Nebraska Administrative Code
Topic - HEALTH AND HUMAN SERVICES SYSTEM
Title 206 - BEHAVIORAL HEALTH SERVICES
Chapter 5 - CONSUMER ELIGIBILITY
Section 206-5-002 - CONSUMER ELIGIBILITY AND PAYMENT FOR SERVICES

Universal Citation: 206 NE Admin Rules and Regs ch 5 ยง 002

Current through September 17, 2024

The Division will reimburse the Regional Behavioral Health Authorities for behavioral health services for consumers who are in Nebraska voluntarily and intend to make Nebraska his or her home and who meet:

(A) The clinical eligibility criteria for the services specified in the contract;

(B) The financial eligibility criteria as specified in the Region's Financial Eligibility Policy and Financial Eligibility Fee Schedule. For the fiscal year July 1, 2012 through June 30, 2013, the Financial Eligibility Policy is based on the 2012 United States Department of Health and Human Services Federal Poverty Guidelines. For future fiscal years, the Financial Eligibility Policy and Financial Eligibility Fee Schedule will be adjusted based on changes to the annual United States Federal Poverty Guidelines and will not be specified in the regulations; and

(C) Lawful presence requirements set forth in Neb. Rev. Stat. §§ 4-108 to 4-114.

002.01 FINANCIAL ASSESSMENT OF ELIGIBILITY. The assessment of a consumer's financial eligibility is an ongoing process. The consumer's financial eligibility status must be re-assessed annually or when known changes occur that increase or decrease the copayment obligations of the consumer.

002.02 REFUSAL TO PROVIDE FINANCIAL INFORMATION. Consumers who refuse to provide financial information shall be charged the full cost of services. The provider may not bill the Division for any service for which the consumer is responsible due to the failure of the consumer to provide financial information or attest to the financial information.

002.03 POLICIES AND FEE SCHEDULES. Regional Behavioral Health Authority's Financial Eligibility Policy and Financial Eligibility Fee Schedule shall be adopted pursuant to Neb. Rev. Stat. § 71-809. The Financial Eligibility Policy and Financial Eligibility Fee Schedule shall be approved by the Division.

002.04 REIMBURSEMENT. For a consumer who meets the clinical eligibility, financial eligibility, and lawful presence criteria, the Regional Behavioral Health Authority will be reimbursed:
(A) At the rate set by the Division for services provided which are pre-authorized;

(B) The Region-determined rate of reimbursement for allowable uncompensated expenses for services provided; and

(C) Not more than the actual cost of the service less any co-payment and third party payment received for the service.

002.05 PAYOR OF LAST RESORT. The Division reserves the right to be the payer of last resort for consumers who meet the Division's clinical criteria for an identified level of care and who are without the financial resources to pay for care. The Division will not reimburse:
(A) For Medicaid reimbursable services provided to Medicaid consumers. If the consumer has accrued personal needs allowance and created savings that disqualify him or her from a benefit such as Medicaid, the full cost of the service must be assessed to the consumer until he or she qualifies for the Medicaid benefit.

(B) For any portion of services required to be paid by a Medicaid recipient to meet a share of cost obligation.

(C) For services eligible for, or covered under, other health insurance benefits that were:
(i) Denied by an insurance company due to provider error, insufficient documentation, or lack of medical necessity;

(ii) That were not submitted to the insurance company in accordance with the policy; or

(iii) That were not submitted to the insurance company at the request of the consumer.

(D) For any service in which the consumer is deemed eligible to pay the cost of the service.

002.06 DETERMINATION OF FINANCIAL ELIGIBILITY. To determine if a consumer meets financial eligibility on the Financial Eligibility Policy and Financial Eligibility Fee Schedule:
(A) Complete the eligibility worksheet to determine the adjusted monthly income. To determine the adjusted monthly income:
(i) Add up wages, alimony, tips or other money received for a good or service in the past 12 month period. Divide this number by 12 to determine the taxable monthly income of the consumer.

(ii) Determine the monthly amount for housing, utilities, transportation, or daycare paid by the consumer. Actual cost claimed cannot exceed the maximum amounts listed on the worksheet for each item. Total the amounts listed for housing, utilities, transportation, and daycare to determine total allowable liabilities.

(iii) Subtract the total allowable liabilities from the taxable monthly income to determine the adjusted monthly income amount to be used to determine eligibility for funded services.

(B) Locate the adjusted monthly income amount on the appropriate fee schedule;
(i) The Financial Eligibility Fee Schedule is used for consumers who do not meet the requirements for the hardship or emergency access fee schedules.

(ii) Hardship fee schedule is used for:
(1) Consumers who meet criteria for severe and persistent mental illness; or

(2) Consumers who meet criteria for serious emotional disorder in youth 19 or under; or

(3) Medical bills or medical debt in excess of 10% of the taxable annual income.

(iii) Emergency access fee schedule is used for:
(1) Consumers receiving assistance from crisis response team, emergency community support, housing related assistance; or

(2) The hospital diversion services where consumers stay less than 24 hours.

(C) Locate the total number of family members dependent on the taxable income; and

(D) Only those consumers who fall within the shaded areas on the fee schedules are eligible for services funded by the Division.

002.07 CO-PAYMENT. In addition to payments made by the Division, the Regional Behavioral Health Authority may assess consumers a co-payment fee based upon the Financial Eligibility Fee Schedule. To determine the maximum co-payment:
(A) Locate the adjusted monthly income amount on the appropriate schedule.

(B) Locate the total number of family members dependent on the taxable income.

(C) Locate the box in which the column and row intersect is the maximum co-payment fee to be charged to the consumer for each appointment or unit of service.

002.08 RESIDENTIAL LEVELS OF CARE. Residential levels of care will receive payment based on the Division's established rates. In addition to room and board fees, co-payment fees may also be assessed. The room and board fee may not be in excess of actual costs incurred for these services by the provider. All co-payments charged must be in compliance with the Region's Financial Eligibility Policy and Financial Eligibility Fee Schedule.

002.09 SUBSTANCE USE DISORDER EDUCATION AND DIVERSION. Fees and copayments for substance use disorder education and diversion services are determined by the Region or other providers and are not subject to the provisions of the Region's Financial Eligibility Policy and Financial Eligibility Fee Schedule.

002.10 ELIGIBILITY VERIFICATION. The Division or the Regional Behavioral Health Authority may request from the provider verification of a consumer's eligibility for service.

Disclaimer: These regulations may not be the most recent version. Nebraska may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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