Common use of Cost Share or Patient Liability Clause in Contracts

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 members residing in a NH are enrolled into a PO 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 the PO 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 PO should collect the liability amount. The PO 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 PO 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 PO 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 PO. If a member fails to pay the cost share or patient liability as billed by the due date, the PO will: Contact the member to determine the reason for non- payment. Remind the member that non-payment may result in loss of Medicaid eligibility and disenrollment unless the member becomes a private pay PACE member. Attempt to convince the member to make payment or negotiate a payment plan. Offer the member assistance with financial management services or refer the member for establishment of a representative payee or legal decision maker if needed. 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. For a member with a cost share, inform the member that if he or she is having a financial hardship, he or she may file an Application for Reduction of Cost Share with the Department, requesting that it be reduced or waived (see Addendum VII.10.). The PO shall also offer to assist the member in completing and submitting the Application. The PO shall reimburse members for cost share or patient liability amounts that were collected by the PO that need to be returned to the member. The income maintenance agency or the Department will retroactively adjust the member’s cost share amount in CARES. Once the PO is informed of retroactive adjustment of the member’s cost share or patient liability, the PO must reimburse the member for the incorrectly collected cost share or patient liability amount within 30 calendar days. If the cost share retroactive adjustment is within the past 365 days, FHiC will adjust the PO’s capitation payment. If the retroactive adjustment is more than 365 days, the PO may need to contact the Department via the enrollment discrepancy mailbox for an adjustment in capitation payment.

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 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. . 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 capitation payment attributable to waiver services, as determined by the Department. . c. 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 the member’s 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 members residing in a NH are enrolled into a PO 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 the PO 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 PO should collect the liability amount. The PO will attempt to collect the patient liability amount from the nursing home when the 820 Report (Report, see Article XV.E) 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 PO 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 PO 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 PO. If a member fails to pay the cost share or patient liability as billed by the due date, the PO will: Contact the member to determine the reason for non- payment. Remind the member that non-payment may result in loss of Medicaid eligibility and disenrollment unless the member becomes a private pay PACE member. Attempt to convince the member to make payment or negotiate a payment plan. Offer the member assistance with financial management services or refer the member for establishment of a representative payee or legal decision maker if needed. 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 or Tribal ADRS (if applicable) for options counseling. For a member with a cost share, inform the member that if he or she the member is having a financial hardship, he or she the member may file an Application for Reduction of Cost Share with the Department, requesting that it be reduced or waived (see Addendum VII.10.). The PO shall also offer to assist the member in completing and submitting the Application. Notify residential providers that member is in jeopardy of or will lose Medicaid eligibility at a minimum of 15 days prior to disenrolling the member. d. The PO shall reimburse members for cost share or patient liability amounts that were collected by the PO that need to be returned to the member. The PO may apply the reimbursement amount towards an outstanding member cost share balance, but the PO must issue the remainder amount to the member when the reimbursement amount is higher than the outstanding balance. The income maintenance agency or the Department will retroactively adjust the member’s cost share amount in CARES. Once the PO is informed of retroactive adjustment of the member’s cost share or patient liability, the PO must reimburse the member for the incorrectly collected cost share or patient liability amount within 30 calendar days. If the cost share retroactive adjustment is within the past 365 days, FHiC will adjust the PO’s capitation payment. If the retroactive adjustment is more than 365 days, the PO may need to contact the Department via the enrollment discrepancy mailbox for an adjustment in capitation payment.

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 members residing in a NH are enrolled into a PO 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 the PO 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 PO should collect the liability amount. The PO 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 PO 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 PO 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 PO. If a member fails to pay the cost share or patient liability as billed by the due date, the PO will: Contact the member to determine the reason for non- payment. Remind the member that non-payment may result in loss of Medicaid eligibility and disenrollment unless the member becomes a private pay PACE member. Attempt to convince the member to make payment or negotiate a payment plan. Offer the member assistance with financial management services or refer the member for establishment of a representative payee or legal decision maker if needed. 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 or Tribal ADRS (if applicable) for options counseling. For a member with a cost share, inform the member that if he or she is having a financial hardship, he or she may file an Application for Reduction of Cost Share with the Department, requesting that it be reduced or waived (see Addendum VII.10.). The PO shall also offer to assist the member in completing and submitting the Application. Notify residential providers that member is in jeopardy of or will lose Medicaid eligibility at a minimum of 15 days prior to disenrolling the member. The PO shall reimburse members for cost share or patient liability amounts that were collected by the PO that need to be returned to the member. The PO may apply the reimbursement amount towards an outstanding member cost share balance, but the PO must issue the remainder amount to the member when the reimbursement amount is higher than the outstanding balance. The income maintenance agency or the Department will retroactively adjust the member’s cost share amount in CARES. Once the PO is informed of retroactive adjustment of the member’s cost share or patient liability, the PO must reimburse the member for the incorrectly collected cost share or patient liability amount within 30 calendar days. If the cost share retroactive adjustment is within the past 365 days, FHiC will adjust the PO’s capitation payment. If the retroactive adjustment is more than 365 days, the PO may need to contact the Department via the enrollment discrepancy mailbox for an adjustment in capitation payment.

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 the member’s 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 members residing in a NH are enrolled into a PO 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 the PO 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 PO should collect the liability amount. The PO 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 PO 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 PO 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 PO. If a member fails to pay the cost share or patient liability as billed by the due date, the PO will: Contact the member to determine the reason for non- payment. Remind the member that non-payment may result in loss of Medicaid eligibility and disenrollment unless the member becomes a private pay PACE member. Attempt to convince the member to make payment or negotiate a payment plan. Offer the member assistance with financial management services or refer the member for establishment of a representative payee or legal decision maker if needed. 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 or Tribal ADRS (if applicable) for options counseling. For a member with a cost share, inform the member that if he or she the member is having a financial hardship, he or she the member may file an Application for Reduction of Cost Share with the Department, requesting that it be reduced or waived (see Addendum VII.10.). The PO shall also offer to assist the member in completing and submitting the Application. Notify residential providers that member is in jeopardy of or will lose Medicaid eligibility at a minimum of 15 days prior to disenrolling the member. The PO shall reimburse members for cost share or patient liability amounts that were collected by the PO that need to be returned to the member. The PO may apply the reimbursement amount towards an outstanding member cost share balance, but the PO must issue the remainder amount to the member when the reimbursement amount is higher than the outstanding balance. The income maintenance agency or the Department will retroactively adjust the member’s cost share amount in CARES. Once the PO is informed of retroactive adjustment of the member’s cost share or patient liability, the PO must reimburse the member for the incorrectly collected cost share or patient liability amount within 30 calendar days. If the cost share retroactive adjustment is within the past 365 days, FHiC will adjust the PO’s capitation payment. If the retroactive adjustment is more than 365 days, the PO may need to contact the Department via the enrollment discrepancy mailbox for an adjustment in capitation payment.

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 PACE. . 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 capitation payment attributable to waiver services, as determined by the Department. . c. The PO is responsible for collecting the members’ monthly cost share or patient liability, subject to the following Department policies and procedures: : i. 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. 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 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 members residing in a NH are enrolled into a PO 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 the PO 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 PO should collect the liability amount. The PO 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 PO 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 PO 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 PO. iv. If a member fails to pay the cost share or patient liability as billed by the due date, the PO 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 PO is willing to waive some or the entire obligation. c) Remind the member that non-payment may result in loss of Medicaid eligibility and disenrollment unless the member becomes a private pay PACE member. . 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. For a member with a cost share, inform the member that if he or she is having a financial hardship, he or she may file an Application for Reduction of Cost Share with the Department, requesting that it be reduced or waived (see Addendum VII.10.). The PO shall also offer to assist the member in completing and submitting the Application. The PO shall reimburse members for cost share or patient liability amounts that were collected by the PO that need to be returned to the member. The income maintenance agency or the Department will retroactively adjust the member’s cost share amount in CARES. Once the PO is informed of retroactive adjustment of the member’s cost share or patient liability, the PO must reimburse the member for the incorrectly collected cost share or patient liability amount within 30 calendar days. If the cost share retroactive adjustment is within the past 365 days, FHiC will adjust the PO’s capitation payment. If the retroactive adjustment is more than 365 days, the PO may need to contact the Department via the enrollment discrepancy mailbox for an adjustment in capitation payment.