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

Monitoring Cost Share or Patient Liability. a. When DHS grants a cost share reduction due to financial hardship, DHS will provide the PO with a copy of the member’s cost share reduction award letter. Annually thereafter, if the reduction is still in effect, the PO shall verify whether the member continues to experience a financial hardship. The IDT 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 IDT must notify the PO’s Room and Board‌ enrollment/eligibility staff. Enrollment/eligibility staff shall verify whether the member’s income and monthly necessary living expenses necessitate the continuation of their cost share reduction. PO 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 PO is unable to verify that an ongoing financial hardship exists, the PO must ensure that this change is reported to the local IM agency. The PO is responsible for the ongoing monitoring of the cost share or patient liability amounts of its members. The PO 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 PO 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 PO becoming aware of the change. Members shall use their own income to pay for the cost of room and board. Any PO contribution to member room and board obligation from capitation revenue shall not be considered a countable expense in developing capitation rates. For each member who resides in community-based residential care as defined in Addendum VIII.A.16, the PO is responsible for all of the following tasks: Determining the Member’s Room and Board Obligation The PO determines the member’s room and board obligation in the facility in which the member resides, excluding members who reside in subsidized housing. POs 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;  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  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; Medical and remedial expense, defined in MEH 15.7.3; and State and federal income taxes. Determining the Member’s Available Income The PO 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 may collect from the 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 PO 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. Any PO contribution to a member’s room and board obligation from capitation revenue shall not be considered a countable expense in developing PACE capitation rates.

Monitoring Cost Share or Patient Liability. a. When DHS grants a cost share reduction due to financial hardship, DHS will provide the PO MCO with a copy of the member’s cost share reduction award letter. Annually thereafter, if the reduction is still in effect, the PO MCO shall verify whether the member continues to experience a financial hardship. The IDT 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 IDT must notify the POMCO’s Room and Board‌ enrollment/eligibility staff. Enrollment/eligibility staff shall verify whether the member’s income and monthly necessary living expenses necessitate the continuation of their cost share reduction. PO 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 PO MCO is unable to verify that an ongoing financial hardship exists, the PO MCO must ensure that this change is reported to the local IM agency. The PO MCO is responsible for the ongoing monitoring of the cost share or patient liability amounts of its members. The PO 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 PO 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 PO 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 PO MCO contribution to member 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 PO MCO is responsible for all of the following tasks: Determining the Member’s 's Room and Board Obligation The PO MCO determines the member’s 's room and board obligation in the facility in which the member resides, excluding members who reside in subsidized housing. POs MCOs must update member room and board obligations annually on February 1st or upon member request. The member’s 's room and board obligation is the lesser of: • The prior calendar year’s 's HUD FMR rental amounts, based on residential type by county, plus the prior calendar year’s 's maximum Supplemental Nutrition Assistance Allocation for one person;  o HUD FMR amounts - 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 's available income for room and board. Round HUD FMR, SNAP allocation, and member’s 's available income down to the nearest dollar. Use the prior calendar year’s '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 '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 expenseexpenses, defined in MEH 15.7.3; and State and federal income taxes. Determining the Member’s Available Income The PO 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 may collect from the 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 PO 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 PO MCO contribution to a member’s room and board obligation from capitation revenue shall not be considered a countable expense in developing PACE 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 member.

Monitoring Cost Share or Patient Liability. a. When DHS the Department grants a cost share reduction due to financial hardship, DHS the Department will provide the PO with a copy of the member’s cost share reduction award letter. Annually thereafter, if the reduction is still in effect, the PO shall verify whether the member continues to experience a financial hardship. The IDT PO 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 Room and Board reduction, the IDT must notify the PO’s Room and Board‌ enrollment/eligibility staff. Enrollment/eligibility staff shall verify whether the member’s income and monthly necessary living expenses necessitate the continuation of their cost share reduction. PO 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 PO is unable to verify that an ongoing financial hardship exists, the PO must ensure that this change is reported to the local IM agency. The PO is responsible for the ongoing monitoring of the cost share or patient liability amounts of its members. The PO 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 PO 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 PO becoming aware of the change. Members shall use their own income to pay for the cost of room and board. Any PO contribution to member room and board obligation from capitation revenue shall not be considered a countable expense in developing capitation rates. For each member who resides in community-based residential care as defined in Addendum VIII.A.16, the PO is responsible for all of the following tasks: Determining the Member’s Room and Board Obligation The PO determines the member’s room and board obligation in the facility in which the member resides, excluding members who reside in subsidized housing. POs 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;  ▪ 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  ▪ 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; Medical and remedial expense, defined in MEH 15.7.3; and State and federal income taxes. Determining the Member’s Available Income The PO 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 may collect from the 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 PO 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. Any PO contribution to a member’s room and board obligation from capitation revenue shall not be considered a countable expense in developing PACE capitation rates.

Monitoring Cost Share or Patient Liability. a. When DHS grants a cost share reduction due to financial hardship, DHS will provide the PO with a copy of the member’s cost share reduction award letter. Annually thereafter, if the reduction is still in effect, the PO shall verify whether the member continues to experience a financial hardship. The IDT 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 IDT must notify the PO’s Room and Board‌ enrollment/eligibility staff. Enrollment/eligibility staff shall verify whether the member’s income and monthly necessary living expenses necessitate the continuation of their cost share reduction. PO 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 PO is unable to verify that an ongoing financial hardship exists, the PO must ensure that this change is reported to the local IM agency. The PO is responsible for the ongoing monitoring of the cost share or patient liability amounts of its members. The PO 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 PO 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 PO becoming aware of the change. Members shall use their own income to pay for the cost of room and board. Any PO contribution to member room and board obligation from capitation revenue shall not be considered a countable expense in developing capitation rates. For each member who resides in community-based residential care as defined in Addendum VIII.A.16, the PO is responsible for all of the following tasks: Determining the Member’s Room and Board Obligation The PO determines the member’s room and board obligation in the facility in which the member resides, excluding members who reside in subsidized housing. POs 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;  ▪ 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  ▪ 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; Medical and remedial expense, defined in MEH 15.7.3; and State and federal income taxes. Determining the Member’s Available Income The PO 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 may collect from the 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 PO 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. Any PO contribution to a member’s room and board obligation from capitation revenue shall not be considered a countable expense in developing PACE capitation rates.