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.
Appears in 2 contracts
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. b. 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. c. 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. d. 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. e. The MCO is responsible for collection of collecting the member’s members’ monthly cost share or patient liability. The MCO’s collection of cost share or patient liability from members must be in accordance with , subject to 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. The MCO will not collect a patient liability for the current month from a member who enrolls in Family Care after the 1st of the month if the member is residing in a nursing home and receiving nursing home Medicaid benefits. The member will pay his or her patient liability to the nursing home for the current month and his or her patient liability to the MCO beginning the next month.
iv. If a member fails to pay the cost share or patient liability as billed by the due date, the MCO MCO, with the assistance of the IHCP, will:
a) Contact the member to determine the reason for non- 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.
dc) Attempt to convince the member to make payment or negotiate a payment plan.
ed) 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) v. If all efforts to assist the member to meet the financial obligation are unsuccessful, the MCO will refer the situation to the income maintenance agency for ongoing eligibility determination and the ADRC or TADRS for options counseling.
Appears in 1 contract
Samples: Family Care Agreement
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 costcapitation payment attributable to waiver services, 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 collecting the member’s members’ monthly cost share or patient liability. The MCO’s collection of cost share or patient liability from members must be in accordance with , subject to 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. The system logic that determines a member’s patient liability amount can offset either a MCO capitation payment or a Nursing Home Fee-for-Service (NH FFS) claim, but not both. The system will offset whichever of the two transactions that process first. Generally, when members residing in a NH are enrolled into a MCO and the enrollment includes past months, the NH FFS claim will be offset by the patient liability amount for the past month(s), and the subsequent capitation payment(s) for the past month(s) will not be offset by the patient liability amount. However, this depends on when the NH FFS claim is submitted and processed in the system, so MCOs should monitor the 820 transaction to determine whether or not the patient liability amount was used to offset the capitation payment. If the patient liability amount was used to offset the capitation payment, the MCO should collect the liability amount. The MCO will attempt to collect the patient liability amount from the nursing home when the 820 Report (see Article XV.E) indicates that the capitation payment was offset by the patient liability amount but the member already paid the patient liability to the nursing home. The MCO will pay the patient liability amount to the nursing home when the 820 Report indicates that the capitation payment was not offset by the patient liability amount but the member already paid the patient liability amount to the MCO.
iv. 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.
Appears in 1 contract
Samples: Contract
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 collecting the member’s members’ monthly cost share or patient liability. The MCO’s collection of cost share or patient liability from members must be in accordance with , subject to 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. The MCO will not collect a patient liability for the current month from a member who enrolls in Family Care after the 1st of the month if the member is residing in a nursing home and receiving nursing home Medicaid benefits. The member will pay his or her patient liability to the nursing home for the current month and his or her patient liability to the MCO beginning the next month.
iv. 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.
Appears in 1 contract
Samples: Contract
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 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.
ii. Cost share and patient liability are is 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 guardian 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.
Appears in 1 contract
Samples: <<program>> Contract
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 costcapitation payment attributable to waiver servicescost, 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 collecting the member’s members’ monthly cost share or patient liability. The MCO’s collection of cost share or patient liability from members must be in accordance with , subject to 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 The MCO will not collect a patient liability for the current month from a member fails to who enrolls in Family Care after the 1st of the month if the member is residing in a nursing home and receiving nursing home Medicaid benefits. The member will pay the cost share his or her patient liability as billed by to the due date, nursing home for the current month and his or her patient liability to the MCO will:
a) Contact beginning the member to determine the reason for non- paymentnext month.
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.
Appears in 1 contract
Samples: Contract
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 guardian 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.
Appears in 1 contract
Samples: Contract
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 MedicaidFamily Care or Partnership.
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 costcapitation payment attributable to waiver services, 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 collecting the member’s members’ monthly cost share or patient liability. The MCO’s collection of cost share or patient liability from members must be in accordance with , subject to the following Department policies and procedures:
i. The MCO will send a xxxx 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 Family Care or Family Care Partnership, generally pay the cost share amount for that month to their IRIS fiscal employer agent. If the MCO capitation payment was offset by the cost share amount for that month, the MCO will attempt to verify whether the member paid his or her cost share to an IRIS fiscal employer agent. If the MCO has documentation to verify the member paid the cost share to the fiscal employer agent, the MCO may request a capitation payment adjustment on an enrollment discrepancy report (see Article IV.0.5.a.).
ii. Cost share and patient liability are not prorated for partial months.
iii. The system logic that determines a member’s patient liability amount can offset either a MCO 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 Forward-Health Online Handbook topic #3188: xxxxx://xxx.xxxxxxxxxxxxx.xx.xxx/WIPortal/Subsystem/KW/Displ ay.aspx ). Generally, when members residing in a NH are enrolled into a MCO and the enrollment includes past months, the NH FFS claim will be offset by the patient liability amount for the past month(s), and the subsequent capitation payment(s) for the past month(s) will not be offset by the patient liability amount. However, this depends on when the NH FFS claim is submitted and processed in the system, so MCOs should monitor the 820 transaction to determine whether or not the patient liability amount was used to offset the capitation payment. If the patient liability amount was used to offset the capitation payment, the MCO should collect the liability amount. The MCO will attempt to collect the patient liability amount from the nursing home when the 820 Report (see Article XV.E) indicates that the capitation payment was offset by the patient liability amount but the member already paid the patient liability to the nursing home. The MCO will attempt to collect the patient liability amount from the member when the 820 Report indicates the capitation payment was offset by the patient liability amount, the paid FFS NH claim was not offset by the patient liability amount, and the member did not pay the patient liability to the nursing home. The MCO will transfer the patient liability amount to the nursing home when the 820 Report indicates that the capitation payment was not offset by the patient liability amount but the member already paid the patient liability amount to the MCO.
iv. 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.
Appears in 1 contract
Samples: Contract
