Pennsylvania Code
Title 55 - HUMAN SERVICES
Part VI - Mental Health/Intellectual Disability/Autism Manual
Subpart C - Administration and Fiscal Management
Chapter 4310 - CLIENT LIABILITY-STATE MH/ID FACILITIES
MAXIMUM LIABILITY FOR SERVICES PROVIDED
Section 4310.6 - Maximum liability-payors/liable persons
Universal Citation: 55 PA Code ยง 4310.6
Current through Register Vol. 54, No. 44, November 2, 2024
The maximum liability for services provided is established by the institutional collections officer for both payors and liable persons within the following:
(1) Maximum charge to Medicare.
(i) The maximum monthly charge to Medicare
shall be the product of the per diem rate multiplied by the number of client
days.
(ii) Medicare reimbursement
includes only covered charges and shall be accepted by the facility as payment
in full for the number of Medicare-eligible days billed, excluding deductibles
and coinsurances.
(iii) If Medicare
deductibles and coinsurances have been deducted from the Medicare
reimbursement, the deductibles and coinsurances shall be billed to MAMIS if the
client is Medical Assistance eligible.
(iv) If the client is not Medical Assistance
eligible, deductibles and coinsurances are the responsibility of the client or
LLR up to his maximum liability.
(2) Maximum charges to third-party payors.
(i) The maximum charge to
third-party payors shall be the product of the per diem rate multiplied by the
number of client days.
(ii) If the
costs of services are to be paid in whole or in part by a third-party payor,
that resource must be fully used. If the third-party payor coverage is limited,
any costs of services in excess of the payment are the responsibility of the
client and LLR up to his maximum liability if these costs cannot be billed to
another third party or to MAMIS.
(iii) If the sum of third-party payments and
client/LLR liability exceed the total charges, the overpayments shall be
refunded to the client/LLR if the imposition of liability resulted in the
overpayment, or to the third-party payor, if no client/LLR liability have been
established.
(3) Legally liable relative maximum liability.
(i) LLR liability for services provided to a
client is based on the LLR's monthly discretionary income. LLR liability may
not exceed the facility monthly per diem rate.
(ii) LLR liability for services to a client
is imposed in excess of amounts paid by third-party payors or other agencies,
but may not exceed the LLR's maximum monthly liability or the facility monthly
per diem rate.
(4) Spouse for spouse liability.
(i) The liability of one spouse for services
to the other is limited to 120 days of continuous inpatient care.
(ii) If the client is discharged for 120
consecutive days and is subsequently readmitted after 120 days to the facility,
spouse for spouse liability recurs.
(iii) If there is court-ordered support, the
amount of the court order must be considered the maximum liability for the
costs of service.
(5) Parental liability.
(i)
Parental liability is limited to the cost of services for children under the
age of 18 who are not Supplemental Security Income (SSI) eligible. If a child
under 18 years of age becomes eligible for SSI, parental liability
ceases.
(ii) If there is a court
order for support, the amount of the court order must be considered the maximum
liability for the costs of services.
(6) Client/resident maximum liability.
(i) Maximum client
liability is based on income or assets of the client, or both, in excess of
amounts paid by third party payors or other agencies, up to the per diem rate
established for the facility. Monthly charges for services provided to mental
health and intellectual disability clients may not exceed the product of the
per diem rate multiplied by the number of days in the month.
(ii) If the client is responsible for
maintaining a spouse or children, client liability is determined by the scale
for LLR monthly liability.
(7) Charges equal to maximum liability.
(i) If the cost of
service (that is, client days multiplied by the per diem rate) exceeds the
maximum liability, the client shall be billed for the amount of the maximum
liability.
(ii) If the cost of
service (that is, client days multiplied by the per diem rate) is less than the
client's maximum liability, the client shall be billed for the amount of the
maximum liability.
(iii) If the
cost of service (that is, client days multiplied by the per diem rate) exceeds
the LLR's maximum liability, the LLR shall be billed for the amount of the
maximum liability.
(iv) If the cost
of service (that is, client days multiplied by the per diem rate) is less than
the LLR's maximum liability, the LLR shall be billed for the amount of the
maximum liability.
(8) Maximum charges for services to MAMIS.
(i) The maximum charge for service billed to
MAMIS is the product of the per diem rate times the client days in the month.
If client and/or LLR liability has been established by the County Assistance
Office, the maximum monthly billing to MAMIS must be the monthly rate minus the
client/LLR liability.
(ii) No
portion of the charges to MAMIS except the liability imposed on the client/LLR
by Medical Assistance may be billed to the client or his LLR.
(iii) Institutional collections officers
shall compute and bill client/LLR liability based on this chapter.
(iv) The difference between the Medical
Assistance liability assessment and the assessment determined within this
chapter may not be billed or collected from the client/LLR or invoiced to
MAMIS.
The provisions of this §4310.6 amended under sections 201(2) and (8) and 202 of the Mental Health and Intellectual Disability Act of 1966 (50 P.S. §§ 4201(2) and (8) and 4202).
Disclaimer: These regulations may not be the most recent version. Pennsylvania 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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