La. Admin. Code tit. 48 § VII-115

Current through Register Vol. 50, No. 11, November 20, 2024

Section VII-115 - Fee Policy for Outpatient Programs

A. Fee Policy

1. All persons seen for services at an OPRADA center or clinic shall be assessed a fee for each chargeable service. Chargeable services are those defined as chargeable under the Medicaid Program, Title XIX of the Social Security Act, regardless of the source of payment. These services are listed in Table 1. The unadjusted fee for each service shall be equivalent to the cost of service computed for reimbursement under Medicaid.

Table 1 Chargeable Services as Defined for Medicaid Reimbursement Procedure
Code	Service
00140	Individual Counseling/Therapy
00141	Group Counseling/Therapy
00142	Family Counseling/Therapy
00143	Collateral Counseling
00144	Medical Treatment
00145	Medical Injection
00146	Occupational Therapy
00147	Recreational Therapy
00148	Music Therapy
00149	Art Therapy
00150	Screening and Intake
00151	Psychosocial Evaluation
00152	Psychiatric Evaluation
00153	Medical Evaluation
00154	Other Evaluation

2. All patients whose gross family income is above the minimum indicated on the fee adjustment schedule shall pay a fee for each service provided. Fees and adjustments to fees are to be established at the time the patient is first admitted to the facility. It is the responsibility of the patient and/or legally responsible family to justify any adjustment to the full fee. The patient or family will be asked to present reasonable proof of income before any adjustment to the full fee will be made. Appropriate center or clinic staff will assist the patient and family in verifying eligibility for a fee adjustment. There shall be adequate documentation of the information used in adjusting any fee. Fees may be adjusted during the patient's course of treatment based on changes in the economic status of the patient. The full fee, and/or the adjusted fee, shall be posted on the patient's ledger card and noted in the patient's permanent record.

3. Patients shall be charged a fee for each service, regardless of which service is provided, in the same manner in which Medicaid is charged. No fee shall be charged for failed or cancelled appointments.

4. All patients shall be asked to pay their fees at the time of service delivery. However, when patients do not pay at the time of the visit, they shall be billed on a regular basis, preferably monthly, but no less frequently than quarterly.

B. Fee Adjustment Schedule

1. The fee adjustment schedule is designed to provide for proportional payment for each service based on the family's ability to pay. Three variable figures are utilized in calculating the schedule:

(1) state median income as promulgated annually the Secretary of the United States Department of Health and Human Services;

(2) family size; and

(3) cost of service provided as computed for Medicaid.

2. The fee adjustment schedule will be recalculated by OPRADA based on current state median income each time OPRADA and the Department of Health and Human Resources, Office of Family Security adjust the figure for cost reimbursement under the Medicaid program.

3. Persons whose gross family income is less than one-half the current state median income adjusted for family size will not be responsible for payment of services. Persons whose gross family income is more than one hundred fifty percent of the current state median income adjusted for family size will be charged the full cost of services provided. Between these two levels, fees will be adjusted in accordance with the following formula.

Gross Family Income as a Percent of Median Income Adjusted for Family Size	Fee as a Percent of Cost
50-55%	4% of cost
55-60%	8%
60-65%	12%
65	16%
70	20%
75	25%
80	30%
85	35%
90	40%
95	45%
100	50%
105	55%
115	60%
120	65%
125	70%
130	75%
135	80%
140	85%
145	90%
150	100%

a. Adjustment of median income for family size shall be computed in accordance with the following formula.

Family Size	% of Median Income for a Family of Four
1	52%
2	68%
3	84%
4	100%
5	116%
6	132%
7 or more	148%

4. In computing each modification of the scale, the OPRADA will round actual fees to the nearest quarter dollar. Fee adjustment schedules will be computed annually based on current cost and distributed to the facilities.

C. Changes in Fees

1. The patient is to be informed that the fee clerk should be notified of any change which may later occur in income, employment, or family composition which might result in a change in the adjusted fee. The fee clerk shall also conduct a periodic check with each patient to determine any change in factors including cost changes, which would caused change in the fee and adjusted fee.

2. No fee may be waived or reduced beyond the fee adjustment scale without the express approval of the facility administrator who must document the reason for change in the patient chart. When waiver or reduction is made, the administrator must sign and date such authorization in the case record and in addition must note and initial the adjusted fee on the ledger card.

3. Examples of acceptable justifications for waiving or reducing a fee include:

a. excessive expense due to other medical costs;

b. family hardship resulting in unusual and unexpected expenses; or

c. more than 20 chargeable services are required by the family unit during any month.

D. Medication. All Medicaid patients are to be provided their medication. Any patient whose adjusted fee is 15 percent or less of the full cost may also be considered eligible to receive medication from the center or clinic. The facility administrator may authorize provision of medication for other patients on presentation of evidence that cost of medication ordered by center physicians will present a serious hardship and exceed three percent of the family's gross income. Documentation of such exceptions and their justification shall be made in the patient's chart and signed by the administrator. This should be reviewed in 90 days or whenever the amount of medication prescribed is reduced appreciably. It will be the responsibility of the physician and nurse reviewing medication orders to so notify the administrator.

E. Failure to Pay Fees. No person shall be denied service because of ability or inability to pay. However, when a patient becomes delinquent in his account, the delinquency shall be handled in accordance with the Department of Health and Human Resources' Policy on Collections. Whenever possible, center or clinic staff shall make an effort to negotiate a plan of payment prior to referring the account to the Department of Health and Human Resources, Bureau of Central Collections. Any negotiated plan of payment shall be approved by the center or clinic administrator and OPRADA fiscal office.

F. Definitions

1. Gross Income means the monthly sum of income received from sources identified by The U.S. Census Bureau in computing the median income and defined in the CFR, Volume 45, Section 228. 66

2. Dependent means all persons dependent on the household income as accepted by the Internal Revenue Service (IRS) for federal income tax purposes. In the case of a minor not claimed as a dependent for income tax purposes, the parents are still responsible for a contribution based on the fee schedule but may increase the dependent deductions by the client(s) in question.

3. Family means the basic family unit consisting of one or more adults and children, if any, related by blood, marriage, or adoption, and residing in the same household. Where related adults, other than spouses, or unrelated adults reside together, each will be considered a separate family, unless they are included as part of the family unit for federal income tax reporting purposes. Children living with nonlegally responsible relatives, emancipated minors, and children living under the care of unrelated persons will be considered as separate family units and will be charged according to the minor's own income whether the source is allowance or earnings.

4. Responsible persons means the client's parents or legal guardians if the client is under the age of 18, unless someone else claims the client as a dependent for federal income tax purposes, in which case it is that person. If the client is over 18, he is responsible for his contribution based on his gross family income and allowed deductions, unless he is claimed as a dependent for income tax purposes, in which case the claimant becomes responsible for the fee toward the cost of care based on the claimant's family income.

G. General Regulations

1. Documentation of income shall include federal and state income tax reports, Medicaid eligibility records, W-2 forms and employer's statements.

2. A person responsible for the payment of charges for services rendered who refuses to supply the information necessary for an accurate determination of the required rate of charges for services rendered shall be presumed to be able to pay the full cost of services rendered and shall be billed accordingly. Any person who is potentially eligible for medical assistance benefits from any federal or state program who refuses to apply for and follow through with application for said benefits shall be presumed to be able to pay the full cost of services rendered and shall be billed accordingly.

3. An insurance company that the responsible party alleges has issued a policy or contract covering the charges for treatment and services rendered shall be billed the full cost of services rendered. Billings shall be made directly to the insurer by the treating facility after securing execution of the forms necessary, including an assignment of benefits to the treatment facility, by the responsible person. The responsible party shall be billed in accordance with the applicable fee schedule up to the amount of charges not covered and paid by insurance. If the responsible person refuses to execute the forms necessary to assign the benefits and the forms necessary to file an insurance claim in accordance with that policy, it shall be presumed that the responsible person is able to pay at the full cost of services rendered and shall be billed accordingly.

4. Collection Procedure

a. If the payment agreement is not kept, a notice shall be mailed 15 days after the due date reminding the responsible party that payment was not received when due.

b. If payment has not been received within 15 days after the first notice was mailed, a second notice shall be sent.

c. If results have not been received within 15 days after the second notice was mailed, a third notice shall be mailed advising the patient that this account will be referred to the Department of Health and Human Resources, Central Collections if payment is not received within 15 days.

d. If payment has not been received 15 days after the third notice was mailed, the account is to be referred to Central Collections for collection. In addition, the following documents and information should be sent: all demographic information accumulated (intake interview sheet); copy of signed agreement; copy of itemized bill; and a copy of the patient's ledger.

e. Only accounts in excess of $25 will be referred to Central Collections for handling. The admitting facility will make every effort to collect outstanding accounts of $25 or less. Only the manager of a facility or his designee may charge off an account in the amount of $25 or less. If the account is in excess of $25, the request for charge off must be submitted through the Central Collections Section for approval by the Office of Management and Finance.

La. Admin. Code tit. 48, § VII-115

Promulgated by the Department of Health and Human Resources, Office of Prevention and Recovery from Alcohol and Drug Abuse, LR 13:246 (April 1987).

AUTHORITY NOTE: Promulgated in accordance with R. S. 36:258(J).