Texas Administrative Code
Title 26 - HEALTH AND HUMAN SERVICES
Part 1 - HEALTH AND HUMAN SERVICES COMMISSION
Chapter 301 - LOCAL AUTHORITY RESPONSIBILITIES
Subchapter C - CHARGES FOR COMMUNITY SERVICES
Section 301.115 - Billing Procedures
Universal Citation: 26 TX Admin Code § 301.115
Current through Reg. 50, No. 13; March 28, 2025
(a) Monthly account.
(1) The LMHA will maintain a monthly
account for each person that lists all services provided to the person during
the month and the standard charges for the services. Each service listed will
indicate whether the service is:
(A) covered
by Medicare third-party coverage;
(B) covered by non-Medicare third-party
coverage;
(C) not covered by
third-party coverage; or
(D)
identified for payment in the person's approved plan utilizing Social Security
work incentive provisions.
(2) If a person has exceeded the maximum
third-party coverage benefit of a particular covered service, then that service
is indicated as not covered by third-party coverage.
(b) Accessing funding sources. The LMHA must access all available funding sources before using the department's funds to pay for a person's services. 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) Billing third-party coverage. The LMHA will bill the person's third-party coverage the monthly account amount for covered services. If the LMHA has negotiated a reimbursement amount with the third-party coverage that is different from the monthly account amount, then the LMHA may bill the third-party coverage the negotiated reimbursement amount for covered services.
(d) Billing the person (or parents).
(1) No third-party coverage. If the monthly
account amount for services not covered by third-party coverage:
(A) exceeds the person's maximum monthly fee
(MMF), then the amount is reduced to equal the MMF and the LMHA bills person
(or parent) the MMF; or
(B) is less
than the person's MMF, then the LMHA bills the person (or parent) the monthly
account amount for services not covered by third-party coverage.
(2) Medicare third-party coverage.
Nothing in this paragraph is intended to conflict with any applicable law,
rule, or regulation with which a LMHA must comply.
(A) The following amounts are added to equal
the total amount applied toward the person's MMF:
(i) the amount of all applicable co-payments
and co-insurance for services listed in the monthly account as covered by
Medicare third-party coverage;
(ii)
the amount Medicare third-party coverage was billed but did not pay because the
deductible hasn't been met; and
(iii) the monthly account amount for services
not covered by third-party coverage.
(B) If the total amount applied toward the
person's MMF as described in paragraph (2)(A) of this subsection:
(i) exceeds the person's MMF, then the amount
is reduced to equal the MMF and the LMHA bills person (or parent) the MMF;
or
(ii) is less than the person's
MMF, then the LMHA bills the person (or parent) the total amount applied toward
the MMF.
(3)
Non-Medicare third-party coverage.
(A)
Cost-sharing exceeds MMF. If the amount of all applicable co-payments,
co-insurance, and deductibles for services listed in the monthly account as
covered by non-Medicare third-party coverage exceeds the person's MMF, then the
LMHA bills the person (or parent) all applicable co-payments, co-insurance, and
deductibles.
(B) Cost-sharing does
not exceed MMF.
(i) If the amount of all
applicable co-payments, co-insurance, and deductibles for services listed in
the monthly account as covered by non-Medicare third-party coverage does not
exceed the person's MMF, then the following amounts are added to equal the
total amount applied toward the person's MMF:
(I) the amount of all applicable co-payments,
co-insurance, and deductibles; and
(II) the monthly account amount for services
not covered by third-party coverage.
(ii) If the total amount applied toward the
person's MMF as described in paragraph (3)(B) of this subsection:
(I) exceeds the person's MMF, then the amount
is reduced to equal the MMF and the LMHA bills person (or parent) the MMF;
or
(II) is less than the person's
MMF, then the LMHA bills the person (or parent) the total amount applied toward
the MMF.
(C)
Annual cost-sharing limit. If the person (or parent) has reached his/her annual
cost-sharing limit (i.e., maximum out-of-pocket expense) as verified by the
non-Medicare third-party coverage, then the LMHA will not bill the person (or
parent) any co-payments, co-insurance, or deductibles, as applicable to the
annual cost-sharing limit, for services covered by the non-Medicare third-party
coverage for the remainder of the policy-year.
(4) Social Security work incentive
provisions.
(A) If the person identified a
payment amount for specific services in his/her approved plan utilizing Social
Security work incentive provisions (i.e., Plan to Achieve Self-Sufficiency;
Impairment Related Work Expense), then the LMHA bills the person the monthly
account amount for the specific services up to the identified payment amount.
If the monthly account amount for the specific services is greater than the
identified payment amount, then the remaining balance is applied toward the
person's MMF.
(B) The following
amounts are added to equal the total amount applied toward the person's MMF:
(i) any remaining balance as described in
paragraph (4)(A) of this subsection; and
(ii) the monthly account amount for services
not covered by third-party coverage.
(C) If the total amount applied toward the
person's MMF as described in paragraph (4)(B) of this subsection:
(i) exceeds the person's MMF, then the amount
is reduced to equal the MMF and the LMHA bills person (or parent) the MMF;
or
(ii) is less than the person's
MMF, then the LMHA bills the person (or parent) the total amount applied toward
the MMF.
(e) Statements.
(1) The LMHA will send to persons (and
parents) who have been determined as having the ability to pay monthly or
quarterly statements that include:
(A) an
itemized list, at least by date and by type, of all services provided during
the period;
(B) the standard charge
for each service;
(C) the total
charge for the period;
(D) the
amount paid (or to be paid) by each funding source; and
(E) the amount to be paid by the person (or
parent).
(2) Unless
requested otherwise, the LMHA does not send statements to persons (or parents)
who have an ability to pay if they maintain a zero balance (i.e., the person
(or parent) does not currently owe any money).
(3) Unless requested otherwise, the LMHA does
not send statements to persons (or parents) who have an inability to
pay.
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