26 Tex. Admin. Code § 301.513 - Billing Procedures
(a) Monthly
account.
(1) The MRA must maintain a monthly
account for a person that lists all services provided to the person during the
month and the standard charges for the services. Each service listed must
indicate whether the service is:
(A) covered
by Medicare third-party coverage;
(B) covered by non-Medicare third-party
coverage;
(C) not covered by
third-party coverage; or
(D)
identified for payment in the person's approved plan utilizing Social Security
work incentive provisions.
(2) If a person has exceeded the maximum
third-party coverage benefit of a particular covered service, then that service
is indicated as not covered by third-party coverage.
(b) Accessing funding sources. The MRA must
access all available funding sources before using DADS funds to pay for a
person's services. Funding sources may include third-party coverage, state
and/or local governmental agency funds (e.g., crime victims fund), Qualified
Medicare Beneficiary (QMB) Program, or a trust that provides for the person's
need for community services.
(c)
Billing third-party coverage. The MRA bills the person's third-party coverage
the monthly account amount for covered services. If the MRA has negotiated a
reimbursement amount with the third-party coverage that is different from the
monthly account amount, then the MRA may bill the third-party coverage the
negotiated reimbursement amount for covered services.
(d) Billing the person (or parent).
(1) No third-party coverage. If the monthly
account amount for services not covered by third-party coverage:
(A) exceeds the person's MMF, then the amount
is reduced to equal the MMF and the MRA bills the person (or parent) the MMF;
or
(B) is less than the person's
MMF, then the MRA bills the person (or parent) the monthly account amount for
services not covered by third-party coverage.
(2) Medicare third-party coverage. Nothing in
this paragraph is intended to conflict with any applicable law, rule, or
regulation with which an MRA must comply.
(A)
The following amounts are added to equal the total amount applied toward the
person's MMF:
(i) the amount of all
applicable co-payments and co-insurance for services listed in the monthly
account as covered by Medicare third-party coverage;
(ii) the amount Medicare third-party coverage
was billed but did not pay because the deductible hasn't been met;
and
(B) If the total
amount applied toward the person's MMF as described in paragraph (2)(A) of this
subsection:
(i) exceeds the person's MMF,
then the amount is reduced to equal the MMF and the MRA bills the person (or
parent) the MMF; or
(ii) is less
than the person's MMF, then the MRA bills the person (or parent) the total
amount applied toward the MMF.
(3) Non-Medicare third-party coverage.
(A) Cost-sharing exceeds MMF. If the amount
of all applicable co-payments, co-insurance, and deductibles for services
listed in the monthly account as covered by non-Medicare third-party coverage
exceeds the person's MMF, then the MRA bills the person (or parent) all
applicable co-payments, co-insurance, and deductibles.
(B) Cost-sharing does not exceed MMF.
(i) If the amount of all applicable
co-payments, co-insurance, and deductibles for services listed in the monthly
account as covered by non-Medicare third-party coverage does not exceed the
person's MMF, then the following amounts are added to equal the total amount
applied toward the person's MMF:
(I) the
amount of all applicable co-payments, co-insurance, and deductibles;
and
(II) the monthly account amount
for services not covered by third-party coverage.
(ii) If the total amount applied toward the
person's MMF as described in paragraph (3)(B)(i) of this subsection:
(I) exceeds the person's MMF, then the amount
is reduced to equal the MMF and the MRA bills person (or parent) the MMF;
or
(II) is less than the person's
MMF, then the MRA bills the person (or parent) the total amount applied toward
the MMF.
(C)
Annual cost-sharing limit. If the person (or parent) has reached the person's
annual cost-sharing limit (i.e., maximum out-of-pocket expense) as verified by
the non-Medicare third-party coverage, then the MRA must not bill the person
(or parent) any co-payments, co-insurance, or deductibles, as applicable to the
annual cost-sharing limit, for services covered by the non-Medicare third-party
coverage for the remainder of the policy-year.
(4) Social Security work incentive
provisions.
(A) If the person identified a
payment amount for specific services in the person's approved plan utilizing
Social Security work incentive provisions (i.e., Plan to Achieve
Self-Sufficiency; Impairment Related Work Expense), then the MRA bills
the person the monthly account amount for the specific services up to the
identified payment amount. If the monthly account amount for the specific
services is greater than the identified payment amount, then the remaining
balance is applied toward the person's MMF.
(B) The following amounts are added to equal
the total amount applied toward the person's MMF:
(i) any remaining balance as described in
paragraph (4)(A) of this subsection; and
(ii) the monthly account amount for services
not covered by third-party coverage.
(C) If the total amount applied toward the
person's MMF as described in paragraph (4)(B) of this subsection:
(i) exceeds the person's MMF, then the amount
is reduced to equal the MMF and the MRA bills person (or parent) the MMF;
or
(ii) is less than the person's
MMF, then the MRA bills the person (or parent) the total amount applied toward
the MMF.
(e) Statements.
(1) The MRA must send to a person (or parent)
who has been determined as having the ability to pay monthly or quarterly
statements that include:
(A) an itemized
list, at least by date and by type, of all services provided during the
period;
(B) the standard charge for
each service;
(C) the total charge
for the period;
(D) the amount paid
(or to be paid) by each funding source; and
(E) the amount to be paid by the person (or
parent).
(2) Unless
requested otherwise, the MRA may not send a statement to a person (or parent)
who has an ability to pay if the person (or parent) maintains a zero balance
(i.e., the person (or parent) does not currently owe any money).
(3) Unless requested otherwise, the MRA may
not send a statement to a person (or parent) who has an inability to
pay.
Notes
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