CHAPTER 4305. LIABILITY FOR COMMUNITY MENTAL HEALTH AND INTELLECTUAL DISABILITY SERVICES
GENERAL PROVISIONS Sec.
4305.1. General.
4305.2. Purpose.
4305.3. Applicability.
4305.4. Definitions.
4305.5. Legal base.
4305.6. [Reserved].
4305.7. [Reserved].
4305.8. [Reserved].
4305.9. [Reserved].
4305.10. [Reserved].
GENERAL REQUIREMENTS
4305.11. Exempt services.
4305.12. Exemptions from liability.
4305.13. Nonexempt service.
4305.14. Application of Internal Revenue Service regulations.
4305.15. Delegation of authority.
4305.16. Copy of this chapter to client.
4305.17. Eligibility of expenditures.
4305.18. Review and audit by the Department.
4305.19. Quarterly reports.
4305.19a. Quarterly liability summaries—statement of policy.
4305.20. Missed mental health appointments.
4305.21. Contributions.
DETERMINATION OF LIABILITY
4305.31. Determinations.
4305.32. Exemptions from determinations.
4305.33. Income to be considered.
4305.34. Income not considered.
4305.35. Income.
4305.36. Deductions.
4305.37. Adjusted family income.
4305.38. Verification.
4305.39. Failure to provide verification.
4305.40. Redeterminations.
4305.41. Liability.
4305.42. More than one client receiving service.
4305.43. Client receiving more than one service.
4305.44. Notice of liability.
BILLING FOR LIABILITY
4305.51. Billing.
4305.52. Insurance.
ADJUSTMENT OF LIABILITY
4305.61. Request for adjustment of liability.
4305.62. Review of requests for adjustment of liability.
4305.63. Reason for adjustment of liability—loss of benefits.
4305.64. Reason for adjustment of liability—substantial financial hardship.
4305.65. Reason for adjustment of liability—financial burden upon Commonwealth.
4305.66. Reason for adjustment of liability—nullify result of care.
4305.67. Decisions on requests for adjustment of liability.
4305.68. Notification of adjustment decision.
4305.69. Appeals.
COLLECTION OF PAST DUE ACCOUNTS
4305.81. Payment plans.
4305.82. Identification of past due account.
4305.83. Cost of service.
4305.84. Collection process.
WRITE-OFF OF PAST DUE ACCOUNT
4305.91. Write-off conditions.
4305.92. Justification of write-offs.
4305.93. Approval of write-offs.
4305.94. Write-off of past due account.
MENTAL HEALTH CLIENT FEE SCHEDULES
4305.101. Applicability.
4305.102. Content of the mental health client fee schedule.
4305.103. Audit of the mental health client fee schedule.Authority The provisions of this Chapter 4305 amended and reissued under sections 201(2) and 504(d) of the Mental Health and Mental Retardation Act of 1966 (50 P.S. § § 4201(2) and 4504(d)), unless otherwise noted.
Source The provisions of this Chapter 4305 amended and reissued January 2, 1987, effective January 3, 1987, 17 Pa.B. 47, unless otherwise noted. Immediately preceding text appears at serial pages (109612), (98059) to (98060), (88841), (79353) to (79354), (88843) to (88844), (79357) to (79358), (105529) to (105534), (88847) to (88848) and (79365) to (79372).
Cross References This chapter cited in 55 Pa. Code § 4210.113 (relating to client liability); 55 Pa. Code § 4300.117 (relating to computation of reimbursement); 55 Pa. Code § 4300.118 (relating to special limitations on unit of service funding); 55 Pa. Code § 4300.148 (relating to uncollected revenue); and 55 Pa. Code § 6350.16 (relating to waiver option).
GENERAL PROVISIONS
§ 4305.1. General.
One of the primary goals of the public mental health and intellectual disability program is to provide easy access to treatment or habilitation services and to encourage people to seek help.
Authority The provisions of this § 4305.1 amended under sections 201(2) and (8) and 202 of the Mental Health and Intellectual Disability Act of 1966 (50 P.S. § § 4201(2) and (8) and 4202).
Source The provisions of this § 4305.1 amended June 17, 2016, effective June 18, 2016, 46 Pa.B. 3177. Immediately preceding text appears at serial page (211837).
§ 4305.2. Purpose.
The purpose of this chapter is to specify the liability and describe the procedures for establishing and collecting liability for clients receiving community mental health or intellectual disability services funded in whole or in part through the county mental health and intellectual disability program.
Authority The provisions of this § 4305.2 amended under sections 201(2) and (8) and 202 of the Mental Health and Intellectual Disability Act of 1966 (50 P.S. § § 4201(2) and (8) and 4202).
Source The provisions of this § 4305.2 amended June 17, 2016, effective June 18, 2016, 46 Pa.B. 3177. Immediately preceding text appears at serial page (211837).
§ 4305.3. Applicability.
(a) This chapter applies to county mental health and intellectual disability programs.
(b) This chapter does not apply to a client who is receiving services covered by Medical Assistance under the Commonwealth’s Medical Assistance Program.
Authority The provisions of this § 4305.3 amended under sections 201(2) and (8) and 202 of the Mental Health and Intellectual Disability Act of 1966 (50 P.S. § § 4201(2) and (8) and 4202).
Source The provisions of this § 4305.3 amended June 17, 2016, effective June 18, 2016, 46 Pa.B. 3177. Immediately preceding text appears at serial page (211837).
§ 4305.4. Definitions.
The following words and terms, when used in this chapter, have the following meanings, unless the context clearly indicates otherwise:
Base service unit—The functional unit responsible for assessing and evaluating client needs, planning comprehensive treatment programs and making available the necessary services on a continuing basis.
County administrator—The administrator of the county mental health and intellectual disability program, or a designee.
Intellectual disability professional—A case manager or an individual who is responsible for the clinical treatment program for the client.
Liability—The maximum monthly amount the liable person is charged toward the cost of service for the client. The term does not include the cost of the client’s room or board.
Liable person—The person responsible for payment of the liability. The term includes the following persons:(i) If the client is 18 years of age or older, the client is not married and the client does not have a legal guardian of estate or a representative payee, the client is the liable person.
(ii) If the client is married, and the client does not have a legal guardian of estate or a representative payee, the client and the client’s spouse are the liable persons.
(iii) If the client is under 18 years of age, the client is not married, the client is not an emancipated minor and the client does not have a legal guardian of estate or a representative payee, both of the client’s parents are the liable persons.
(iv) If the client is under 18 years of age, the client is not married, the client is an emancipated minor and the client does not have a legal guardian of estate or a representative payee, the client is the liable person.
(v) If the client has a legal guardian of estate or a representative payee, the legal guardian of estate or the representative payee is the liable person.
Mental health client fee schedule—A list of the provider’s usual and customary charges to the general public for a unit of service.
Mental health professional—An individual practicing in a generally recognized clinical discipline including, but not limited to, psychiatry, social work, psychology, nursing, rehabilitation or activity therapies, who has a graduate degree and clinical experience.
Net charge—The amount the provider bills for services provided.Outpatient unit of service—One-half hour of treatment in a licensed mental health outpatient clinic/program.
Parent—A biological or adoptive mother or father of the client.
Partial hospitalization unit of service—Three hours per day of treatment in a licensed mental health partial hospitalization program.
Representative payee—A person or an organization selected by a benefit issuing agency to receive and manage benefits on behalf of a beneficiary.
Authority The provisions of this § 4305.4 amended under sections 201(2) and (8) and 202 of the Mental Health and Intellectual Disability Act of 1966 (50 P.S. § § 4201(2) and (8) and 4202).
Source The provisions of this § 4305.4 amended June 17, 2016, effective June 18, 2016, 46 Pa.B. 3177. Immediately preceding text appears at serial pages (211837) to (211838).
Cross References This section cited in 55 Pa. Code § 4300.117 (relating to computation of reimbursement).
§ 4305.5. Legal base.
The legal authority for this chapter is sections 201(2) and 504(d) of the Mental Health and Intellectual Disability Act of 1966 (50 P.S. § § 4201(2) and 4504(d)).
Authority The provisions of this § 4305.5 amended under sections 201(2) and (8) and 202 of the Mental Health and Intellectual Disability Act of 1966 (50 P.S. § § 4201(2) and (8) and 4202).
Source The provisions of this § 4305.5 amended June 17, 2016, effective June 18, 2016, 46 Pa.B. 3177. Immediately preceding text appears at serial page (211838).
§ 4305.6. [Reserved].
§ 4305.7. [Reserved].
§ 4305.8. [Reserved].
§ 4305.9. [Reserved].
§ 4305.10. [Reserved].
GENERAL REQUIREMENTS
§ 4305.11. Exempt services.
The following mental health and intellectual disability community services are exempt from liability requirements specified in the chapter:
(1) Vocational, as defined in Chapter 2390 (relating to vocational facilities).
(2) Early intervention, as defined in Chapter 4226 (relating to early intervention services).
(3) Adult day care, as defined in Chapter 2380 (relating to adult training facilities).
(4) Respite care, as defined in Chapters 6350 and 6400 (relating to family resource services; and community homes for individuals with an intellectual disability).
(5) Family aid services, as defined in Chapter 6350.
(6) In-home therapy, as defined in Chapter 6350.
(7) Homemaker services, as defined in Chapter 6350.
(8) Family education and training, as defined in Chapter 6350.
(9) Recreation/leisure activities, as defined in Chapter 6350.
(10) Specialized vocational training services that are outside the scope of Chapter 2390.
(11) Other intellectual disability family support services including and limited to sitter and companionship services, parent and family training, speech therapy, aural rehabilitation, hearing aid evaluations, dactylogic therapy, physical therapy, occupational therapy, mobility training, behavioral programming, adaptive appliances, special diets and home rehabilitation.
Authority The provisions of this § 4305.11 amended under sections 201(2) and (8) and 202 of the Mental Health and Intellectual Disability Act of 1966 (50 P.S. § § 4201(2) and (8) and 4202).
Source The provisions of this § 4305.11 amended June 17, 2016, effective June 18, 2016, 46 Pa.B. 3177. Immediately preceding text appears at serial page (296229).
Cross References This section cited in 55 Pa. Code § 4305.13 (relating to nonexempt service); 55 Pa. Code § 4305.31 (relating to determinations); and 55 Pa. Code § 4305.32 (relating to exemptions from determinations).
§ 4305.12. Exemptions from liability.
(a) No liability may be charged for the initial contact. The initial contact is defined as the face-to-face interview or another contact made with a person authorized to determine the need for diagnostic and treatment services, to make arrangements for services and to complete the initial liability determination process.
(b) In addition to the initial contact, six psychiatric outpatient or five partial hospitalization units of service to children and adolescents will be exempt from liability. One exemption period will be allowed for each 3 years from the date of first entry into the service until the age of 18, if the following conditions are met:
(1) The liable person has no third party coverage for psychiatric outpatient or partial hospitalization services.
(2) The liable person has an adjusted family income liability of $100 or less per month.
§ 4305.13. Nonexempt service.
Liability requirements specified in this chapter apply to a mental health and intellectual disability community service not listed in § 4305.11 (relating to exempt services).
Authority The provisions of this § 4305.13 amended under sections 201(2) and (8) and 202 of the Mental Health and Intellectual Disability Act of 1966 (50 P.S. § § 4201(2) and (8) and 4202).
Source The provisions of this § 4305.13 amended June 17, 2016, effective June 18, 2016, 46 Pa.B. 3177. Immediately preceding text appears at serial page (296230).
§ 4305.14. Application of Internal Revenue Service regulations.
Internal Revenue Service statutes, regulations or standards in this chapter are defined as those in effect in calendar year 1986. Subsequent changes in those statutes, regulations or standards are not incorporated by reference. Changes will be incorporated by amendment to this chapter.
§ 4305.15. Delegation of authority.
(a) The county administrator has the authority to delegate the functions required in this chapter to base service units or providers of community mental health and intellectual disability services, except for the functions of adjusting liability amounts specified in § § 4305.61—4305.69 (relating to adjustment of liability) and write-off of past due accounts specified in § § 4305.91—4305.94 (relating to write-off of past due account).
(b) If functions required in this chapter are delegated to providers of community mental health and intellectual disability services, the county administrator shall retain responsibility for compliance with the requirements of this chapter.
Authority The provisions of this § 4305.15 amended under sections 201(2) and (8) and 202 of the Mental Health and Intellectual Disability Act of 1966 (50 P.S. § § 4201(2) and (8) and 4202).
Source The provisions of this § 4305.15 amended June 17, 2016, effective June 18, 2016, 46 Pa.B. 3177. Immediately preceding text appears at serial page (296230).
§ 4305.16. Copy of this chapter to client.
The county administrator shall offer the liable person a copy of this chapter during the initial liability determination meeting and advise of the right to appeal a liability determination.
§ 4305.17. Eligibility of expenditures.
Expenditures by a county mental health and intellectual disability program on behalf of a client are eligible for reimbursement by the Department only if a liability has been billed and collection has been pursued according to the requirements specified in this chapter.
Authority The provisions of this § 4305.17 amended under sections 201(2) and (8) and 202 of the Mental Health and Intellectual Disability Act of 1966 (50 P.S. § § 4201(2) and (8) and 4202).
Source The provisions of this § 4305.17 amended June 17, 2016, effective June 18, 2016, 46 Pa.B. 3177. Immediately preceding text appears at serial page (211841).
§ 4305.18. Review and audit by the Department.
The liability determination, billing and collection process and forms and documents required in this chapter, are subject to review and audit by the Department.
§ 4305.19. Quarterly reports.
The county administrator shall submit a summary of adjustments of liability and write-offs of liability to the Department on a quarterly basis. The summary shall be submitted on forms prescribed by the Department.
§ 4305.19a. Quarterly liability summaries—statement of policy.
(a) Form MH/MR 877, titled ‘‘Liability Decision Summary Face Sheet’’ and Form MH/MR 883, titled ‘‘Summary of Write-Offs’’ shall be submitted by counties to the following addresses:
Office of Mental Health:
Office of Community Programs Liability Write-Off Reports Room 308, Health and Welfare Building Harrisburg, Pennsylvania 17120
Office of Mental Retardation:
The following appropriate Regional Mental Retardation Program Manager:
Regional Mental Retardation Program Manager Southeast Region 306 State Office Building 1400 Spring Garden Street Philadelphia, Pennsylvania 19130
Regional Mental Retardation Program Manager Northeast Region 100 Lackawanna Avenue Third Floor, Room 315 Scranton, Pennsylvania 18503
Regional Mental Retardation Program Manager Central Region 2330 Ararat BoulevardPost Office Box 2675 Harrisburg, Pennsylvania 17105
Regional Mental Retardation Program Manager Western Region 1403 State Office Building 300 Liberty Avenue Pittsburgh, Pennsylvania 15222
(b) Forms MH/MR 877 and MH/MR 883 are due on a quarterly basis on July 10, October 10, January 10 and April 10 of each year. If there are no write-offs or adjustments, reports indicating ‘‘none’’ shall be submitted.
Source The provisions of this § 4305.19a adopted February 5, 1988, effective January 29, 1988, 18 Pa.B. 596.
§ 4305.20. Missed mental health appointments.
If there is failure to give 24-hour notice of cancellation of a mental health service appointment, the service provider has the authority to bill the liable person the client fee schedule amount for the mental health service. This billing may not be deducted from the liability.
§ 4305.21. Contributions.
Contributions made to the county mental health and intellectual disability program or the provider by charitable organizations, friends or neighbors on behalf of the client toward the cost of care shall be treated as payment by the liable person. Contributions may not be counted as income to the client as part of the total family income.
Authority The provisions of this § 4305.21 amended under sections 201(2) and (8) and 202 of the Mental Health and Intellectual Disability Act of 1966 (50 P.S. § § 4201(2) and (8) and 4202).
Source The provisions of this § 4305.21 amended June 17, 2016, effective June 18, 2016, 46 Pa.B. 3177. Immediately preceding text appears at serial page (211842).
DETERMINATION OF LIABILITY
§ 4305.31. Determinations.
(a) The county administrator shall determine a liability for clients receiving a community mental health or intellectual disability service funded in whole or in part through the county mental health or intellectual disability program that is not listed as an exempt service in § 4305.11 (relating to exempt services).
(b) The liability shall be determined prior to client referral to or placement into community mental health and intellectual disability services, except for emergency referrals or placements in which the liability shall be determined within 15 days after emergency referral or placement.
Authority The provisions of this § 4305.31 amended under sections 201(2) and (8) and 202 of the Mental Health and Intellectual Disability Act of 1966 (50 P.S. § § 4201(2) and (8) and 4202).
Source The provisions of this § 4305.31 amended June 17, 2016, effective June 18, 2016, 46 Pa.B. 3177. Immediately preceding text appears at serial page (211842).
§ 4305.32. Exemptions from determinations.
The county administrator may not determine a liability if a client is receiving or is expected to receive only services listed as exempt services in § 4305.11 (relating to exempt services).
§ 4305.33. Income to be considered.
(a) If the client is 18 years of age or older and the client is not married, the client’s income alone shall be considered the total family income.
(b) If the client is married, the client’s income and the client’s spouse’s income shall be combined to determine the total family income.
(c) If the client is under 18 years of age, the client is not married, and the client is not an emancipated minor, the client’s income that is in excess of the Internal Revenue Service tax threshold, and both parents’ income shall be combined to determine the total family income.
(d) If the client is under 18 years of age, the client is not married, and the client is an emancipated minor, the client’s income alone shall be considered the total family income.
(e) If the parents of an unmarried, nonemancipated client under 18 years of age are separated or divorced and have a legally binding financial agreement, the parents are individually financially responsible in accordance with the terms of that financial agreement. If the client earns more than the Internal Revenue Service tax threshold, the client’s income that is in excess of the Internal Revenue Service tax threshold shall be included in the total family income of the parent who has legal custody of the client. If there is joint custody, the client’s income that is in excess of the Internal Revenue Service tax threshold shall be divided equally and included in the total family income of both parents.
(f) If the parents of an unmarried, nonemancipated client under 18 years of age are separated or divorced and there is no legally binding financial agreement, a separate total family income shall be determined for each parent. If the client earns more than the Internal Revenue Service tax threshold, the client’s income that is in excess of the Internal Revenue Service tax threshold shall be included in the total family income of the parent who has legal custody of the client. If there is joint custody, the client’s income that is in excess of the Internal Revenue Service tax threshold shall be divided equally and included in the total family income of both parents.
(g) Parents who adopt children under the Pennsylvania Adoption Assistance program, § 3140.207 (relating to entitlement to other services and benefits), have no liability for mental health and intellectual disability services. The child shall be considered a family of one and liability shall be determined based on the income of the child.
Authority The provisions of this § 4305.33 amended under sections 201(2) and (8) and 202 of the Mental Health and Intellectual Disability Act of 1966 (50 P.S. § § 4201(2) and (8) and 4202).
Source The provisions of this § 4305.33 amended June 17, 2016, effective June 18, 2016, 46 Pa.B. 3177. Immediately preceding text appears at serial page (211843).
Cross References This section cited in 55 Pa. Code § 4305.34 (relating to income not considered).
§ 4305.34. Income not considered.
(a) Income that is not specified in § 4305.33 (relating to income to be considered) may not be considered as part of the total family income.
(b) Income of the financial guardian or representative payee may not be considered as part of the total family income unless the financial guardian or representative payee is the spouse of the client or the parent of a client under 18 years of age.
§ 4305.35. Income.
The following income from the previous calendar year shall be combined to determine the total family income.
(1) Wages, salaries, fees, commissions, tips, bonuses, net rental income, net business income and other income subject to Federal income taxation.
(2) Interest income including, but not limited to, interest received from accounts with banks, savings and loan associations, money market funds, credit unions or bonds.
(3) Dividends received from corporate stock holdings or cash dividends from life insurance policies.
(4) Benefits, including but not limited to unemployment compensation, Social Security payments, Supplemental Security Income received by clients 18 years or older, public assistance, pensions, black lung benefits and railroad retirement pensions. Restricted benefits are counted as income only if the benefit is paid on behalf of the client. Food Stamps are not counted as income.
(5) Alimony payments.
(6) One hundred percent of a net capital gain. The net capital gain is considered as the total capital gain less the total capital loss for the year.
Cross References This section cited in 55 Pa. Code § 4305.37 (relating to adjusted family income).
§ 4305.36. Deductions.
(a) The following amounts from the previous calendar year shall be deducted from the total family income.
(1) Actual Federal, State and local taxes paid.
(2) Mandatory payroll deductions.
(3) Real estate taxes on the principal residence.
(4) Health insurance premiums.
(5) Verified medical expenses exceeding 5.0% of total family income.
(6) Verified child care costs, up to Internal Revenue Service limits.
(7) Child support payments for the client made directly to the facility in which the child is in residence.
(8) Net business losses claimed on the previous year’s Internal Revenue Service form.
(9) A family living allowance of $9,000.
(b) An individual allowance equal to the prevailing Internal Revenue Service dependent deduction amount for a person who is currently eligible to be claimed as a dependent on this calendar year’s Internal Revenue Service form, shall also be deducted from the total family income.
Cross References This section cited in 55 Pa. Code § 4305.37 (relating to adjusted family income); and 55 Pa. Code § 4305.64 (relating to reason for adjustment of liability—substantial financial hardship).
§ 4305.37. Adjusted family income.
The adjusted family income shall be the total family income specified in § 4305.35 (relating to income) minus the deductions specified in § 4305.36 (relating to deductions).
§ 4305.38. Verification.
Income and deductions shall be verified by written documentation, such as income tax statements, pay stubs, written employer statements or by affidavit. Copies of these verification documents shall be kept on file.
§ 4305.39. Failure to provide verification.
If the liable person fails to provide written verification of income and deductions, the county administrator shall bill for the full cost of service.
§ 4305.40. Redeterminations.
(a) The county administrator shall inform the liable person in writing that increases or decreases in monthly income of greater than 5.0% shall be reported by the liable person to the county within 30 days of the income change.
(b) The county administrator shall complete a redetermination of the liability for a client at least once every 12 months.
(c) The county administrator shall complete a redetermination of the liability for a client more frequently than every 12 months if the adjusted family income amount increases or decreases by more than 5.0% on an annualized basis. The redetermination shall be based upon the revised adjusted family income. The liability resulting from redetermination shall be retroactive to the date of the income change.
§ 4305.41. Liability.
(a) The liability shall be the amount listed in Appendixes A and B based on the adjusted family income.
(b) If the liability amount listed in Appendixes A or B—nonresidential services or residential and short-term inpatient services—exceeds 12.5% of the total monthly family income, the liability shall be 12.5% of the total monthly income. Total monthly family income shall be determined on an annualized basis.
(c) The amount billed may not exceed the actual cost of the service provided.
§ 4305.42. More than one client receiving service.
(a) If more than one client in the family is receiving services, only one liability shall be determined and billed.
(b) If at least one client in the family is receiving community mental health or intellectual disability residential services or short-term inpatient services, the liability shall be the amount listed in Appendix B.
(c) If clients in the family are receiving only community mental health or intellectual disability nonresidential services, the liability shall be the amount listed in Appendix A.
Authority The provisions of this § 4305.42 amended under sections 201(2) and (8) and 202 of the Mental Health and Intellectual Disability Act of 1966 (50 P.S. § § 4201(2) and (8) and 4202).
Source The provisions of this § 4305.42 amended June 17, 2016, effective June 18, 2016, 46 Pa.B. 3177. Immediately preceding text appears at serial page (211846).
§ 4305.43. Client receiving more than one service.
(a) If services received by the client in a calendar month are community mental health and intellectual disability nonresidential services or noninpatient services, the liability shall be the amount listed in Appendix A.
(b) If services received by the client in a calendar month are community mental health and intellectual disability residential services or short-term inpatient services, even if community mental health and intellectual disability nonresidential services or short-term inpatient services are also provided, the liability shall be the amount listed in Appendix B.
Authority The provisions of this § 4305.431 amended under sections 201(2) and (8) and 202 of the Mental Health and Intellectual Disability Act of 1966 (50 P.S. § § 4201(2) and (8) and 4202).
Source The provisions of this § 4305.43 amended June 17, 2016, effective June 18, 2016, 46 Pa.B. 3177. Immediately preceding text appears at serial page (211846).
§ 4305.44. Notice of liability.
At the time the liability is determined, a written notice of the liability shall be given to the liable person on a form prescribed by the Department.
BILLING FOR LIABILITY
§ 4305.51. Billing.
(a) The county administrator shall bill the liable person each month that community mental health and intellectual disability services are received.
(b) If the liability exceeds the actual cost of intellectual disability services or the net charge for mental health services received for a month, the county administrator shall bill the liable person for the actual cost of intellectual disability services or the net charge for mental health services received.
Authority The provisions of this § 4305.51 amended under sections 201(2) and (8) and 202 of the Mental Health and Intellectual Disability Act of 1966 (50 P.S. § § 4201(2) and (8) and 4202).
Source The provisions of this § 4305.51 amended June 17, 2016, effective June 18, 2016, 46 Pa.B. 3177. Immediately preceding text appears at serial page (211846).
§ 4305.52. Insurance.
(a) If a client is receiving or is expected to receive a community mental health or intellectual disability service, or both, that is eligible for insurance, the county administrator or the provider of service shall bill the insurance company for the service prior to billing the liable person. The amount received from the insurance company for services provided over a calendar month shall be deducted from the liability for intellectual disability services or the client fee schedule per unit times the number of units delivered that month for mental health services. The liable person shall be billed the remainder up to the liability.
(b) If insurance benefits are not assignable, the provider shall bill the liable person for the total amount of the liability or the amount the insurance company will pay, whichever is greater, and shall assist the person in completing the insurance forms if necessary or requested.
Authority The provisions of this § 4305.52 amended under sections 201(2) and (8) and 202 of the Mental Health and Intellectual Disability Act of 1966 (50 P.S. § § 4201(2) and (8) and 4202).
Source The provisions of this § 4305.52 amended June 17, 2016, effective June 18, 2016, 46 Pa.B. 3177. Immediately preceding text appears at serial pages (211846) to (211847).
ADJUSTMENT OF LIABILITY
§ 4305.61. Request for adjustment of liability.
(a) The liable person has the right to request adjustment of liability.
(b) Requests for adjustment of liability shall be made within 30 calendar days of the time that conditions warranting the adjustment occur.
(c) Requests for adjustment of liability shall be made by the liable person, the client, or the mental health or intellectual disability professional.
(d) Requests for adjustment of liability shall be submitted to the county administrator on a form prescribed by the Department.
Authority The provisions of this § 4305.61 amended under sections 201(2) and (8) and 202 of the Mental Health and Intellectual Disability Act of 1966 (50 P.S. § § 4201(2) and (8) and 4202).
Source The provisions of this § 4305.61 amended June 17, 2016, effective June 18, 2016, 46 Pa.B. 3177. Immediately preceding text appears at serial page (211847).
Cross References This section cited in 55 Pa. Code § 4305.15 (relating to delegation of authority).
§ 4305.62. Review of requests for adjustment of liability.
The county administrator shall review requests for adjustment of liability.
Cross References This section cited in 55 Pa. Code § 4305.15 (relating to delegation of authority).
§ 4305.63. Reason for adjustment of liability—loss of benefits.
The county administrator shall have the power to reduce or eliminate the liability if the payment of the liability would make the client ineligible for benefits or payments.
Cross References This section cited in 55 Pa. Code § 4305.15 (relating to delegation of authority); and 55 Pa. Code § 4305.67 (relating to decisions on requests for adjustment of liability).
§ 4305.64. Reason for adjustment of liability—substantial financial hardship.
(a) The county administrator shall have the power to reduce or eliminate the liability if the payment of the liability would cause substantial financial hardship on the client, a person owing a legal duty to support the person or the family of either.
(b) The following debt payments may not be considered when deciding if there is a substantial financial hardship.
(1) Mortgage or rent on principal residence.
(2) Utility payments.
(3) Automobile payments.
(4) Medical expenses already deducted under § 4305.36(5) (relating to deductions).
(5) Insurance premiums.
(6) A debt payment for which the liable person has not incurred a legal obligation to pay.
(7) Retail charge purchases for personal items, food and commodities.
(8) Debts incurred after treatment has begun if services are provided for less than 365-consecutive days.
(9) Debts not paid on a regularly scheduled basis.
(c) A debt not listed in subsection (b) shall be considered as allowable debt payments in reviewing the request for adjustment of the liability based upon substantial financial hardship.
(d) Debts caused by the cost of college or graduate school education may be considered as allowable debt payments in reviewing the request for adjustment of liability based upon substantial financial hardship.
(e) Debts caused by unforeseen circumstances over which the person has no control, such as loss from fire or flood not covered by insurance, shall be considered in reviewing the request for adjustment of the liability based upon substantial financial hardship.
(f) The county administrator shall compute the liability adjustment for substantial financial hardship as follows:
(1) If the amount of annual allowable debt payments divided by the adjusted family income amount exceeds or is equal to .8, the liability shall be eliminated.
(2) If the amount of annual allowable debt payments divided by the adjusted family income amount is less than .8, but greater than or equal to .7, the liability shall be reduced by 75%.
(3) If the amount of annual allowable debt payments divided by the adjusted family income amount is less than .7, but greater than or equal to .6, the liability shall be reduced by 50%.
(4) If the amount of annual allowable debt payments divided by the adjusted family income amount is less than .6, but greater than or equal to .5, the liability shall be reduced by 25%.
(5) If the amount of annual allowable debt payments divided by the adjusted family income amount is less than .5, the liability may not be adjusted.
Notes of Decisions Since the regulations providing for determination of parents’ liability for mentally retarded son’s care in State institution have a rational basis, relating payment to discretionary income of liable party, the regulations do not violate equal protection. Faix v. Department of Public Welfare, 499 A.2d 411 (Pa. Cmwlth. 1985).
Regulations providing for determination of parent’s liability for mentally retarded son’s care in State institution are valid since they were promulgated to recover public funds whenever possible under section 501 of the Mental Health and Mental Retardation Act of 1966 (50 P.S. § 4501), thus evincing a rational relationship to a legitimate governmental interest. Faix v. Department of Public Welfare, 499 A.2d 411 (Pa. Cmwlth. 1985).
Cross References This section cited in 55 Pa. Code § 4305.15 (relating to delegation of authority); and 55 Pa. Code § 4305.67 (relating to decisions on requests for adjustment of liability).
§ 4305.65. Reason for adjustment of liability—financial burden upon Commonwealth.
The county administrator shall have the power to reduce or eliminate the liability if the payment of the liability would result in greater financial burden upon the Commonwealth.
Cross References This section cited in 55 Pa. Code § 4305.15 (relating to delegation of authority); and 55 Pa. Code § 4305.67 (relating to decisions on requests for adjustment of liability).
§ 4305.66. Reason for adjustment of liability—nullify result of care.
(a) The county administrator shall have the power to reduce or eliminate the liability if the imposition of the liability would create a financial burden upon the client as to nullify the results of care, treatment, service or other benefits.
(b) Requests for an adjustment of the liability due to nullification of the result of care shall include documentation by a mental health/intellectual disability professional justifying the clinical reasons for the request and how the client’s welfare would be seriously harmed if the liability is not adjusted.
Authority The provisions of this § 4305.66 amended under sections 201(2) and (8) and 202 of the Mental Health and Intellectual Disability Act of 1966 (50 P.S. § § 4201(2) and (8) and 4202).
Source The provisions of this § 4305.66 amended June 17, 2016, effective June 18, 2016, 46 Pa.B. 3177. Immediately preceding text appears at serial page (375695).
Cross References This section cited in 55 Pa. Code § 4305.15 (relating to delegation of authority); and 55 Pa. Code § 4305.67 (relating to decision on requests for adjustment of liability).
§ 4305.67. Decisions on requests for adjustment of liability.
(a) The county administrator shall make a decision on a request for adjustment of the liability within 30 calendar days of receipt of the request.
(b) The county administrator shall make a decision on requests for adjustment of the liability based upon the requirements specified in § § 4305.63—4305.66.
Cross References This section cited in 55 Pa. Code § 4305.15 (relating to delegation of authority).
§ 4305.68. Notification of adjustment decision.
(a) The county administrator shall notify the liable person of the adjustment decision in writing within 30 calendar days of receipt of the request.
(b) The written notice of the adjustment decision shall include the decision, the reasons for decision, the new liability if applicable, the length of time the new liability will be in effect not to exceed 12 months, a copy of the prescribed appeal form and the appeal rights and procedures in accordance with § 4305.69 (relating to appeals).
Cross References This section cited in 55 Pa. Code § 4305.15 (relating to delegation of authority).
§ 4305.69. Appeals.
(a) The liable person has the right to file a written appeal for a fair hearing to review the county administrator’s adjustment decision within 30 calendar days of the date the decision is mailed.
(b) The written request for appeal and reasons for the appeal shall be submitted directly to the Office of Hearings and Appeals, Department of Human Services, Post Office Box 2675, Harrisburg, Pennsylvania 17105, on a form prescribed by the Department.
(c) The county administrator shall participate in any fair hearings conducted by the Office of Hearings and Appeals.
Cross References This section cited in 55 Pa. Code § 4305.15 (relating to delegation of authority); and 55 Pa. Code § 4305.68 (relating to notification of adjustment decision).
COLLECTION OF PAST DUE ACCOUNTS
§ 4305.81. Payment plans.
The county administrator shall attempt to establish a payment plan for a liable person who is unable to pay the bill immediately upon receipt of the bill.
§ 4305.82. Identification of past due account.
An account is considered past due if the following exist:
(1) A bill was sent and payment was not received within 90 calendar days.
(2) Request for adjustment of liability has not been received or no payment plan has been agreed to and followed.
§ 4305.83. Cost of service.
If there is a past due account for a client, the Department will not participate in the cost of future service for that client.
§ 4305.84. Collection process.
(a) The county administrator shall attempt to collect a past due account by mailing three successive dunning statements notifying the liable person that the account is past due and requesting payment. The statements shall be mailed at 10 day intervals. During a period not to exceed 45 calendar days after mailing the first dunning statement, effort shall be made by telephone or personal contact with the liable person concerning the past due account.
(b) If the requirements in subsection (a) have been completed and the past due account exceeds $150, the past due account shall be referred to a private collection agency familiar with the collection of debts arising from medical or social services for collection.
(c) If the requirements in subsection (a) have been completed and the past due account amount is $150 or less, the past due account may be written off.
Cross References This section cited in 55 Pa. Code § 4305.91 (relating to write-off conditions).
WRITE-OFF OF PAST DUE ACCOUNT
§ 4305.91. Write-off conditions.
The past due account may be considered for write-off if the following conditions are met:
(1) The requirements of § 4305.84 (relating to collection process) have been met.
(2) An account balance continues to exist.
(3) No payment plan has been agreed to or the agreed-to payment plan is not being followed.
Cross References This section cited in 55 Pa. Code § 4305.15 (relating to delegation of authority).
§ 4305.92. Justification of write-offs.
The write-off of a past due account shall be justified by at least one of the following considerations:
(1) There is an adverse court decision under similar factual situations or an adverse legal opinion prepared by the county solicitor or a designee.
(2) There is doubt as to collectibility.
Cross References This section cited in 55 Pa. Code § 4305.15 (relating to delegation of authority).
§ 4305.93. Approval of write-offs.
(a) The county administrator is responsible for approving write-offs. By approving a write-off, the county administrator is certifying that the requirements in this chapter have been met and the account is deemed uncollectible.
(b) The county administrator shall respond in writing to a request for a write-off within 15 days of receipt of the request.
(c) Documentation supporting the county administrator’s decision to approve or deny a write-off shall be kept. This shall include a record of the collection effort and relevant comments and recommendations.
Cross References This section cited in 55 Pa. Code § 4305.15 (relating to delegation of authority).
§ 4305.94. Write-off of past due account.
The write-off of a past due account does not absolve the liable person from payment of a past due account.
Cross References This section cited in 55 Pa. Code § 4305.15 (relating to delegation of authority).
MENTAL HEALTH CLIENT FEE SCHEDULES
§ 4305.101. Applicability.
The requirements specified in § § 4305.102 and 4305.103 (relating to content of the mental health client fee schedule; and audit of the mental health client fee schedule) are applicable only for clients receiving community mental health services.
§ 4305.102. Content of the mental health client fee schedule.
(a) A provider of service and a county mental health program providing services to county mental health program clients shall establish a fee schedule of charges known as ‘‘client fee schedule’’. This client fee schedule shall state a rate per unit of service and shall reflect as accurately as possible the cost of service. The cost of providing service is expected to vary from provider to provider depending on the nature of the services provided, the combination of personnel who provide these services and the client target group being served.
(b) The client fee schedule may not be higher than the fee schedule used by the provider for its private clients.
(c) The client fee schedule rate may exceed the county program rate of reimbursement.
Cross References This section cited in 55 Pa. Code § 4305.101 (relating to applicability).
§ 4305.103. Audit of the mental health client fee schedule.
Cost of service and client fee schedules based on these costs are subject to audit by the Commonwealth.
Cross References This section cited in 55 Pa. Code § 4305.101 (relating to applicability).
APPENDIX A
Monthly Liability for Community Mental Health
and Intellectual Disability Nonresidential Services
Adjusted
Family IncomeNumber of Dependents 1 2 3 4 5 6 7 8 9 10 0- 499 0 0 0 0 0 0 0 0 0 0 500- 999 10 9 8 7 6 5 4 3 2 1 1000-1499 20 17 14 12 10 8 6 5 4 3 1500-1999 30 25 20 16 13 11 9 7 5 4 2000-2499 40 34 29 25 22 19 16 13 11 9 2500-2999 50 43 37 32 28 24 20 17 15 12 3000-3499 60 52 45 39 34 29 25 22 19 16 3500-3999 70 61 53 46 40 34 30 26 22 19 4000-4499 80 69 61 53 46 40 35 31 27 24 4500-4999 90 78 68 59 52 44 38 33 29 25 5000-5499 100 87 76 66 58 50 44 39 35 31 5500-5999 115 100 88 77 68 59 52 46 40 35 6000-6499 130 114 100 88 77 68 60 53 47 41 6500-6999 145 127 112 98 87 76 67 59 53 47 7000-7499 160 140 123 109 96 84 75 66 58 52 7500-7999 175 153 135 119 105 92 81 72 64 56 8000-8499 190 166 146 128 113 99 88 77 68 60 8500-8999 205 179 157 138 121 106 93 82 72 63 9000-9499 220 192 168 147 129 113 99 87 76 66 9500-9999 235 205 179 156 136 119 104 91 79 69 10000-10499 255 223 195 170 149 130 113 99 86 75 10500-10999 275 240 210 184 161 141 123 107 94 82 11000-11499 295 258 225 197 172 151 132 115 101 88 11500-11999 315 275 240 210 184 161 140 123 107 94 12000-12499 335 292 255 223 195 170 148 129 113 98 12500-12999 355 310 270 236 206 179 156 136 118 103 13000-13499 375 327 285 248 216 188 163 142 123 107 13500-13999 395 344 299 260 226 197 171 148 128 111 14000-14499 415 361 313 272 236 205 177 153 132 113 14500-14999 435 378 328 284 246 212 183 158 135 116 15000-15499 455 394 342 295 255 220 189 162 138 117 15500-15999 475 411 355 306 264 227 194 165 140 119 16000-16499 495 428 369 318 273 233 199 169 143 121 16500-16999 515 444 382 328 281 240 204 172 144 124 17000-17499 535 462 398 343 294 252 214 182 153 128 17500-17999 555 480 414 357 307 263 225 191 162 136 18000-18499 575 498 430 372 320 275 236 201 171 144 18500-18999 595 516 447 386 333 287 247 211 180 153 19000-19499 615 534 463 401 346 299 257 221 189 161 19500-19999 635 551 479 415 359 311 268 231 198 169 20000-20499 655 569 495 430 373 323 279 241 207 178 20500-20999 675 587 511 444 386 335 290 251 216 186 21000-21499 695 605 527 458 399 346 300 260 225 194 21500-21999 715 623 543 473 412 358 312 271 235 203 22000-22499 735 641 559 488 425 370 322 280 244 211 22500-22999 755 659 575 502 438 382 333 290 252 220 23000-23499 775 677 591 517 451 394 344 300 262 228 23500-23999 795 695 607 531 464 406 355 310 271 236 24000-24499 815 713 623 545 477 418 365 320 280 245 24500-24999 835 731 640 560 491 430 376 330 289 253 25000-25499 855 749 656 575 504 441 387 340 298 261 Formulae if Adjusted Family Income Exceeds $25,499
The liability for 1 dependent is adjusted family income times 0.0336 The liability for 2 dependents is adjusted family income times 0.0294 The liability for 3 dependents is adjusted family income times 0.0257 The liability for 4 dependents is adjusted family income times 0.0225 The liability for 5 dependents is adjusted family income times 0.0197 The liability for 6 dependents is adjusted family income times 0.0172 The liability for 7 dependents is adjusted family income times 0.0150 The liability for 8 dependents is adjusted family income times 0.0132 The liability for 9 dependents is adjusted family income times 0.0115 The liability for 10 dependents is adjusted family income times 0.0101
Authority The provisions of this Appendix A amended under sections 201(2) and (8) and 202 of the Mental Health and Intellectual Disability Act of 1966 (50 P.S. § § 4201(2) and (8) and 4202).
Source The provisions of this Appendix A amended June 17, 2016, effective June 18, 2016, 46 Pa.B. 3177. Immediately preceding text appears at serial pages (211853) to (211854).
Cross References This appendix cited in 55 Pa. Code § 4305.41 (relating to liability); 55 Pa. Code § 4305.42 (relating to more than one client receiving service); and 55 Pa. Code § 4305.43 (relating to client receiving more than one service).
APPENDIX B
Monthly Liability for Community Mental Health and Intellectual Disability
Residential and Short-Term Inpatient Services
Adjusted
Family IncomeNumber of Dependents 1 2 3 4 5 6 7 8 9 10 500- 999 13 11 10 9 8 6 5 4 3 2 1000-1499 25 21 18 15 13 10 8 6 5 4 1500-1999 38 31 25 20 16 14 11 9 6 5 2000-2499 50 43 36 31 28 24 20 16 14 11 2500-2999 63 54 46 40 35 30 25 21 19 15 3000-3499 75 65 56 49 43 36 31 28 24 20 3500-3999 88 76 66 58 50 43 38 33 28 24 4000-4499 100 86 76 66 58 50 44 39 34 30 4500-4999 113 98 85 74 65 55 48 41 36 31 5000-5499 125 109 95 83 73 63 55 49 44 39 5500-5999 144 125 110 96 85 74 65 58 50 44 6000-6499 163 143 125 110 96 85 75 66 59 51 6500-6999 181 159 140 125 109 95 84 74 66 59 7000-7499 200 175 154 136 120 105 94 83 73 65 7500-7999 219 191 169 149 131 115 101 90 80 70 8000-8499 238 208 183 160 141 124 110 96 85 75 8500-8999 256 224 196 173 151 133 116 103 90 79 9000-9499 275 240 210 184 161 141 124 109 95 83 9500-9999 294 256 224 195 170 149 130 114 99 86 10000-10499 319 279 244 213 186 163 141 124 108 94 10500-10999 344 300 265 230 201 176 154 134 118 103 11000-11499 369 323 281 246 215 189 165 144 126 110 11500-11999 394 343 300 263 230 201 175 154 134 118 12000-12499 419 365 319 279 244 213 185 161 141 123 12500-12999 444 388 338 295 258 224 195 170 148 129 13000-13499 469 409 356 310 270 235 204 178 154 134 13500-13999 494 430 374 325 283 246 214 185 160 139 14000-14499 519 451 391 340 295 256 221 191 165 141 14500-14999 544 473 410 355 308 265 229 198 169 145 15000-15499 569 493 428 369 319 275 236 203 173 146 15500-15999 594 514 444 383 330 284 243 206 175 149 16000-16499 619 535 461 398 341 291 249 211 179 151 16500-16999 644 555 478 410 351 300 255 215 180 155 17000-17499 669 578 498 429 368 315 268 228 191 160 17500-17999 694 600 518 446 384 329 281 239 203 170 18000-18499 719 623 538 465 400 344 295 251 214 180 18500-18999 744 645 559 483 416 359 309 264 225 191 19000-19499 769 668 579 501 433 374 321 276 236 201 19500-19999 794 689 599 519 449 389 335 289 248 211 20000-20499 819 711 619 538 466 404 349 301 259 223 20500-20999 844 734 639 555 483 419 363 313 270 233 21000-21499 869 756 659 573 499 433 375 325 281 243 21500-21999 894 779 679 591 515 448 390 339 294 254 22000-22499 919 801 699 610 531 463 403 350 305 264 22500-22999 944 824 719 628 548 478 416 363 315 275 23000-23499 969 846 739 646 564 493 430 375 328 285 23500-23999 994 869 759 664 580 508 444 388 339 295 24000-24499 1019 891 779 681 596 523 456 400 350 306 24500-24999 1044 914 800 700 614 538 470 413 361 316 25000-25499 1069 936 820 719 630 551 484 425 373 326 Formulae if Adjusted Family Income Exceeds $25,499
The liability for 1 dependent is adjusted family income times 0.0420 The liability for 2 dependents is adjusted family income times 0.0368 The liability for 3 dependents is adjusted family income times 0.0321 The liability for 4 dependents is adjusted family income times 0.0281 The liability for 5 dependents is adjusted family income times 0.0246 The liability for 6 dependents is adjusted family income times 0.0215 The liability for 7 dependents is adjusted family income times 0.0188 The liability for 8 dependents is adjusted family income times 0.0165 The liability for 9 dependents is adjusted family income times 0.0144 The liability for 10 dependents is adjusted family income times 0.0126 The liability for 11 dependents is adjusted family income times 0.0110
Authority The provisions of this Appendix B amended under sections 201(2) and (8) and 202 of the Mental Health and Intellectual Disability Act of 1966 (50 P.S. § § 4201(2) and (8) and 4202).
Source The provisions of this Appendix B amended June 17, 2016, effective June 18, 2016, 46 Pa.B. 3177. Immediately preceding text appears at serial pages (211855) to (211856).
Cross References This appendix cited in 55 Pa. Code § 4305.41 (relating to liability); 55 Pa. Code § 4305.42 (relating to more than one client receiving service); and 55 Pa. Code § 4305.43 (relating to client receiving more than one service).
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