| (a) An individual's co-payment is a percentage of the
monthly cost of services provided to the individual. To calculate
an individual's co-payment, a provider must:
(1) determine the individual's total net monthly income
in accordance with subsections (f) - (i) of this section;
(2) determine the individual's co-payment percentage
by using the individual's net monthly income and the CMPAS co-pay
schedule located in the DADS Consumer Managed
Personal Assistance Services Provider Manual;
(3) inform the individual of the individual's estimated
monthly co-payment by multiplying the authorized hours of service
per month by the hourly reimbursement rate, multiplied by the co-payment
percentage;
(4) calculate the amount of the individual's actual
monthly co-payment each month by multiplying the individual's co-payment
percentage amount by the reimbursement rate, multiplied by the number
of hours of service actually provided during the month.
(b) An individual who suffers undue hardship as a result
of legal financial obligations for reasons such as a catastrophic
illness of the individual or a family member may request that his
or her co-payment be temporarily reduced or waived. To request a reduction
or waiver of a co-payment, the individual must make the request to
the assessor of need and document the legal financial obligation that
necessitates the reduction or waiver.
(1) The provider may approve a reduction or waiver
for a three-month period. The individual must resubmit a new request
to receive three-month extensions to the waiver or reduction.
(2) If the provider does not approve a reduction or
waiver, the provider must offer the individual orally and in writing
an informal dispute resolution (IDR) process which includes a meeting
of the IDT and notify the individual of the right to a fair hearing
as provided by §44.503 of this subchapter (relating to Fair Hearing).
(c) The provider must bill a co-payment amount to an
individual by or on the 15th day of the month following the month
in which services were provided. The bill must show the co-payment
percentage, the reimbursement rate, the total number of hours of
service for the month, the total cost, and the actual amount of the
co-payment due. If payment is not made within 15 days after billing,
the provider must send a second notice to the individual within 10
days after the bill was due. If the individual does not pay the amount
due by the 20th day of the month after the month in which the second
notice was sent, the provider must suspend services.
(d) A provider must not charge an individual a fee
for late payment.
(e) In collecting monthly co-payments, a provider must:
(1) provide the individual a receipt containing the
provider's name, individual's name, amount paid, and the date of the
payment;
(2) retain a copy of the receipt;
(3) deduct the co-payment from reimbursement claims
submitted to DADS under §44.505 of this subchapter (relating
to Reimbursement); and
(4) maintain a current individual co-payment ledger
system, in accordance with generally accepted accounting principles,
that reflects all charges to and all payments by an individual.
(f) A provider must calculate an individual's total
monthly income by adding:
(1) the gross monthly earnings of the individual and
the individual's spouse, including:
(A) employee wages or salary; and
(B) commissions, tips, piece-rate payments, and cash
bonuses;
(2) the net monthly receipts of the individual and
the individual's spouse from non-farm self-employment, calculated
by subtracting business expenses from gross receipts, as described
in subsection (g) of this section;
(3) the net monthly receipts of the individual and
the individual's spouse from farm self-employment, calculated by subtracting
business expenses from gross receipts, as described in subsection
(h) of this section;
(4) the gross monthly benefits received by the individual
and the individual's spouse, including:
(A) pensions, retirement, disability, and survivors'
benefits;
(B) education loans, scholarships, and grants to the
extent funds are or may be applied to living costs;
(C) payments from annuities, insurance, and irrevocable
trust funds;
(D) public assistance payments, such as Temporary Assistance
to Needy Families or Supplemental Security Income, and including general
assistance from a local government source;
(E) court-ordered support payments, such as alimony
and child support payments for a minor child;
(F) unemployment compensation and union strike payments;
(G) workers' compensation payments or other compensation
for work injuries;
(H) Veterans Administration payments, such as subsistence
allowances and refunds of GI insurance premiums; and
(I) other monthly support, such as allotments or payments
from friends or relatives; and
(5) the net monthly income from property of the individual
or the individual's spouse, calculated by averaging receipts over
a 12-month period, including:
(A) dividends and interest payments;
(B) receipts from a life estate, other estate, or trust
fund;
(C) income from a mortgage, promissory note, or other
negotiable instrument;
(D) income from lease of mineral rights, calculated
by subtracting the following prorated payments from gross royalties
or lease payments:
(i) property taxes (not including windfall profit
taxes); and
(ii) excise taxes; and
(E) income from rental property, including rent from
boarders, calculated by subtracting the following prorated payments
from gross receipts:
(i) mortgage interest;
(ii) property repair and maintenance expenses (not
including improvements or depreciation charges);
(iii) property insurance; and
(iv) property taxes.
(g) For purposes of calculating net monthly receipts
from non-farm self-employment in accordance with subsection (f)(2)
of this section:
(1) gross receipts means the value of all goods sold
and services provided by the non-farm self-employment enterprise;
and
(2) business expenses means the actual operating expenses
of the non-farm self-employment enterprise, including:
(A) purchased goods or services;
(B) rent;
(C) utilities;
(D) depreciation charges;
(E) wages and salaries; and
(F) business taxes, which do not include personal income
taxes.
(h) For purposes of calculating net monthly receipts
from farm self-employment in accordance with subsection (f)(3) of
this section:
(1) gross receipts means the value of all goods sold
and services provided by the farm self-employment enterprise, except
for goods and services used for family living. Gross receipts include
receipts from:
(A) the sale of crops;
(B) the rental of farm equipment;
(C) the sale of wood, sand, gravel, and similar items;
and
(D) government crop loans;
(2) business expenses means the actual operating expenses
of the farm self-employment enterprise, including:
(A) the cost of feed, fertilizer, seed, and other farming
supplies;
(B) wages and salaries;
(C) depreciation charges;
(D) rent;
(E) interest on farm mortgages;
(F) farm building repairs; and
(G) farm taxes, which do not include personal income
taxes.
(i) A provider must calculate an individual's income
exclusions by adding:
(1) payments to satisfy a judgment of the Indian Claims
Commission or its successor agency, the U.S. Court of Claims;
(2) any payment received under the federal Uniform
Relocation Assistance and Real Property Acquisition Policies Act of
1970;
(3) education loan, grant, and scholarship funds that
are not or cannot be applied to living costs;
(4) Veterans Administration payments, such as aid-and-attendance
benefits, homebound elderly benefits, and payments for purchase of
medications;
(5) in-kind credits, such as rent subsidies;
(6) infrequent or irregular payments from any source
that occur no more often than once a quarter and that do not exceed
$20 a month;
Cont'd... |
