Current through Register Vol. 49, No. 18, September 16, 2024
PURPOSE: This rule prescribes a standard means test
as required by section
630.210,
RSMo, to determine amounts to be charged for services provided or procured by
the Department of Mental Health.
(1) Definitions. The terms defined in section
630.005, RSMo, are
incorporated by reference as though set out in this rule. The following other
terms used in this rule, unless the text clearly requires otherwise, shall
mean:
(A) Adjusted gross monthly income the
income remaining after allowable deductions permitted by this rule;
(B) Community psychiatric rehabilitation
center (CPR provider or CPR program) an organization which provides or arranges
for, at the minimum, the following core services: intake and annual
evaluations, crisis intervention and resolution, medication services,
consultation services, medication administration, community support, and
psychosocial rehabilitation in a nonresidential setting for individuals with
serious mental illness in conjunction with standards set forth in
9 CSR
30-4.031-9 CSR
30-4.047;
(C) Community services any services purchased
or provided by the department that are not included in the definition of "long
term care";
(D) Community support
services for the Division of Developmental Disabilities (DD), this means all
Purchase of Service (POS) services, case management services for clients
residing in Community Placement Program (CPP) facilities and in their natural
homes, Choices for Families services, and all voucher services; for the
Division of Comprehensive Psychiatric Services (CPS), this means Family
Preservation services, Intensive Case Management services for children and
adults, Supported Housing Voucher Program or Housing and Urban Development
(HUD) Housing Voucher Program services, and Intergrated Employment Support
services; for the Division of Alcohol and Drug Abuse (ADA), this applies to
drug free counseling services provided to clients participating in a methadone
maintenance program who have become drug free;
(E) Early intervention services developmental
services provided by qualified personnel to meet infant's or toddler's
developmental needs in one (1) or more of the following areas: physical
development, cognitive development, language and speech development,
psychosocial development, or self help skills. Early intervention services must
be provided in conformity with an individualized family service plan. Early
intervention services may include, but are not limited to:
1. Family training, counseling, and home
visits;
2. Special
instructions;
3. Speech pathology
and audiology;
4. Occupational
therapy;
5. Physical
therapy;
6.
Transportation;
7. Psychological
services;
8. Social work;
9. Case management services;
10. Nursing services;
11. Nutrition services;
12. Medical services for diagnostic or
evaluation purposes;
13. Early
identification, screening, and assessment services; and
14. Health services which enable infants or
toddlers to benefit from other early intervention services;
(F) Financially responsible person
the individual who is obligated by law or this rule to pay charges for
services;
(G) Gross monthly income
(earned and unearned) the total monthly income from all sources before payroll
deductions, other with holdings, and expenses incurred in earning the income.
Examples would include salaries and wages, dividends, annuities, interest,
rents, pensions, disability and survivor benefits, Workers' Compensation,
unemployment compensation, maintenance and child support payments, bonuses,
tips and gratuities, income from business or profession, and any other taxable
and nontaxable income;
(H)
Household size the number of persons dependent upon the income of the
financially responsible person including the person (recipient) receiving
services, except for a blended family situation. Dependency for family members,
other than the recipient, must meet the dependency test in the federal
Internal Revenue Code;
(I) Long term care continuous residential
care (excluding supportive housing) which meets any of the following
conditions:
1. Admission to a habilitation
center;
2. Admission to a community
placement facility;
3. A statement
signed by a physician or a qualified mental health professional that the care
is for an indeterminate period; or
4. The care has been provided for at least
twenty four (24) months without any documentation in the recipient's
individualized treatment, habilitation, or rehabilitation plan indicating
discharge is imminent (within ninety (90) days);
(J) Monthly rate the amount determined by
application of the sliding fee scale to be charged for services provided in a
month;
(K) Provider a public or
private agency offering services to individuals approved for Department of
Mental Health (DMH) funded services;
(L) Recipient client, patient, or resident
the person receiving services;
(M)
Representative payee guardian, trustee, conservator, or other fiduciary
appointed to receive a beneficiary's benefits (for example, Social Security,
Railroad Retirement);
(N) Sliding
fee scale a table for determining the monthly rate to be charged to a
financially responsible person for services; and
(O) Unearned income income that is not
derived from employment. Examples would include maintenance and child support
monies, interests, pensions, unemployment benefits, Workers' Compensation, and
benefits from the Social Security Administration, Railroad Retirement Board,
Civil Service Commission, Veterans Administration, and other similar types of
income.
(2) Charges Not
to Exceed Costs. The charges determined by the application of this rule shall
not exceed costs. For providers operated by the department, the costs are
determined annually as required by section
630.210,
RSMo. For other providers, the costs are authorized by contract with the
department. If more than one (1) source of reimbursement is being charged, then
collectively the charges shall not exceed costs.
(3) Community Support Incentives/POS. The
following financial incentives shall be provided to clients and families
receiving less costly community support services:
(A) Clients or their financially responsible
parties shall be assessed at a rate of one fourth (1/4) their monthly ability
to pay, for community support services which are received by the client, except
for the case management services specified in subsection (3)(B). Insurance
companies and other third party payers shall be billed at actual cost for all
community support services, including the case management services specified in
subsection (3)(B); and
(B) For case
management services reimbursed by the Division of Developmental Disabilities
and intensive case management services reimbursed by the Division of
Comprehensive Psychiatric Services, only clients or their financially
responsible parties with annual adjusted gross incomes exceeding one hundred
thousand dollars ($100,000) in 1991 dollars, adjusted annually for inflation
using the Consumer Price Index (CPI), shall be assessed a charge, and the
charge shall be the lesser of actual cost or one fourth (1/4) their monthly
ability to pay.
(4)
Health Insurance. The provider shall apply to the costs incurred for providing
services to the recipient the benefits received or available on behalf of or to
the recipient from private and public health insurance, health services
corporation and health maintenance organization plans, policies and contracts
including individual, company, fraternal, group, Medicare, Medicaid, and
similar plans to the extent and limits of the coverage for the recipient. If a
federal program requires the department to accept federal reimbursement as full
payment as a condition of participation in the program for certain services,
the provider shall not charge the financially responsible person for the
services except the federally permitted deductibles or coinsurances.
(5) Financial Responsibility. As set out in
section
630.205,
RSMo, the following are jointly and severally liable to pay under this rule for
services rendered to a recipient:
(A) The
recipient;
(B) The recipient's
estate only to the extent of the assets in the estate, if the recipient has a
conservator or is deceased;
(C) The
recipient's spouse unless otherwise provided for in a separation agreement or
dissolution order approved by a court of competent jurisdiction;
(D) The recipient's natural parents' ability
to pay is based separately on their own income with each claiming the children
from that marriage as dependents. All child support, even if it is for other
children that were a result of that marriage that are not our clients, will be
considered in total income;
(E) Any
fiduciary, such as a trustee, only to the extent of the assets the fiduciary is
holding on behalf of or for the recipient, which assets may be used according
to law; except for any assets held in the Missouri Family Trust Fund on behalf
of or for the recipient;
(F) Any
representative payee to the extent of the benefits and assets under the law
governing and permitting payment of benefits and assets for the
recipient;
(G) The recipient's
parents if the recipient is a minor (under age eighteen (18)), except the
following:
1. The parents of a minor
recipient who has been emancipated;
2. The parents of a minor recipient if the
parents have relinquished parental responsibility through legal adoption or
have had parental rights terminated by an action of a juvenile court;
3. The parents of a recipient age three to
eighteen (3-18), a recipient age three to twenty-one (3-21), or the spouse or
estate of a recipient age three to twenty-one (3-21) are not liable for the
cost of education, special education, or related services. The parents of a
recipient age birth to three (0-3) are not liable for the cost of prevention
and early intervention services provided through
P.L.
102-1 1 9 Part H First Steps. The term special
education, as used in this rule, is defined in 34 CFR Section 300a.14. The term
related services, as used in this rule, is defined in 34 CFR 300a.13;
4. The adoptive parents of a minor recipient
who had been, before the adoption, court committed to the legal custody of the
department, the Department of Social Services, or a charitable organization;
and
5. Stepparents'
income;
(H) If two (2)
or more members of a household receive services in the same month, the provider
shall charge no more than the amounts determined by application of the sliding
fee scale for one (1) recipient. Before this shall apply, the financially
responsible person shall notify the provider when services are provided to more
than one (1) member of the household in the same month;
(I) If the recipient is eligible for Medicaid
(under any state entitlement program), Supplemental Security Income (SSI),
General Relief (GR), or Food Stamps, the Standard Means Test (SMT) is not
required to be implemented, with the exceptions that are found in other parts
of this rule. Documentation of the eligibility must be placed in the financial
file in lieu of an SMT;
(J) If the
recipient is eligible for Title IV-A, the SMT will not need to be implemented.
Documentation of eligibility must be placed in the financial file in lieu of an
SMT;
(K) If it appears from the
application of the SMT that the recipient could be assessed under more than one
(1) client identifier, the formula which requires the least amount of client
pay will be used; and
(L) The
department shall consider noncustodial parents court orders regarding support
payments and medical coverage obligations.
(6) Charges for Nonresidents. If a recipient
of any age is not domiciled in this state, as defined in
9 CSR
10-31.016, then those responsible to pay, the parents,
school district, special district or state department or agency of the
recipient's domicile, under this rule are liable to pay the full cost of the
services.
(7) Sliding Fee Scale.
The scale determines the monthly rate to be charged to a financially
responsible person for services. The scale was developed using three hundred
percent (300%) of the federal poverty guidelines for the year 2009 and income
withholding tables for federal and state taxes. The scale shall be updated
annually when changes have occurred in the federal poverty guidelines or the
tax withholding tables. The adjusted gross monthly income on the sliding fee
scale is determined by deducting the following expenses from gross income:
(A) Business expenses and expenses incurred
on income producing property when the income is included in gross income under
this rule and the expenses were deducted on the federal income tax
return;
(B) Business expenses which
have no history and are now being claimed will be based on federal tax
guidelines; if a review finds business expenses were invalid, then the rate
will be adjusted to their ability to pay, retroactively;
(C) Medical expenses deducted by the taxpayer
(financially responsible person) on the most recent filed tax year that exceed
the federal percentage rate allowable of the federal adjusted gross income in
(1996) or medical expenses that exceed the federal percentage and cannot be
claimed on the federal tax return due to inability to itemize deductions, proof
of payment must be presented;
(D)
Medical expenses, anticipated or unanticipated, that will be scheduled as a
monthly payment. Documentation must be presented that the payments have been or
are being made. If a review finds that payments were not or are not being made,
then the rate will be adjusted to their actual ability to pay, retroactively;
and
(E) Child support paid by a
parent, whether the parent can claim the child as a dependent or not, shall be
a deduction to income. Documentation must be provided that payments are being
made.
(8) Charges for
Long Term Care. The charges shall be determined under this section, and only
under this section, when the recipient requires long term care.
(A) If the recipient is with his/her spouse
or dependents, the provider shall charge the recipient, his/her estate,
fiduciary, or representative payee as follows: If the recipient is with his/her
spouse or dependents, all unearned income should be treated as earned income
and assessed according to the sliding fee scale, except in those cases where
the spouses are estranged.
(B) If
the recipient in a residential care or inpatient facility purchased or operated
by DMH is without spouse or dependents, then the provider shall consider all of
a recipient's real and personal property when the provider has obtained and
filed an annual statement from a licensed physician or a qualified mental
health professional indicating that the recipient requires full time
residential services or, if the recipient has been in full time residential
services, twenty-four (24) or more continuous months previously. The provider
shall charge all costs until the recipient's estate is reduced to the allowable
amount for Medicaid eligibility, except cash and securities shall not exceed
ninety-five percent (95%) of the Medicaid limit on cash and securities. The
provider (DMH operated or purchased facility) shall apply all unearned income
to the cost of services, except that the provider shall make an allowance of
thirty dollars ($30) or more per month for personal spending as specified in
the recipient's individualized treatment, habilitation, or rehabilitation plan.
If the representative payee is the conservator, then the court ordered costs
shall be a reduction in the amount assessed upon the recipient's
benefits.
(C) Subsections (8)(A)
and (B) of this rule may be waived whenever the release of the recipient is
imminent (within ninety (90) days), the unmet needs of the recipient have been
documented and the recipient's existing funds are inadequate to pay the costs
of the needs documented in the recipient's individualized habilitation,
rehabilitation, or treatment plan.
(9) Charges for Community Services. Only
financially responsible persons whose income is equal to, or greater than,
three hundred percent (300%) of the federal poverty guidelines shall be
assessed a monthly rate using the sliding fee scale, except that no financially
responsible person shall be assessed a monthly rate for services received
through a Community Psychiatric Rehabilitation Center or Compulsive Gambling
services as defined in
9 CSR
30-3.134(1).
(10) Working Clients. If the recipient is a
working client and is without a spouse, dependents, or both, the provider shall
apply to costs of services forty percent (40%) of all net earned income
exceeding one hundred dollars ($100) per month, except in cases where DMH is
not paying room and board costs. In these cases, the sliding fee scale shall be
applied.
(11) Documentation
Requirements. For community services, the financially responsible persons shall
certify their income to the provider. If the provider has reasons to believe
that the income certified by the financially responsible persons is inaccurate,
then the provider shall request the documentation required below for
individuals receiving long term care. For long term care, the financially
responsible persons shall furnish the provider written statements of their
income (for example, most recent year's filed complete federal tax return) or
other supporting documentation requested by the provider for income
verification. If the provider applies the long term care provisions under this
rule, then the provider shall obtain a statement of the recipient's personal
and real assets and other supporting documentation. Documentation must be
provided for any deductions to gross income.
(12) Failure to Comply. The provider shall
have the recipient or financially responsible person apply for benefits and
entitlements described in this rule if it appears the recipient is eligible.
The provider may charge the financially responsible person all costs of
providing or procuring the services when the recipient or financially
responsible person
(A) Deliberately fails to
divulge financial resources upon request of the provider;
(B) Fails to apply or permit the provider to
apply for benefits; or
(C) Fails to
assign benefits.
(13)
Failure to Pay. The provider may take action to collect any unpaid amounts
charged based on the sliding fee scale or the full cost based on the failure to
comply. These actions may include, but are not limited to, Missouri State
Income Tax Intercept and any further action allowable under state and federal
law.
(14) Voluntary Payments. The
provider may accept voluntary payments from individuals not legally obligated
to pay and payments made in addition to the amounts determined by application
of this rule. Providers operated by the department shall receive gifts,
donations, devises, or bequests as set out in section
630.330,
RSMo. For services to clients, vendors or department operated providers may set
a minimal charge for services to clients which may exceed the monthly charge
applicable under this rule. The charge shall not exceed five dollars ($5) per
visit and shall be an offset against any charges determined as otherwise
applicable under this rule, per program, per provider. If one (1) client is
assessed a minimal charge, all clients in that program must be assessed the
same minimal charge. The provider can determine that an urgent need for
immediate services overrides any inability or refusal to pay.
(15) Test Application Procedures. The
director delegates his/her authority to complete the SMT to any provider
operated by the department. Other providers (for example, nonstate community
mental health centers or substance abuse programs) which serve recipients
directly without having them go through department case management shall apply
the test if the providers agree to do so under the terms of contracts with the
department.
(A) The provider shall apply the
SMT contained in this rule at admission, annually after admission if the
recipient is still receiving services, upon request from the recipient or
responsible party, or by the initiative of the provider or the department
director due to any significant change in financial status.
(B) The provider shall apply the test in this
rule on all recipients as of February 26, 1993.
(C) Upon request for review, the provider
shall change the monthly rate, if warranted, effective to the first day of the
month of the date of request.
(D)
As other substantial changes occur in income or asset status, the provider
shall reapply the test and the changes shall be effective as of the first day
of the month following the date of the reapplication of the test. If inaccurate
or fraudulent information was provided for determining charges, or if the
recipient is entitled to retroactive benefits, the provider shall retroactively
change the amount charged.
(16) Appeal Procedures. The application of
the SMT may be appealed by the financially responsible person to the chief
administrative officer of the provider and then the department director as
follows:
(A) The chief administrative officer
of the provider shall review upon appeal the application of the test as to the
verification of financial resources, the determination of charges, and issue a
decision to the financially responsible person;
(B) The decision of the chief administrative
officer of the provider may be appealed to the department director within
fifteen (15) days of the receipt of the decision. The director will review
appeals only if the recipient or responsible party alleges the incorrect
application of the test. Upon completion of the review, the director shall
issue a decision which may alter application of the test;
(C) As set out in section
630.210,
RSMo, the decision of the director may be reviewed in the circuit court of Cole
County or the circuit court in the county where the financially responsible
person legally obligated to pay resides according to the procedure set out in
Chapter 536, RSMo; and
(D) Pending
the decision upon appeal by the provider's chief administrative officer, the
decision of the department director, if appealed, or decision of a court of
competent jurisdiction, if judicially reviewed, whichever is later, the
department shall hold the provider harmless and shall pay disputed amounts to
the provider, if necessary, to continue services to the recipient. If the
financially responsible person is deemed obligated to pay any of the disputed
amounts after the appeal is completed, then the financially responsible person
shall pay the amounts to the provider as an offset to the department's future
support or to the department if no future department support is to be
provided.
(17) Probation
and Parole Clients. For services provided under terms and conditions of
probation and parole, the provider may determine charges related to income and
consistent with the treatment and rehabilitation goals of the terms and
conditions of probation and parole as approved in writing by the department and
the supervising court.
(18) Waiver
Authority. The director may waive the application of the SMT to specific
services, programs, or populations, or for specific purposes, or in specific
situations, when the director determines that it is in the best interests of
the state, the department, and the individuals served by the department to do
so. Examples of situations in which waivers may be deemed appropriate include
natural or man made disasters, temporary services or programs which are not
suited to the current SMT process, specific situations in which collections do
not justify the administrative burden of applying the SMT, and situations in
which the cost of providing services is fully covered by another funding
source.
*Originalauthority: 630.050, RSMo 1980, amended 1993, 1995,
2008 and 630.210, RSMo 1980, amended 1981, 1982, 1993,
2004.
