26 Tex. Admin. Code § 301.509 - Determination of Ability to Pay
(a) Financial
assessment.
(1) An MRA must conduct and
document a financial assessment for a person within 30 days after the person
begins to receive services.
(2)
Except for a Medicaid recipient who is receiving Supplemental Security Income
(SSI) benefits but not receiving employment income, the MRA must update a
person's financial assessment at least annually while the person is receiving
services. The MRA must monitor the continuing availability of benefits for a
person with income-based public insurance.
(3) The MRA must update a person's financial
assessment if the person experiences a significant financial change.
(4) The financial assessment must be
conducted using the financial documentation listed in § 2.105(d) of this
subchapter (relating to Accountability) that represents the finances of:
(A) the person who is age 18 years or older
and the person's spouse; or
(B) the
parents of the person who is under age 18 years.
(b) MMF. A person's MMF is based on the
financial assessment and calculated using the Monthly Ability-To-Pay Fee
Schedule, as referenced in § 2.110 of this subchapter (relating to Monthly
Ability-To-Pay Fee Schedule). The calculation is based on the number of family
members and annual gross income, reduced by extraordinary expenses paid during
the past 12 months or projected for the next 12 months. No other sliding scale
is used.
(1) An MMF that is greater than zero
is established for a person who is determined as having an ability to pay. If
two or more members of the same family are receiving services, then the MMF is
for the family.
(2) An MMF of zero
is established for a person who is determined as having an inability to
pay.
(c) Third-party
coverage.
(1) Third-party coverage that will
pay. A person with third-party coverage that will pay for needed services is
determined as having an ability to pay for those services.
(2) Third-party coverage that will not pay.
(A) If the person's third-party coverage will
not pay for needed services because the MRA does not have an approved provider
on its network, then the MRA must propose to refer the person to the person's
third-party coverage to identify a provider for which the third-party coverage
will pay unless:
(i) the MRA is identified as
being responsible for providing court-ordered services to the person;
(ii) the MRA is able to negotiate adequate
payment for services with the person's third-party coverage; or
(iii) the person (or parent) voluntarily
agrees to pay the standard charge(s) for the needed service(s).
(B) If the MRA proposes to refer
the person to the person's third-party coverage as described in paragraph
(2)(A) of this subsection, then the MRA must provide written notification to
the person (or parent) in accordance with § 2.109(e)(1) of this subchapter
(relating to Payments, Collections, and Non-payment), which provides an
opportunity to appeal. The MRA must also comply with §2.109(e)(2) - (3) of
this subchapter as initiated by the person (or parent).
(C) If the MRA refers the person to
third-party coverage, then the MRA must assist the person (or parent) in
identifying a provider for which the third-party coverage will pay.
(D) If a person who has been referred to
third-party coverage is unable to identify or access needed services from an
approved provider or if access will be unduly delayed, then the MRA must:
(i) assist the person (or parent) in
resolving the matter with the third-party coverage (e.g., contacting customer
service at the third-party coverage, filing a complaint with the third-party
coverage or the Texas Department of Insurance); and
(ii) if indicated, ensure the provision of
the needed services to the person pending resolution.
(E) The MRA must maintain documentation of:
(i) all referrals as described in paragraph
(2)(C) of this subsection;
(ii) all
assistance as described in paragraph (2)(D)(i) of this subsection;
and
(iii) whether the person
received services pending resolution as described in paragraph (2)(D)(ii) of
this subsection.
(d) Social Security work incentive
provisions. A person who identified payment for specific needed services in the
person's approved plan utilizing Social Security work incentive provisions
(i.e., Plan to Achieve Self-Sufficiency; Impairment Related Work
Expense) is determined as having an ability to pay for the specific
services. A person is not required to identify payment for any service for
which the person may be eligible as part of the person's approved plan for
utilizing the Social Security work incentive provisions.
(e) Notification. After a financial
assessment is conducted, the MRA must provide written notification to the
person (or parent) that includes:
(1) the
determination of whether the person (or parent) has an ability or an inability
to pay;
(2) a copy of the financial
assessment form and a copy of the Monthly Ability-to-Pay Fee Schedule, with the
applicable areas indicated (i.e., annual gross income, number of family
members);
(3) the amount of the
MMF;
(4) the name and phone number
of at least one MRA staff who the person (or parent) may contact during office
hours to discuss the information contained in the written notification;
and
(5) a statement that the person
(or parent) may voluntarily pay more than the maximum monthly fee.
Notes
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