter dollar. Fee adjustment schedules will be computed annually
by the central office based on current cost and distributed to the
facilities.
C. Changes
in Fees
1. The patient is to be informed that
the fee clerk should be notified of any change which may later occur in income,
employment, or family composition which might result in a change in the
adjusted fee. The fee clerk shall also conduct a periodic check (no less
frequently than annually) with each patient to determine any change in factors
including cost changes which would cause change in the fee and adjusted fee.
The staff member assigned to the case is also responsible for notifying the fee
clerk of such changes as they occur. The fee clerk is authorized to adjust the
fee appropriately in accordance with the fee adjustment schedule. The facility
administrator is ultimately responsible for assuring that adjusted fees are
current and correct.
2. No fees may
be waived or reduced beyond the fee adjustment scale without the express
approval of the facility administrator who must document the reason for change
in the patient chart. When waiver or reduction is made, the administrator must
sign and date such authorization in the case record and in addition must note
and initial the adjusted fee on the ledger card.
3. Examples of acceptable justifications for
waiving or reducing a fee include:
a.
excessive expense due to other medical costs;
b. family hardship resulting in unusual and
unexpected expenses; or
c. more
than 20 chargeable services are required by the family unit during any
month.
D.
Medication
1. All Medicaid patients are to be
provided their medication. Any patient whose adjusted fee is 15 percent or less
of the full cost may also be considered eligible to receive medication from the
center or clinic. The facility administrator may authorize provision of
medication for other patients on presentation of evidence that cost of
medication ordered by center physicians will present a serious hardship and
exceed 3 percent of family's gross income. Documentation of such exceptions and
their justification shall be made in the patient's chart and signed by the
administrator. This should be reviewed in 90 days or whenever the amount of
medication prescribed is reduced appreciably. It will be the responsibility of
the physician and nurse reviewing medication orders to so notify the
administrator.
E.
Failure to Pay Fees
1. No person shall be
denied service because of ability or inability to pay. However, when a patient
becomes delinquent in his account, the delinquency shall be handled in
accordance with DHHR policy on collections. Whenever possible, center or clinic
staff shall make an effort to negotiate a plan of payment prior to referring
the account to the Bureau of Central Collections. Any negotiated plan of
payment shall be approved by the center or clinic administrator and OMH fiscal
office.
Dependent-as used herein, means all persons
dependent on the household income as accepted by the Internal Revenue Service
(IRS) for federal income tax purpose. In the case of a minor not claimed as a
dependent for income tax purposes, the parents are still responsible for a
contribution based on the fee schedule but may increase the dependent
deductions by the client(s) in question.
Family-for purposes of establishing fees
under the procedures, the basic family unit is defined as consisting of one or
more adults and children, if any, related by blood, marriage or adoption, and
residing in the same household. Where related adults, other than spouses, or
unrelated adults reside together, each will be considered a separate family,
unless they are included as part of the family unit for federal income tax
reporting purposes. Children living with non-legally responsible relative,
emancipated minors, and children living under the care of unrelated persons
will be considered a member of the family. Minors seen without the consent and
knowledge of parents or legal guardians will be considered as separate family
units and will be charged according to the minor's own income whether the
source is allowance or earnings.
Gross Income-the monthly sum of income
received from sources identified by the U. S. Census Bureau in computing the
median income and defined in the Code of Federal Regulations,
Volume 45, Section 228. 66
Responsible Persons-as used herein, the
client's parents or guardians if the client is under the age of 18, unless
someone else claims the client as a dependent for federal income tax purposes,
in which case it is that person. If the client is over 18, he is responsible
for his contribution based on his gross family income and allowed deductions,
unless he is claimed as a dependent for income tax purposes, in which case the
claimant becomes responsible for the fee toward the cost of care based on the
claimant's family income.
G. General
Regulations
1. Documentation of Income. This
shall include federal and state income tax reports, Medicaid eligibility
records, W-2 forms and employers' statements.
2. Failure to Provide Information. A person
responsible for the payment of charges for services rendered who refuses to
supply the information necessary for an accurate determination of the required
rate of charges for services rendered shall be presumed to be able to pay the
full cost of services rendered and shall be billed accordingly. Any person who
is potentially eligible for medical assistance benefits from any federal or
state program who refuses to apply for and follow through with application for
said benefits shall be presumed to be able to pay the full cost of services
rendered and shall be billed accordingly.
3. Insurance. An insurance company that the
responsible party alleges has issued a policy or contract covering the charges
for treatment and services rendered shall be billed the full cost of services
rendered. Billings shall be made directly to the insured by the treating
facility after securing execution of the forms necessary, including an
assignment of benefits to the treatment facility, by the responsible person.
The responsible party shall be billed in accordance with the applicable fee
schedule up to the amount of charges not covered and paid by insurance. If the
responsible person refuses to execute the forms necessary to assign the
benefits under the policy alleged by him to cover the charges for treatment and
services rendered and the forms necessary to file an insurance claim in
accordance with the policy, that responsible party shall be presumed to be able
to pay at the full cost of services rendered and shall be billed
accordingly.
4. Collections. If the
payment agreement is not kept, 15 days after the due date, a notice is to be
mailed reminding the responsible party that payment was not received when due.
If results have not been received within 15 days after the first notice was
mailed, a second notice is to be sent. If results have not been received within
15 days after the second notice was mailed, a third notice is to be mailed
advising the patient that his account will be referred to Central Collections
for collection if payment is not received within 15 days. If payment has not
been received 15 days after the third notice was mailed, the account is to be
referred to Central Collections for collection. At the time account is referred
to Central Collections, the following documents and information should be sent:
a. all demographic information accumulated
(intake interview sheet);
b. copy
of signed agreement;
c. copy of
itemized bill;
d. copy of patient's
ledger.
5. Only accounts
in excess of $25 will be referred to Central Collections for handling. The
admitting facility will make every effort to collect the $25 or less accounts.
Only the director of a facility or his designee may charge off an account in
the amount of $25 or less. If the account is in excess of $25, the request for
charge off must be submitted through the Central Collections Section for
approval by the Office of Management and Finance. Any request for adjustments
in fees which deviate from the uniform fee schedule must be submitted to the
undersecretary or his designee for review and decision. All collections
received by agency, or institution after assignment of account to Central
Collections will be deposited directly to the State Treasurer's Office through
the regional bank and a list of all payments, giving patient name and amount
paid, will be mailed to Central Collections on a weekly basis. Accounts will be
referred to Central Collections when an insurance company refuses to pay a bill
for any reason which is not clearly valid. Upon receipt of an account, Central
Collections will send a series of collection letters and make telephone
contacts with individuals regarding payments. If account is not brought current
within 60 days or a satisfactory payment schedule arranged, the account will be
assigned to an attorney for collection or charged off as a bad debt if total
outstanding balance is less than $100.
AUTHORITY NOTE:
Promulgated in accordance with
R.S.
28:144.
