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Home My WebLink AboutMHIDD-302 Individual Financial Liability1 FRANKLIN/FULTON COUNTY MENTAL HEALTH/INTELLECTUAL & DEVELOPMENTAL DISABILITIES/EARLY INTERVENTION 425 Franklin Farm Lane Chambersburg, PA 17202 (717) 264-5387 MH/IDD/EI PROCEDURE STATEMENT PROCEDURE SUBJECT: Individual Financial Liability PROCEDURE NUMBER: MHIDD-302 Effective Date: January 1, 2004 Date Revised: November 30, 2022 Reference: Commonwealth of Pennsylvania, Pennsylvania Code, Title 55. Department of Human Services (DHS), Chapter 4305. Liability for Community Mental Health and Intellectual Disabilities Services INTRODUCTION: Two (2) of the primary goals of the public Mental Health, Intellectual & Developmental Disabilities, and Early Intervention programs (MH/IDD/EI) are to encourage people to seek help and to provide easy access to treatment and/or habilitation services. An individual who is receiving services funded in whole or in part through the MH/IDD/EI Program will have a liability (which may be zero). A liability is the maximum monthly amount the liable person is charged toward the cost of service(s) received by the individual. The liability is based on various factors including income and unpaid medical expenses, etc. The liable person has the right to request adjustment of this charge. The MH/IDD/EI Administrator shall have the authority to reduce or eliminate the liability if the payment of the liability would result in greater financial burden upon the Commonwealth. Similarly, the MH/IDD/EI Administrator shall have the power to reduce or eliminate the liability if the imposition of the liability would create a financial burden upon the individual as to nullify the results of care, treatment, service or other benefits. Requests for an adjustment of the liability due to nullification of the result of care shall include documentation by a MH/IDD/EI professional justifying the clinical reasons for the request and how the individual’s welfare would be seriously harmed if the liability is not adjusted. PROCEDURE: Non-Residential Service: 1. Individuals receiving services who are covered by Medical Assistance and/or Perform Care under the Commonwealth's Medical Assistance Program are exempt from 2 the liability process. Individuals whose Medical Assistance eligibility status does not include outpatient mental health services will be opened through the Case Manager and/or Supports Coordinator (if dually diagnosed Mental Health and Intellectual and Developmental Disabilities) and a liability will be completed. 2. If an individual is receiving, or is expected to receive, community-based outpatient mental health services that are eligible for full or partial insurance coverage [i.e., BC/BS, Tricare], the provider of service shall bill the insurance company for the service prior to billing the liable person. The liable person shall be billed the remainder of the liability. A liability determination will be completed by the Case Manager. 3. If insurance benefits are not assignable, the provider shall bill the liable person for the total amount of the liability or the amount the insurance company will pay, whichever is greater, and will assist the person in completing the insurance forms if necessary or requested. 4. In order for the cost of a medication to be reimbursed by the MH/IDD/EI Program, individual liability and third party revenues must be exhausted first. The service provider must explore insurance and prescription programs in order to assist the individual to pay for mental health prescriptions. Residential Services: 1. If an individual is receiving or is expected to receive a community residential Mental Health/Intellectual & Developmental Disabilities placement in Pennsylvania and is eligible for full or partial insurance coverage (i.e. BC/BS, Tricare), the provider of service shall bill the insurance company for the service prior to billing the liable person or the MH/IDD/EI program. The MH/IDD/EI Program will be billed for the service not covered by insurance or the individual's liability. MH/IDD/EI reimbursement will not exceed the allowable rate of payment. 2. When and if an individual exhausts insurance coverage for mental health services, the service provider shall refer the individual to the Case Management provider. Case Managers will require a letter of denial from the insurance company (and when applicable, DHS also). During this process, the Case Manager may do a 60-day DHS referral, for mental health services only. 3. At the completion of the individual liability determination, the Case Manager will complete the Authorization Form and send the original form to the service provider. The amount (if any) for which the individual is liable will be designated on the form. Clinical Abatement Procedure: 1. A current liability must be in effect at the time the abatement process is initiated. 2. Requests for adjustments of liability will be made to the Case Manager/Supports Coordinator by the liable individual or the staff person of a contracted provider. The Case Manager/Supports Coordinator will discuss with the individual what an affordable monthly amount would be. This determination will be made based upon the individual’s present situation as well as their current liability. 3. The Case Manager/Supports Coordinator completes the upper portion of MH/IDD form 881 “Request for County Administrator Review (Clinical Reasons)” [attached] including checking the appropriate box and filling in the agreed upon amount (if applicable) and forwards it to the service provider for signature and date along with a cover letter supporting the abatement request. This letter must address whether the payment of the 3 liability would create substantial financial hardship and/or financial burden upon the Commonwealth or would create a financial burden upon the individual as to nullify the results of care, treatment or service. 4. Staff from the service provider will forward the completed form and letter requesting adjustment of liability to the Case Manager/Supports Coordinator. All information is copied and retained in the individual’s record. The original paperwork is forwarded to the MH/IDD/EI Administrator for processing. 5. Requests are submitted to the MH/IDD/EI Administrator or designee on MH/IDD form 881. All requests will be submitted within 30 calendar days of the date when conditions warranting the adjustment occur. 6. The MH/IDD/EI Administrator will review the request and notify the liable person of the decision for adjustment of the liability within 30 calendar days of the receipt of the request. This written notice of the adjustment decision will include the reasons for the decision, the new liability, if applicable, the length of time the new liability will be in effect [not to exceed six (6) months based upon the 4305.68 Department of Human Services regulations], and the appeal rights and procedures. Copies shall be forwarded to the liable person and to the Case Manager/Supports Coordinator and retained in the individual's record. The original paperwork will then be forwarded to the designated provider agency. 7. For those receiving services through the Intellectual and Developmental Disabilities system, the liable person has the right to file a written appeal for a fair hearing to review the MH/IDD/EI Administrator’s adjustment decision within 30 calendar days of the date the decision is mailed. ATTACHMENT: MH/ID Form 881, Request for County Administrator Review (Clinical Reasons) S:\Fiscal\Liabilities\ID Liabilities\ID Abatement.Doc ddh MH/ID 881 – 2/2015 REQUEST FOR COUNTY ADMINISTRATOR REVIEW (CLINICAL REASONS) CLIENT’S NAME: CLIENT CASE # LIABLE PERSON’S NAME (IF DIFFERENT FROM CLIENT): AGENCY NAME AND CONTACT: I hereby request the review by the County Administrator of this liable person’s maximum liability. I request that this liability be: ADJUSTED TO 0 ADJUSTED TO PER MONTH I hereby certify that to the best of my knowledge and belief, the imposition of this liability would be likely to negate the effectiveness of treatment or prohibit the client’s entry into treatment. I further certify that, to the best of my knowledge and belief, the failure to provide such treatment would result in serious harm to the client’s welfare or in greater cost to the Commonwealth due to deterioration in the client’s condition. The grounds for such belief are fully spelled out in the client’s record. SIGNATURE OF MH OR ID TREATING PROFESSIONAL DATE PRINT NAME AND TITLE