Waiver or Patient Liability Sample Clauses

Waiver or Patient Liability. The Contractor is responsible for the ongoing monitoring of the waiver or patient liability amounts of its members. The Contractor is to receive and monitor medical claim amounts and apply allowable costs against the liability to ensure member responsibility is met; and to cover allowable costs after the liability is met.

Waiver or Patient Liability. The Contractor is responsible for the ongoing monitoring of the waiver or patient liability amounts of its members. The Contractor is to receive and monitor medical claim amounts and apply allowable costs against the liability to ensure member responsibility is met; and to cover allowable costs after the liability is met. Members may be required to pay a monthly waiver or patient liability in order to be eligible for PathWays. Liability is the term applied to the monetary amount that IHCP members in long-term care (HCBS or nursing facility) must contribute toward their monthly care. a. Waiver liability is similar to a deductible and applies to members who live in the community (such as their own home, an adult family home, a community-based residential facility or a residential care apartment complex). Waiver members will be allowed to keep a monthly personal needs allowance (PNA) equivalent to the current year’s special income limit amount (SIL, as specified by 405 IAC 2-1.1- 1(g)). Long term care claims are not reimbursable until the waiver liability has been met. ▪ For waiver members with a waiver liability assigned, the Contractor must provide a system to track Medicaid-allowable expenses; when such expenses exceed the waiver liability amount, they should be paid by the Contractor. The provider should be able to see the waiver liability obligation and balance in the portal or when checking eligibility. ▪ Monthly waiver liability summary notices must be sent to the member and any authorized representative. The notice must detail the services and amounts applied to the waiver liability. The member is not required to pay the provider until the expense has been included in the waiver liability summary notice. The Contractor must be available to answer questions for members and their authorized representatives as to how the claims were applied to the liability. ▪ It is the member’s responsibility to supply verification of medical expenses not allowed for payment by Medicare or Medicaid to the DFR for possible deduction in the initial liability assignment calculation. ▪ The Contractor must also establish systems and procedures to properly apply Medicare Crossover Payments to waiver liability according to Indiana Health Coverage Programs guidance regarding third-party liability. For members with waiver liability who have not met their liability for the month, Medicare crossover claims credit the waiver liability with the combined sum of the amounts shown as t...