Current through Register Vol. 50, No. 9, September 20, 2024
A. Fee Policy
1. All persons seen for services at an OPRADA
center or clinic shall be assessed a fee for each chargeable service.
Chargeable services are those defined as chargeable under the Medicaid Program,
Title XIX of the Social Security Act, 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 Procedure
|
|
Code
|
Service
|
|
00140
|
Individual Counseling/Therapy
|
|
00141
|
Group Counseling/Therapy
|
|
00142
|
Family Counseling/Therapy
|
|
00143
|
Collateral Counseling
|
|
00144
|
Medical Treatment
|
|
00145
|
Medical Injection
|
|
00146
|
Occupational Therapy
|
|
00147
|
Recreational Therapy
|
|
00148
|
Music Therapy
|
|
00149
|
Art Therapy
|
|
00150
|
Screening and Intake
|
|
00151
|
Psychosocial Evaluation
|
|
00152
|
Psychiatric Evaluation
|
|
00153
|
Medical Evaluation
|
|
00154
|
Other Evaluation
|
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 at the time the patient is first
admitted to the facility. It is the responsibility of the patient and/or
legally responsible family to justify any adjustment to the full fee. The
patient or family will be asked to present reasonable proof of income before
any adjustment to the full fee will be made. 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. Fees may be adjusted during the patient's course of
treatment based on changes in the economic status of the patient. 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:
(1) state median income as promulgated
annually the Secretary of the United States Department of Health and Human
Services;
(2) family size; and
(3) cost of service provided as
computed for Medicaid.
2. The fee adjustment schedule will be
recalculated by OPRADA based on current state median income each time OPRADA
and the Department of Health and Human Resources, Office of Family Security
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 one hundred fifty 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%
|
a. 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%
|
4. In computing each modification of the
scale, the OPRADA will round actual fees to the nearest quarter dollar. Fee
adjustment schedules will be computed annually 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 with each
patient to determine any change in factors including cost changes, which would
caused change in the fee and adjusted fee.
2. No fee 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. 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 three percent of the 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. 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 the Department of Health
and Human Resources' 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 Department of Health and Human Resources, Bureau of Central
Collections. Any negotiated plan of payment shall be approved by the center or
clinic administrator and OPRADA fiscal office.
F. Definitions
1. Gross Income means the monthly sum of
income received from sources identified by The U.S. Census Bureau in computing
the median income and defined in the CFR, Volume 45, Section 228. 66
2. Dependent means all persons dependent on
the household income as accepted by the Internal Revenue Service (IRS) for
federal income tax purposes. 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.
3. Family
means the basic family unit 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 nonlegally responsible relatives, emancipated minors, and children
living under the care of unrelated persons 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.
4. Responsible persons means the client's
parents or legal 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 shall include federal and state income tax reports, Medicaid eligibility
records, W-2 forms and employer's statements.
2. 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. 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 insurer
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 and the forms necessary to file an insurance claim in
accordance with that policy, it shall be presumed that the responsible person
is able to pay at the full cost of services rendered and shall be billed
accordingly.
4. Collection
Procedure
a. If the payment agreement is not
kept, a notice shall be mailed 15 days after the due date reminding the
responsible party that payment was not received when due.
b. If payment has not been received within 15
days after the first notice was mailed, a second notice shall be
sent.
c. If results have not been
received within 15 days after the second notice was mailed, a third notice
shall be mailed advising the patient that this account will be referred to the
Department of Health and Human Resources, Central Collections if payment is not
received within 15 days.
d. 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. In addition,
the following documents and information should be sent: all demographic
information accumulated (intake interview sheet); copy of signed agreement;
copy of itemized bill; and a copy of the patient's ledger.
e. Only accounts in excess of $25 will be
referred to Central Collections for handling. The admitting facility will make
every effort to collect outstanding accounts of $25 or less. Only the manager
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.
AUTHORITY NOTE:
Promulgated in accordance with R. S. 36:258(J).
