Texas Administrative Code
Title 26 - HEALTH AND HUMAN SERVICES
Part 1 - HEALTH AND HUMAN SERVICES COMMISSION
Chapter 301 - LOCAL AUTHORITY RESPONSIBILITIES
Subchapter J - CHARGES FOR COMMUNITY SERVICES
Section 301.509 - Determination of Ability to Pay

Universal Citation: 26 TX Admin Code § 301.509

Current through Reg. 50, No. 13; March 28, 2025

(a) Financial assessment.

(1) An MRA must conduct and document a financial assessment for a person within 30 days after the person begins to receive services.

(2) Except for a Medicaid recipient who is receiving Supplemental Security Income (SSI) benefits but not receiving employment income, the MRA must update a person's financial assessment at least annually while the person is receiving services. The MRA must monitor the continuing availability of benefits for a person with income-based public insurance.

(3) The MRA must update a person's financial assessment if the person experiences a significant financial change.

(4) The financial assessment must be conducted using the financial documentation listed in § 2.105(d) of this subchapter (relating to Accountability) that represents the finances of:
(A) the person who is age 18 years or older and the person's spouse; or

(B) the parents of the person who is under age 18 years.

(b) MMF. A person's MMF is based on the financial assessment and calculated using the Monthly Ability-To-Pay Fee Schedule, as referenced in § 2.110 of this subchapter (relating to Monthly Ability-To-Pay Fee Schedule). The calculation is based on the number of family members and annual gross income, reduced by extraordinary expenses paid during the past 12 months or projected for the next 12 months. No other sliding scale is used.

(1) An MMF that is greater than zero is established for a person who is determined as having an ability to pay. If two or more members of the same family are receiving services, then the MMF is for the family.

(2) An MMF of zero is established for a person who is determined as having an inability to pay.

(c) Third-party coverage.

(1) Third-party coverage that will pay. A person with third-party coverage that will pay for needed services is determined as having an ability to pay for those services.

(2) Third-party coverage that will not pay.
(A) If the person's third-party coverage will not pay for needed services because the MRA does not have an approved provider on its network, then the MRA must propose to refer the person to the person's third-party coverage to identify a provider for which the third-party coverage will pay unless:
(i) the MRA is identified as being responsible for providing court-ordered services to the person;

(ii) the MRA is able to negotiate adequate payment for services with the person's third-party coverage; or

(iii) the person (or parent) voluntarily agrees to pay the standard charge(s) for the needed service(s).

(B) If the MRA proposes to refer the person to the person's third-party coverage as described in paragraph (2)(A) of this subsection, then the MRA must provide written notification to the person (or parent) in accordance with § 2.109(e)(1) of this subchapter (relating to Payments, Collections, and Non-payment), which provides an opportunity to appeal. The MRA must also comply with §2.109(e)(2) - (3) of this subchapter as initiated by the person (or parent).

(C) If the MRA refers the person to third-party coverage, then the MRA must assist the person (or parent) in identifying a provider for which the third-party coverage will pay.

(D) If a person who has been referred to third-party coverage is unable to identify or access needed services from an approved provider or if access will be unduly delayed, then the MRA must:
(i) assist the person (or parent) in resolving the matter with the third-party coverage (e.g., contacting customer service at the third-party coverage, filing a complaint with the third-party coverage or the Texas Department of Insurance); and

(ii) if indicated, ensure the provision of the needed services to the person pending resolution.

(E) The MRA must maintain documentation of:
(i) all referrals as described in paragraph (2)(C) of this subsection;

(ii) all assistance as described in paragraph (2)(D)(i) of this subsection; and

(iii) whether the person received services pending resolution as described in paragraph (2)(D)(ii) of this subsection.

(d) Social Security work incentive provisions. A person who identified payment for specific needed services in the person's approved plan utilizing Social Security work incentive provisions (i.e., Plan to Achieve Self-Sufficiency; Impairment Related Work Expense) is determined as having an ability to pay for the specific services. A person is not required to identify payment for any service for which the person may be eligible as part of the person's approved plan for utilizing the Social Security work incentive provisions.

(e) Notification. After a financial assessment is conducted, the MRA must provide written notification to the person (or parent) that includes:

(1) the determination of whether the person (or parent) has an ability or an inability to pay;

(2) a copy of the financial assessment form and a copy of the Monthly Ability-to-Pay Fee Schedule, with the applicable areas indicated (i.e., annual gross income, number of family members);

(3) the amount of the MMF;

(4) the name and phone number of at least one MRA staff who the person (or parent) may contact during office hours to discuss the information contained in the written notification; and

(5) a statement that the person (or parent) may voluntarily pay more than the maximum monthly fee.

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