To use contract dollars as a payer source for addiction intervention and treatment services, provider eligibility begins with funding via a fully executed contractual agreement with DHS/DASA that specifies the types of services that are reimbursable and the rates for these respective services.
In order to maintain eligibility, providers must deliver substance abuse services in accordance with DHS rules that specify:
- The minimum standards necessary to deliver quality care (Part 2060);
- The minimum standards designed for administration of funding (Parts 509, 511, and 2030) as well as any other specific contractual obligations, if applicable.
Violations may result in a financial penalty or a disbursement adjustment and are considered in determining the continuation of contractual agreements with providers.
Family Income Eligibility Criteria
To be eligible for reimbursement utilizing contract dollars as specified in a valid contract with DHS/DASA, a total family income eligibility criteria is utilized to determine the appropriateness of Department contract dollars to pay for substance abuse treatment. If the patient meets the income criteria and can supply documented proof of such, 100% of the uniform or negotiated rate will be reimbursed.
Family Income Eligibility Criteria Contract Reimbursed (Non-medicaid)
FY 2012 FAMILY INCOME ELIGIBILITY
|For each additional person
- Dependents are defined as the number of dependents living in the patient's immediate household as well as any for whom financial responsibility exists.
- Annual income is defined as all projected annual gross income per calendar year.
The FY 2012 Family Income Eligibility Criteria is double the minimum amounts contained in the most recent poverty guidelines published by the Department of Health and Human Services (HHS) in the Federal Register, Vol. 76, No. 13, January 20, 2011, pp. 3637-3638. The Income Eligibility Criteria contained in this manual is in effect for all of FY 2012. Organizations must establish policies and procedures to ensure income eligibility is updated when new information concerning the patient's income status becomes available. At a minimum, patient income must be re-verified on an annual basis.
The Provider shall also establish systems regarding eligibility, billing and collection to ensure that persons entitled to other third party payment benefits (other than state or federal funds) are reimbursed therefrom.
Income Eligibility Wavier Criteria
Providers shall have the ability to utilize income eligibility waiver criteria on a case-by-case basis based upon hardship guidelines approved by the organization's governing board that shall, at a minimum, allow for service to be provided to:
- a dependent adult whose spouse or other responsible party is unwilling to assume financial responsibility for the cost of treatment, and the dependent adult would, as a result, be denied access to treatment services; or
- a dependent minor who is not Medical Benefits, All Kids and Family Care eligible and/or whose parent(s) or legal guardian is unwilling to assume financial responsibility for the cost of treatment or intervention, and the dependent minor would, as a result, be denied access to treatment or intervention services; or
- a pregnant woman who is not Medical Benefits, All Kids and Family Care eligible and has no insurance benefit that covers the cost of treatment; or
- a member of a family unit whose combined debt for prior medical expenses (not covered by insurance) exceeds 7.5% of the total gross family income, and the individual would be denied access to treatment due to the unwillingness or inability of the family to assume further debt; or
- a patient with an extenuating circumstance that meets any additional hardship guidelines adopted by the provider's governing body; or
- an individual for whom the fee is the sole inhibitor to accept treatment.
- other approved governing body criteria.
Treatment or intervention services provided to those individuals for whom exceptions to the income eligibility criteria have been granted must be done so within the current terms and conditions of the contract.
Documentation of Income
The patient must supply documentation of income which is required to be kept in the patient record or a separate financial record. Acceptable examples of proof of income are a copy of the most recently filed Federal Income Tax Return or any other document indicating current status of family income (i.e., pay check stubs, W-2 forms, unemployment cards, Medicare or Medicaid cards). When a provider is unable to secure income verification from the patient, the provider must document in the patient record or a separate financial record what attempts were made to secure such information and the reason for the absence of such information.
Documentation from the patient supporting his or her claim shall be kept in the patient record or a separate financial record. Providers are not required to submit such documentation to DASA but this information is subject to review. Failure to maintain this documentation will result in disallowance of payments and recoupment.
Each patient whose treatment is reimbursed through contract dollars should also be assessed a co-payment. The purpose of this co-payment is to endorse the therapeutic value of a patient's direct contribution toward the cost of their care. Collection of this co-payment is the responsibility of the provider and inability to collect cannot be used as justification for discharge or denial of treatment services. A sliding fee scale must be developed by each provider in order to determine the amount of the co-payment. The co-payment may be waived on a case by case basis if need exists. Any waiver of co-pay must be documented.