The Department of Health and Human Resources (DHHR), Office of Mental Health (OMH), has adopted uniform policies, rules, and fee scales for outpatient centers and clinics of the Office of Mental Health. Fees will be based on cost and adjusted according to the ability of the recipient to pay.
A. Fee Policy 1. All persons seen for services at an OMH center or clinic shall be assessed a fee for each chargeable service. Chargeable services are those defined as chargeable under Medicaid, 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 |
Code | Service |
00071 | Psychosocial evaluation |
00072 | Psychiatric evaluation |
00073 | Psychological evaluation |
00074 | Physical evaluation |
00075 | Other evaluation assessment service |
00076 | Individual counseling/therapy |
00077 | Group counseling/therapy |
00078 | Family/group counseling/therapy |
00079 | Medication management |
00080 | Medication injection |
00081 | Occupational therapy |
00082 | Recreational therapy |
00083 | Music therapy |
00084 | Art therapy |
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 by the fee clerk at the time the patient is first admitted to the facility. It is the responsibility of the patient and/or his legally responsible family to justify any adjustment to the full fee authorized under this policy. The patient or family will be asked to present reasonable proof of income before any adjustment to the full fee will be made by the fee clerk. 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. Such documentation shall be signed by the fee clerk who verifies the information and sets the adjusted fee. 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: a. state median income as promulgated annually by the Secretary of the United States Department of Health, Education and Welfare;c. cost of service provided [for purposes of this scale the cost of service provided will be that figure currently agreed upon between OMH and the Office of Family Security (OFS) as the cost to be reimbursed under the Medicaid program].2. The fee adjustment schedule will be calculated by OMH based on current state median income each time OMH and OFS 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 150 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% |
4. 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% |
5. In computing each modification of the scale, the OMH will round actual fees to the nearest quarter dollar. Fee adjustment schedules will be computed annually by the central office 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 (no less frequently than annually) with each patient to determine any change in factors including cost changes which would cause change in the fee and adjusted fee. The staff member assigned to the case is also responsible for notifying the fee clerk of such changes as they occur. The fee clerk is authorized to adjust the fee appropriately in accordance with the fee adjustment schedule. The facility administrator is ultimately responsible for assuring that adjusted fees are current and correct.2. No fees 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; orc. more than 20 chargeable services are required by the family unit during any month.D. Medication 1. 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 3 percent of 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 1. 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 DHHR 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 Bureau of Central Collections. Any negotiated plan of payment shall be approved by the center or clinic administrator and OMH fiscal office.Dependent-as used herein, means all persons dependent on the household income as accepted by the Internal Revenue Service (IRS) for federal income tax purpose. 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.
Family-for purposes of establishing fees under the procedures, the basic family unit is defined as 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 non-legally responsible relative, emancipated minors, and children living under the care of unrelated persons will be considered a member of the family. Minors seen without the consent and knowledge of parents or legal guardians 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.
Gross Income-the monthly sum of income received from sources identified by the U. S. Census Bureau in computing the median income and defined in the Code of Federal Regulations, Volume 45, Section 228. 66
Responsible Persons-as used herein, the client's parents or 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. This shall include federal and state income tax reports, Medicaid eligibility records, W-2 forms and employers' statements.2. Failure to Provide Information. 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. Insurance. 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 insured 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 under the policy alleged by him to cover the charges for treatment and services rendered and the forms necessary to file an insurance claim in accordance with the policy, that responsible party shall be presumed to be able to pay at the full cost of services rendered and shall be billed accordingly.4. Collections. If the payment agreement is not kept, 15 days after the due date, a notice is to be mailed reminding the responsible party that payment was not received when due. If results have not been received within 15 days after the first notice was mailed, a second notice is to be sent. If results have not been received within 15 days after the second notice was mailed, a third notice is to be mailed advising the patient that his account will be referred to Central Collections for collection if payment is not received within 15 days. 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. At the time account is referred to Central Collections, the following documents and information should be sent: a. all demographic information accumulated (intake interview sheet);b. copy of signed agreement;c. copy of itemized bill;d. copy of patient's ledger.5. Only accounts in excess of $25 will be referred to Central Collections for handling. The admitting facility will make every effort to collect the $25 or less accounts. Only the director 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. Any request for adjustments in fees which deviate from the uniform fee schedule must be submitted to the undersecretary or his designee for review and decision. All collections received by agency, or institution after assignment of account to Central Collections will be deposited directly to the State Treasurer's Office through the regional bank and a list of all payments, giving patient name and amount paid, will be mailed to Central Collections on a weekly basis. Accounts will be referred to Central Collections when an insurance company refuses to pay a bill for any reason which is not clearly valid. Upon receipt of an account, Central Collections will send a series of collection letters and make telephone contacts with individuals regarding payments. If account is not brought current within 60 days or a satisfactory payment schedule arranged, the account will be assigned to an attorney for collection or charged off as a bad debt if total outstanding balance is less than $100.La. Admin. Code tit. 48, § III-305
Promulgated by the Department of Health and Human Resources, Office of Mental Health, LR 13:246 (April 1987).AUTHORITY NOTE: Promulgated in accordance with R.S. 28:144.