Cost Share or Patient Liability a. Members may be required to pay a monthly cost share or patient liability in order to be eligible for Medicaid.
i. Cost share, also called post eligibility treatment of income, applies to members who live in their own home, an adult family home, a community–based residential facility or a residential care apartment complex.
ii. Patient liability applies to members who reside in a nursing home or Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF-IID) for 30 or more consecutive days or are likely to reside there for 30 or more consecutive days.
b. The income maintenance agency is responsible for determining the member’s cost share or patient liability. Cost share is imposed on members in accordance with 42 C.F.R. § 435.726. Patient liability is imposed in accordance with 42 C.F.R. § 435.725. The Department will ensure that a member who has a cost share is not required to pay any amount in cost share which is in excess of the average cost, as determined by the Department, of waiver services in a given month for all MCO waiver participants.
c. The MCO is responsible for collection of the member’s monthly cost share or patient liability. The MCO’s collection of cost share or patient liability from members must be in accordance with the following Department policies and procedures:
i. The MCO will send a xxxx to any member who has a cost share or patient liability in advance of or as early as possible during the month in which the cost share or patient liability is due.
ii. Cost share and patient liability are not prorated for partial months.
iii. If a member fails to pay the cost share or patient liability as billed by the due date, the MCO will:
a) Contact the member to determine the reason for non- payment.
b) Determine whether the cost share or patient liability presents an undue hardship for which the MCO is willing to waive some or the entire obligation.
c) Remind the member that non-payment may result in loss of eligibility and disenrollment.
d) Attempt to convince the member to make payment or negotiate a payment plan.
e) Offer the member assistance with financial management services or refer the member for establishment of a representative payee or legal decision maker if needed.
f) If all efforts to assist the member to meet the financial obligation are unsuccessful, refer the situation to the income maintenance agency for ongoing eligibility determination and the ADRC for options counseling.
Cost Share or Patient Liability. Members may be required to pay a monthly cost share or patient liability in order to be eligible for Medicaid PACE. Cost share, also called post eligibility treatment of income, applies to members who live in their own home, an adult family home, a community–based residential facility or a residential care apartment complex. Patient liability applies to members who reside in a nursing home or Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF-IID) for 30 or more consecutive days or are likely to reside there for 30 or more consecutive days. The income maintenance agency is responsible for determining the member’s cost share or patient liability. Cost share is imposed on members in accordance with 42 C.F.R. § 435.726. Patient liability is imposed in accordance with 42 C.F.R. § 435.725. The Department will ensure that a member who has a cost share is not required to pay any amount in cost share which is in excess of the average capitation payment attributable to waiver services, as determined by the Department. The PO is responsible for collecting the members’ monthly cost share or patient liability, subject to the following Department policies and procedures: The PO will send a bill to any member who has a cost share or patient liability in advance of or as early as possible during the month in which the cost share or patient liability is due. Members who were enrolled in IRIS as of the first day of the month in which they transition to PACE, generally pay the cost share amount for that month to their IRIS fiscal employer agent. If the PO capitation payment was offset by the cost share amount for that month, the PO will attempt to verify whether the member paid his or her cost share to an IRIS fiscal employer agent. If the PO has documentation to verify the member paid the cost share to the fiscal employer agent, the PO may request a capitation payment adjustment on an enrollment discrepancy report. Cost share and patient liability are not prorated for partial months. The system logic that determines a member’s patient liability amount can offset either a capitation payment or a Nursing Home Fee-for-Service (NH FFS) claim, but not both. ForwardHealth automatically deducts the appropriate monthly patient liability amount from the first NH FFS claim or capitation payment received for the member. (See ForwardHealth Online Handbook topic #3188: xxxxx://xxx.xxxxxxxxxxxxx.xx.xxx/WIPortal/Subsystem/KW/Displ ay.aspx ). Generally, when ...
Cost Share or Patient Liability. The PO is responsible for collecting the members’ monthly cost share or patient liability, subject to the following Department policies and procedures:
