32 Miss. Code. R. § 22-3.4 - COMMUNITY REHABILITATION PROGRAMS

  1. § 32-22-3.4.1 - Public (§ 32-22-3.4.1.1 to 32-22-3.4.1.3)
  2. § 32-22-3.4.2 - PRIVATE (§ 32-22-3.4.2.1 to 32-22-3.4.2.2)
  3. § 32-22-3.4.3 - CRP Referral Package Documentation
  4. § 32-22-3.4.4 - Employment Identity & Eligibility (I-9) Information

Current through December 27, 2021

Community Rehabilitation Programs (CRP) are programs that provide or facilitate the provision of vocational rehabilitation services to individuals with disabilities. These programs are used to provide services that promote integration into competitive employment.

3.5 COMPARABLE SERVICES & BENEFITS

The major purpose of the Comparable Services and Benefits provision is to provide vocational rehabilitation agencies with an organized method for assessing an individual's eligibility for benefits under other programs and drawing upon these programs to provide rehabilitation services. This is not the same as the determination of economic need.

During the initial interview, the counselor will thoroughly investigate any comparable services and benefits to which the client may be entitled. This is to be documented in the clients case file. Determination of benefits will be made in all areas prior to the authorization of VR funds (exceptions are listed in the OVR/OVRB Policy and Procedures Manual).

During the time the IPE is being developed, the counselor will follow up on all appropriate comparable services and benefits. The counselor must list on the IPE any comparable services and benefits available to offset, in whole or part, the cost of each planned service. If there is any possibility a comparable benefit will pay for a service, it must be listed in the "Comparable Benefits" section of the IPE under the applicable planned service. If "Other" is selected from the AACE list, the comparable benefit must be identified in the "Other Comments" section.

If the counselor has determined the comparable benefit will not pay on a service, "None" should be listed under Comparable Benefits. In the "Other Comments" section, the counselor must enter "Insurance, Medicaid, etc. will not pay..." The counselor must also document how verification was obtained that the comparable benefit will not pay. Documentation may be included on the IPE (as documented by the counselors review of the insurance policy; counselors contact with Mr. Smith at the Medicaid office; counselors talking with Mr. Smith, the benefit specialist for XXX Insurance Company, etc.) or documentation may be in a case note (as documented in the case notes).

If a comparable benefit obviously does not pay for a planned service, "None" may be entered in the "Comparable Benefits" section with no further explanation. Examples: Medicaid or other insurance would obviously not pay for AbilityWorks services, job placement, or counseling and guidance by MDRS staff.

3.5.1 Types

Examples of comparable services and benefits include, but are not limited to:

I. Grants/Scholarships (non-merit), which do not have to be repaid (See the Post-secondary Education Services section of this Resource Guide for further information.)

Medicaid - Medicaid is a Federal-State supported program which helps pay for medical services for low-income families. This is NOT an insurance program. It is supported by special appropriations made by the United States Congress and the State Legislature from general revenue Federal and State tax funds. The program varies from state to state.

If a doctor or medical facility refuses to accept Medicaid or Medicare, the counselor is required to direct the client to another physician or facility that will accept these third-party payers.

This is a very comprehensive, technical, medical assistance service program. Benefits change often (almost constantly for certain benefits) depending upon the availability of appropriated funds and current needs demand.

Eligibility is primarily based upon economic need although age, disability, and dependency (Temporary Assistance for Needy Families - TANF) are also factors to be considered. All SSI beneficiaries are eligible for Medicaid. All eligibility factors and benefit allowances are subject to change or termination at any time.

Some services currently provided are prescription drugs, clinic visits, lab tests, physician office visits, dental care, ambulance transportation, surgery, hospitalization, home health care, and family planning.

Medicaid does have some limitations such as deductibles, co-payments, per diems with limitations on number of days, and upper limit fees for all medically approved service procedures. For example, a recipient may be provided 30 in-patient hospital days in one calendar year. VR does not pay for deductible, co-payments, etc.

The recipient CANNOT be charged more than the established co-payment and/or deductible. The vendor must accept the established upper limit payment less the co-payment and/or deductible as payment in full for services rendered.

Under the HealthMACS program, the individual may choose a particular doctor or health care facility from a list of HealthMACS providers to be his/her primary health care provider. Medicaid benefits stay the same under the HealthMACS program.

The Agency may not supplement any Medicaid covered service but may purchase other uncovered, services, which are deemed vocationally necessary. When a client has both, Medicaid may be used to supplement Medicare. The VR counselor must always determine a client's current Medicaid status. To do this, write the Mississippi Medicaid Commission at Sillers Building, 550 High Street Suite 1000, Jackson, MS 39201-1399 or telephone: 601-359-6050 or toll free: 1-800-421-2408.

III. Medicaid - Disabled Child Living at Home - A child with a disability(ies) age 18 or under who lives at home may qualify for Medicaid if the following conditions are met:
A. The child requires the level of care provided in a hospital or nursing facility.
B. It is appropriate to provide this care outside a nursing facility.
C. The cost of care at home is no more expensive than the Medicaid cost of nursing facility care.

Eligibility for Medicaid begins the month the child is eligible on all factors, which may be up to three months prior to the month of Medicaid application. Medicaid has 90 days to process the claim for a disabled child.

IV. Medicaid - Early and Periodic Screening, Diagnosis and Treatment (EPSDT) - Individuals under age 21 who are on Medicaid are eligible for EPSDT services. Medicaid will provide a comprehensive physical assessment, vision and hearing tests, immunizations (as needed), blood and urine tests, nutritional and developmental assessments, and health and developmental history.

The Medicaid Commission also provides, on an as needed basis, referral to a doctor for health problems; visual examination and glasses; hearing examinations and hearing aids; adolescent counseling and case management; and all other medical services for which a Medicaid recipient is eligible. It also provides, based on medical need, in-patient hospital services and rehabilitation hospital services.

V. Medicare - Medicare is administered by the Social Security Administration. It is a Federal government health insurance program for people 65 and older qualifying for Social Security payment benefits. Individuals with disabilities under age 65 drawing SSDI payments are eligible for Medicare benefits after receiving disability benefits for two years; chronic end-stage renal dialysis patients are eligible after three months after the month dialysis begins or the month of kidney transplant surgery.

Medicare has two parts:

Part A - Mandated of all Social Security participants. Coverage includes hospital insurance and in-patient care at skilled nursing facilities after hospitalization. It may also provide for some home health care services. Part A covers all costs after the annual deductible is met for the first 60 days of hospitalization. Beginning on the 61st day there is a fixed per diem payment that is reduced further on the 91st day.

Part B - This is medical insurance coverage. This protection is an option available to the individual. Eligible recipients authorize premium payments to be withheld from benefit payment checks. Part B only pays about eighty percent (80%) of the provider's usual and customary charges after the deductible is met. Therefore, an approximate 20 percent coinsurance payment plus the annual deductible will be required for most individuals.

A Medicare benefit period begins the day the individual enters a hospital and ends when he/she has been out of the hospital for 60 consecutive days. There is no limit to the number of benefit periods a person can have in one year for hospital and skilled nursing facility care. The patient must meet an annual deductible for both Part A and Part B. The deductible, per diem, premiums, hospital and medical service costs are all subject to change and revision.

Services covered under Medicare include, but are not limited to, the following: hospitalization, skilled nursing home care, home health care, physician services (hospital and nursing home, in-patient and out-patient), durable medical equipment, renal dialysis equipment and supplies, orthotic and/or prosthetic appliances and devices, braces, artificial eyes, and cataract lens.

Medicare may be supplemented by treating the Medicare payment as you would private insurance. VR does pay deductible, co-payment, etc.

VI. Mississippi Department of Health - Children's Medical Program (CMP) - CMP provides financial assistance to Mississippi families of children (birth - age 21) with special health care needs. The program is habilitative or rehabilitative; its goal is the correction or reduction of physical handicaps. It also provides assistance to the family in finding other available community resources.

Factors such as family size, income, and assets as well as the estimated total cost of treatment services determine financial eligibility for treatment services.

General categories of medically eligible conditions under CMP include, but are not limited to, the following: cleft palate, congenital heart defects, and congenital defects of the nervous system, cerebral palsy, cystic fibrosis, gastrointestinal defects, genitourinary defects, hemophilia, orthopedic conditions, scoliosis, seizure disorders, sickle cell, and spina bifida.

Certain conditions are NOT eligible under CMP. These include, but are not limited to, the following: acute illnesses (e.g., flu, measles, colds, broken bones, etc.), allergies, asthma, flat feet, hyaline membrane disease, malignancies (except where a secondary reconstructive procedure is indicated), mental disorders, rheumatic fever and heart disease (except where surgery is required), speech conditions (other than cleft palate), and spinal cord injuries.

Services provided include: clinic services, hospitalization, surgery, physical therapy, artificial appliances and limbs, wheelchairs, medication, evaluation, treatment and follow-up for any eligible condition. Hospitalization is limited to 20 days per year. CMP utilizes the usual and customary rate schedule with payment at 50 percent of that rate. Medicaid and private insurance must be the first sources of payment. CMP will not pay until all insurance has been utilized. Applications for CMP are available through the local county health department.

VII. Mississippi Workers' Compensation Commission - Workers' Compensation (WC) is a no-fault insurance plan paid for by employers and supervised by the State. Almost every working Mississippian is protected by the Workers' Compensation Act, but there are a few exceptions, such as persons employed by a company with fewer than five employees. There is no "waiting period" for coverage; the employee is covered from the date of employment. There is no deductible to be met by the worker or the employer. Any injury or illness that is job-related is covered. This Act guarantees three kinds of benefits - medical services and supplies, cash payments for lost wages, and rehabilitation services.

Medical services include, but are not limited to, the following: treatment by physicians and surgeons, mileage for out-of-town doctors' appointments, hospital and nursing services, medicine, physical therapy, and crutches. The employer's insurance company makes payments directly to the medical service provider.

The employer's insurance company makes cash compensation payments for lost work time. If the employee is off work for less than 14 days, medical benefits, but not cash compensation payments, are paid for the first five days. If the employee misses more than 14 days, cash compensation payments are made beginning with the first day he/she is off work. The time an employee receives cash benefits varies according to the extent of the injury and the loss of wages. The maximum length of time for cash benefits to be paid, as established by State legislation, is 450 weeks. The worker will not receive the full amount of his/her paycheck. Cash benefits can be as much as two-thirds of the worker's average weekly wage, up to a maximum set by the legislature, but workers' compensation payments are tax-free.

In order for the Agency to be reimbursed for service expenditures which should have been covered by Workers' Compensation, the counselor will need to send a letter to the client's/claimant's attorney with copies to the insurance carrier and the Workers' Compensation Commission. This letter should detail the service(s) provided, amount paid by the Agency for each service and request reimbursement for the specified costs once the claim has been settled.

VIII. Private Hospital and Medical Insurance - When planning physical restoration for a client who has private hospital and/or medical insurance, the counselor will advise the hospital personnel and the physicians involved that the client has insurance and provide the name of the insurer, if available. The counselor will remind all vendors in the case that the acceptance of the insurance benefits or the Agency authorization is optional. The counselor will call their attention to the advantages and disadvantages, the procedure, and their responsibility in each situation. The counselor will also advise the client of the hospital's and doctor's options, explain the Agency's position, limitations of responsibility, authority, etc. The counselor must also advise the client that he/she has the right to decline services offered by the hospital and/or the doctors if they reject the authorization and accept the insurance benefits making the client responsible for possible additional costs. The option MUST be exercised no later than the time of hospital admission and/or before any service is rendered.

If the decision is to refuse the authorization and accept the insurance benefits in lieu thereof, the hospital administrator (or representative) and the physicians involved must assume responsibility for advising the client (patient) of the decision made and work out an acceptable plan for payment of any possible cost difference. The refusal to accept authorizations as co-sponsor relieves the Agency of all responsibility for the services involved.

If the decision is to accept the authorization and to use any insurance benefits the client may have toward paying for the services, the Agency is obligated only for the amount authorized in keeping with current Agency per diems and/or fee schedules less any amount the insurance company pays. The authorization must show the total costs less the amount the insurance will pay (as close as the counselor can determine at the time the authorization is issued) and the net amount to be paid by the Agency.

The client will be instructed to notify the counselor when he/she enters and is discharged from the hospital. The counselor will advise the client to take his/her insurance policy/identification card to the hospital at the time of admission.

The Agency authorization covers all services in the hospital contract per diem and/or the current established fee schedule. If it is accepted, the hospital will not bill the client for any additional charges. The client should inform the counselor if he/she receives a bill for services that have been authorized. The counselor will assume responsibility for follow-up on cases where reimbursements are due. The Statement of Account will not be processed until all insurance benefits have been paid. In case the total number of days authorized is not needed, the unused per Diem should be canceled. If the physician determines additional hospitalization is required and informs the counselor, a supplemental authorization may be issued for the additional days. (See the OVR/OVRB Fee Schedule for exceptions to the per diem.)

NOTE: This is the procedure to be followed when using any other similar benefits and resources the client may have.

3.5.2 Processing VR Authorizations for Comparable Benefits

The following examples are offered as further explanation of how the accounts must be handled when Agency authorizations for in-patient hospital care are involved:

* The Agency authorizes $550 per day, or $5,500. The actual cost is $5,850. Insurance pays $5,600. In this case, the hospital should accept the insurance payment, and the Agency authorization would be canceled. The client should not be billed for the difference and the hospital would show a loss of $250.

* The Agency authorizes $550 per day, or $5,500. The actual cost is $5,500. Insurance pays $3,000. In this case, the Agency pays the difference of $2,500 and the hospital has no loss.

* The Agency authorizes $550 per day, or $5,500. The actual cost is $6,300. The client has no insurance. In this case, the Agency will pay $5,500, leaving the hospital with a loss of $800, for which the client should not be billed.

* The Agency authorizes $550 per day, or $5,500. The actual cost is $4,800. The client has no insurance. In this case, the Agency will pay $5,500, giving the hospital an excess of $700.

Notes

32 Miss. Code. R. § 22-3.4

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