Current through Reg. 50, No. 13; March 28, 2025
(a) Prohibition from denying services. Local
mental health authorities are prohibited from denying services to a person:
(1) because of the person's inability to pay
for the services;
(2) in crisis
because:
(A) a financial assessment has not
been completed;
(B) financial
responsibility has not been determined;
(C) the person has a past-due account;
or
(D) the person had his/her
services involuntarily reduced or terminated for non-payment under §
412.109(d) of this title (relating to Payments, Collections, and Non-payment);
or
(3) pending resolution
of an issue relating solely to payment for services, including failure of the
person (or parent) to comply with any requirement in subsections (c), (d), (e),
and (g) of this section.
(b) Identifying funding sources. Local
authorities are responsible for identifying and accessing available funding
sources other than the department, and for assisting persons (and parents) in
identifying and accessing available funding sources other than the department,
to pay for services. Available funding sources may include third-party
coverage, state and/or local governmental agency funds (e.g., crime victims
fund), Qualified Medicare Beneficiary (QMB) Program, indigent pharmaceutical
programs, or a trust that provides for the person's healthcare and
rehabilitative needs.
(c)
Requirement for parents to enroll their children in income-based public
insurance. Parents of children who may be eligible for Medicaid or the
Children's Health Insurance Program (CHIP) must enroll their children in
Medicaid or CHIP or provide documentation that they have been denied Medicaid
or CHIP benefits or that their Medicaid or CHIP enrollment is pending. The LMHA
shall provide assistance as needed to facilitate the enrollment
process.
(d) Financial
documentation. If requested by the LMHA, persons (or parents) must provide the
following financial documentation:
(1) annual
or monthly gross income/earnings, if any;
(2) extraordinary expenses (as defined) paid
during the past 12 months or projected for the next 12 months;
(3) number of family members (as defined);
and
(4) proof of any third-party
coverage.
(e) Authorizing
third-party coverage payment to the LMHA. Persons (and parents) with
third-party coverage must execute an assignment of benefits authorizing
third-party coverage payment to the LMHA.
(f) Failure to comply.
(1) Except as provided by paragraph (2) of
this subsection, if the person (or parent) fails to comply with any requirement
in subsections (c) - (e) or (h) of this section, then the LMHA will charge the
person (or parent) the standard charge(s) for services. If, within 30 days
after the person (or parent) initially failed to comply, the person (or parent)
complies with the requirements, then the LMHA will adjust the person's account
to retroactively reflect compliance.
(2) The LMHA will not charge the person the
standard charge(s) for services if the LMHA makes a decision, based on a
clinical determination that is documented and includes input from the person's
team, that the person's failure to comply is related to the person's mental
illness. The clinical determination must be reassessed at least every three
months. If the LMHA decides that a person's failure to comply is related to the
person's mental illness, then the LMHA must develop and implement a plan to
reduce or eliminate the barriers related to the person's failure to
comply.
(g) Requirement
for adult persons to apply for SSI to become eligible for Medicaid. Adult
persons who may be eligible for Medicaid must apply for Supplemental Security
Income (SSI) or provide documentation that they have been denied SSI or that
their SSI application is pending. The LMHA shall provide assistance as needed
to facilitate all aspects of the application process. If the adult person is
unable to act in accordance with the requirement because of the person's mental
illness, then the LMHA must develop and implement a plan to reduce or eliminate
the barriers related to the person's inability to act in accordance with the
requirement.
(h) Requirement for
persons to enroll in Medicare Part D prescription drug plan.
(1) A person who is a full subsidy eligible
individual under Medicare Part D must choose and enroll in a Medicare Part D
prescription drug plan.
(2) The
LMHA shall educate persons who are not full subsidy eligible individuals about
the benefits of enrollment in a Medicare Part D prescription drug plan. The
LMHA shall assess whether enrollment in a Medicare Part D prescription drug
plan will be cost effective to the person and to the LMHA and shall provide the
results of this assessment to the person to assist him or her determine whether
to enroll in a Medicare Part D prescription drug plan. If the person decides to
enroll in a Medicare Part D prescription drug plan, The LMHA may pay the
person's incurred costs under the Medicare Part D prescription drug
plan.
(3) The LMHA shall provide
assistance as needed to facilitate all aspects of the Medicare Part D
enrollment process. If the person is unable to act in accordance with the
requirements set forth in paragraph (1) or (2) of this subsection because of
the person's mental illness, lack of adequate notification, or other
circumstances beyond the individual's control, the LMHA shall continue to
provide medications and must develop and implement a plan to reduce or
eliminate the barriers related to the person's inability to act in accordance
with the requirement.
