| (a) Monthly account.
(1) The LMHA will maintain a monthly account for each
person that lists all services provided to the person during the month
and the standard charges for the services. Each service listed will
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 LMHA must access
all available funding sources before using the department's 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, indigent
pharmaceutical programs, or a trust that provides for the person's
healthcare and rehabilitative needs.
(c) Billing third-party coverage. The LMHA will bill
the person's third-party coverage the monthly account amount for covered
services. If the LMHA has negotiated a reimbursement amount with the
third-party coverage that is different from the monthly account amount,
then the LMHA may bill the third-party coverage the negotiated reimbursement
amount for covered services.
(d) Billing the person (or parents).
(1) No third-party coverage. If the monthly account
amount for services not covered by third-party coverage:
(A) exceeds the person's maximum monthly fee (MMF),
then the amount is reduced to equal the MMF and the LMHA bills person
(or parent) the MMF; or
(B) is less than the person's MMF, then the LMHA 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 a LMHA 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
(iii) the monthly account amount for services not covered
by third-party coverage.
(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 LMHA bills person (or parent) the MMF; or
(ii) is less than the person's MMF, then the LMHA 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 LMHA 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) of this subsection:
(I) exceeds the person's MMF, then the amount is reduced
to equal the MMF and the LMHA bills person (or parent) the MMF; or
(II) is less than the person's MMF, then the LMHA bills
the person (or parent) the total amount applied toward the MMF.
(C) Annual cost-sharing limit. If the person (or parent)
has reached his/her annual cost-sharing limit (i.e., maximum out-of-pocket
expense) as verified by the non-Medicare third-party coverage, then
the LMHA will 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 his/her approved plan utilizing Social Security work incentive
provisions (i.e., Plan to Achieve Self-Sufficiency; Impairment Related
Work Expense), then the LMHA 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 LMHA bills person (or parent) the MMF; or
(ii) is less than the person's MMF, then the LMHA bills
the person (or parent) the total amount applied toward the MMF.
(e) Statements.
(1) The LMHA will send to persons (and parents) who
have 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 LMHA does not send
statements to persons (or parents) who have an ability to pay if they
maintain a zero balance (i.e., the person (or parent) does not currently
owe any money).
(3) Unless requested otherwise, the LMHA does not send
statements to persons (or parents) who have an inability to pay.
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| Source Note: The provisions of this §412.108 adopted to be effective September 1, 2002, 27 TexReg 2041; amended to be effective September 15, 2005, 30 TexReg 5806; amended to be effective February 19, 2017, 42 TexReg 561 |
