Common use of Monitoring Cost Share or Patient Liability Clause in Contracts

Monitoring Cost Share or Patient Liability. The MCO is responsible for the ongoing monitoring of the cost share or patient liability amounts of its members. The MCO is also responsible for knowing what the member’s ongoing medical/remedial expenses are and reporting changes in those amounts to the income maintenance agency. The MCO is also responsible to report changes in other circumstances of members that may affect the amount of cost share or patient liability to the income maintenance agency within ten (10) calendar days of the MCO becoming aware of the change. Room and Board Members shall use their own income to pay for the cost of room and board. Any MCO supplementation of member payment of room and board from capitation revenue shall not be considered a countable expense in developing MCO capitation rates. For each member who resides in community-based residential care as defined in Addendum VIII.A.16, the MCO is responsible for all of the following tasks: Determining Cost The MCO determines the cost of room and board in the facility in which the member resides. The MCO shall use one method for all its members. It shall select one of the three following methods: Actual Cost Methodology This method requires calculation of actual room and board costs for each community residential facility with which the MCO contracts. Facility- specific costs are split between care and supervision on the one hand and room and board on the other. Total costs attributable to room and board are divided by the number of residents licensed or certified for the living arrangement to get a room and board rate. Costs attributable to Room and Board: Rent, mortgage payments, title insurance, mortgage insurance Property and casualty insurance Building and grounds maintenance costs Residents’ food Household supplies and equipment necessary for the room and board of the individual Furnishings used by the individual (does not include office furnishings)

Monitoring Cost Share or Patient Liability. The MCO is responsible for the ongoing monitoring of the cost share or patient liability amounts of its members. The MCO is also responsible for knowing what the member’s ongoing medical/remedial expenses are and reporting changes in those amounts to the income maintenance agency. The MCO is also responsible to report changes in other circumstances of members that may affect the amount of cost share or patient liability to the income maintenance agency within ten (10) calendar days of the MCO becoming aware of the change. Room and Board Members shall use their own income to pay for the cost of room and board. Any MCO supplementation of contribution to member payment of room and board obligation from capitation revenue shall not be considered a countable expense in developing MCO capitation rates. For each member who resides in community-based residential care as defined in Addendum VIII.A.16VII.A.17, the MCO is responsible for all of the following tasks: Determining Cost the Member’s Room and Board Obligation The MCO determines the cost of member’s room and board obligation in the facility in which the member resides. The MCO shall use one method for all its members. It shall select one of the three following methods: Actual Cost Methodology This method requires calculation of actual room and board costs for each community residential facility with which the MCO contracts. Facility- specific costs are split between care and supervision on the one hand and room and board on the other. Total costs attributable to room and board are divided by the number of residents licensed or certified for the living arrangement to get a room and board rate. Costs attributable to Room and Board: Rent, mortgage payments, title insurance, mortgage insurance Property and casualty insurance Building and grounds maintenance costs Residents’ food Household supplies and equipment necessary for the room and board of the individual Furnishings used by the individual (does not include office furnishings)

Monitoring Cost Share or Patient Liability. When the Department grants a cost share reduction due to financial hardship, the Department will provide the MCO with a copy of the member’s cost share reduction award letter. Annually thereafter, if the reduction is still in effect, the MCO shall verify whether the member continues to experience a financial hardship. The MCO shall conduct this verification during the member’s annual reassessment. If the member indicates that they continue to experience a financial hardship and therefore need a cost share reduction, the MCO’s enrollment/eligibility staff shall verify whether the member’s income and monthly necessary living expenses necessitate the continuation of their cost share reduction. MCO staff may request any documentation needed to verify whether an ongoing hardship exists. If the member indicates that they no longer need a cost share reduction or the MCO is unable to verify that an ongoing financial hardship exists, the MCO must ensure that this change is reported to the local IM agency. The MCO is responsible for the ongoing monitoring of the cost share or patient liability amounts of its members. The MCO is also responsible for knowing what the member’s ongoing medical/remedial expenses are and reporting changes in those amounts to the income maintenance agency. The MCO is also responsible to report changes in other circumstances of members that may affect the amount of cost share or patient liability to the income maintenance agency within ten (10) calendar days of the MCO becoming aware of the change. Room and Board Board‌ Members shall use their own income to pay for the cost of room and board. Any MCO supplementation of contribution to member payment of room and board obligation from capitation revenue shall not be considered a countable expense in developing MCO capitation rates. For each member who resides in community-based residential care as defined in Addendum VIII.A.16VI.A.15, the MCO is responsible for all of the following tasks: Determining Cost the Member's Room and Board Obligation The MCO determines the cost of member's room and board obligation in the facility in which the member resides, excluding members who reside in subsidized housing. MCOs must update member room and board obligations annually on February 1st or upon member request. The member's room and board obligation is the lesser of: • The prior calendar year's HUD FMR rental amounts, based on residential type by county, plus the prior calendar year's maximum Supplemental Nutrition Assistance Allocation for one person; o HUD FMR amounts: HUD FMR rents are set at the 40% percentile of surveyed rental costs reflecting modest but reasonable housing, include utilities, vary by county and apartment size, and are updated yearly: xxxxx://xxx.xxxxxxx.xxx/portal/datasets/fmr.html o SNAP allocation: xxxxx://xxx.xxx.xxxxxxxxx.xxx/foodshare/fpl.htm • The member's available income for room and board. Round HUD FMR, SNAP allocation, and member's available income down to the nearest dollar. Use the prior calendar year's efficiency rent for owner-occupied Adult Family Homes, the one bedroom rent for corporate-operated Adult Family Homes and Community Based Residential Facilities, and the two-bedroom rent for Residential Care Apartment Complexes. Use the HUD FMR amount for the county where the member lives. For a member residing in a shared room, divide the HUD FMR by two and add the maximum SNAP allocation. To calculate the amount of income the member has available for room and board, MCOs must use the following calculation: Deduct from the member's gross monthly income: Discretionary income allowance of $100 for basic living expenses; Health insurance premiums, defined in MEH 28.6.4.4; Spousal income allocation, defined in MEH 18.6; Income used for supporting others, defined in MEH 15.7.2.1; Expenses associated with establishing and maintaining a guardianship, defined in MEH 15.7.2.3; Court ordered fees and payments, defined in MEH 15.7.2.3; Garnishments; Deductions from unearned income, including IRS and SSA paybacks; and Medical and remedial expenses, defined in MEH 15.7.3; State and federal income taxes. Determining the Member’s Available Income The MCO determines the amount of available income the member has to pay for room and board, using procedures specified by the Department. The Room and board obligation calculation is not pro-rated for partial months. The MCO shall use one method for all its members. It shall select one of may collect from the three following methods: Actual Cost Methodology This method requires calculation of actual room and board costs for each community residential facility with which the MCO contracts. Facility- specific costs are split between care and supervision on the one hand and room and board on the other. Total costs attributable to room and board are divided by the number of residents licensed or certified for the living arrangement to get a room and board rate. Costs attributable to Room and Board: Rent, mortgage payments, title insurance, mortgage insurance Property and casualty insurance Building and grounds maintenance costs Residents’ food Household supplies and equipment necessary for member the room and board for actual days in residence. Implementing Contingencies if the Member Lacks Funds for Room and Board If the member lacks sufficient income available to pay room and board in the facility, the MCO either: Develops an alternative plan of care to support the member’s needs and outcomes; or May contribute to the member’s payment to the facility. The MCO may use its discretion to determine an amount to contribute to the member’s room and board obligation. Any MCO contribution to a member’s room and board obligation from capitation revenue shall not be considered a countable expense in developing MCO capitation rates. Collecting and Giving the Member’s Room and Board Obligation to the Residential Facility The MCO shall collect the member’s room and board obligation and give it to the residential facility on behalf of the individual Furnishings used by the individual (does not include office furnishings)member.