§ 4310.24. Write-off requests.
(a) Write-off is the termination of all collection activity with regard to a specific amount.
(b) In the event that all collection efforts fail or there is documented evidence that the account cannot be collected, or both, the outstanding balance shall be submitted to the Division of Institutional Collections for review and forwarded to the Office of the Attorney General for final approval for write-off.
(c) Write-off does not exonerate the client/LLR from paying the account. It is authorization to remove the account from active accounts receivable. These charges shall be billed at a later date if the client/LLR becomes financially able to pay.
(d) The write-off of any account shall be justified by at least one of the following considerations:
(1) There is doubt as to liability, when a bona fide dispute exists, either as a question of fact or of law. This doubt may be the result of:
(i) Adverse court decisions under similar factual situations.
(ii) Adverse legal opinions prepared by the Office of Legal Counsel.
(2) When the legal liability of the debtor is clear and unequivocal, doubt may exist as to the collectability of the claim. The doubts may include, but are not limited to:
(i) Inability to locate the debtor.
(ii) Death of the debtor, and no estate exists or the estate is so small that expenses would deplete the assets of such estate.
(iii) Bankruptcy of the debtor.
(iv) Other judgments against the debtor having priority over the Commonwealth’s claim.
(e) If any of the conditions for write-off exist, the institutional collections officer shall prepare the account for write-off and submit it to the Office of the Attorney General.
(f) The Office of the Attorney General has sole authority to authorize write-off of delinquent accounts. If an authorization is received, it shall be maintained as part of the client’s financial file.
Source The provisions of this § 4310.24 adopted December 3, 1982, effective December 4, 1982, 12 Pa.B. 4149.
APPENDIX A
LLR
MONTHLY LIABILITY SCALE
Annual Discretionary Income Monthly Liability for Institutional Care Annual Discretionary Income Monthly Liability for Institutional Care 0-249 -3- 9000-9499 329. 250-499 11. 9500-9999 356. 500-999 22. 10,000-10,499 384. 1000-1499 36. 10,500-10,999 413. 1500-1999 50. 11,000-11,499 443. 2000-2499 65. 11,500-11,999 474. 2500-2999 79. 12,000-12,499 506. 3000-3499 94. 12,500-12,999 540. 3500-3999 108. 13,000-13,499 574. 4000-4499 122. 13,500-13,999 610. 4500-4999 137. 14,000-14,499 646. 5000-5499 151. 14,500-14,999 684. 5500-5999 170. 15,000-15,499 723. 6000-6499 189. 15,500-15,599 763. 6500-6999 210. 16,000-16,499 804. 7000-7499 231. 16,500-16,999 846. 7500-7999 254. 17,000 and over 1/20 of 8000-8499 278. discretionary 8500-8999 303. income +$23.00
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF HUMAN SERVICES
NOTICE OF ASSESMENT
…
…
TO:
…
…
THIS IS NOT A BILL
CLIENT’S NAME RELATIONSHIP TO CLIENT EFFECTIVE DATE OFASSESSMENT AMOUNT OF LIABILITY* $ BASED ON INCOME
*Plus any amount required to maintain the $1500.00 asset level.
DearUnder Sections 501, 502 and 503 of the Mental Health and Intellectual Disability Act of 1966, you are liable for services provided the client mentioned above. According to the Department of Human Service’s Regulations promulgated as Chapter 4310 your monthly liability has been assessed in the maximum amount specified above. You will be billed monthly for services provided in accordance with charges established by the Department of Human Services or the amount of your liability, whichever is the lesser amount. It is your responsibility to report significant changes in income which may effect the amount of your liability.
If payment of the liability will cause a hardship for you, you may request an abatement or modification of liability by completing the form on the reverse side of this notice with a full explanation of the hardship created. Forward the PW-83 and a copy of the Determination of Liability - PW-833 to the Secretary of Human Services, Box 2675, Harrisburg, Pennsylvania 17105. If you need assistance, the facility providing the service will assist you in completing this request.
The basis for granting an abatement or modification of liability are detailed in the Notice of Rights - S1-83 provided with the Notice of Assessment - PW-83.
Debts that cannot be considered in granting abatement or modification of liability include:
(a) mortgage or rent on principal residence;
(b) utility payments;
(c) payments on first automobile;
(d) medical expenses already considered;
(e) debts incurred after treatment has begun;
(f) any other debt or payment for which the client has not incurred
a legal obligation to pay;
(g) retail charge purchases for personal use items, food and/or
commodities.
Any request for review must be made within 30 days from receipt of this notice. The time limit will not apply where hardship has been caused by unforeseen circumstances over which you have no control.
INSTITUTIONAL COLLECTIONS OFFICER…DATE
REQUEST FOR REVIEW OF LIABILITY
NAME OF PERSON MAKING REQUEST FOR REVIEW BIRTHDATE IF LEGALLY RESPONSIBLE RELATIVE
RELATION TO CLIENT
ADDRESS COUNTY TELEPHONE NO.
CLIENT’S NAME AND INSTITUTION CARE NUMBER BIRTHDATE AMOUNT OF LIABILITY AS DETER-
MINED BY INSTITUTIONAL
COLLECTION OFFICER
[rArr ] $ NAME OF INSTITUTION PROVIDING SERVICES FOR WHICH LIABILITY IS INCURRED
INCOME ( as indicated on PW-833) [rArr ] $
PERSONS DEPENDING ON ABOVE INCOME: Including Self and Client
Name Address Age Relationship ACCUMULATED DEBTS: Include only those debts on which payments are made on a regularly scheduled basis that meet the criteria on the reverse side of this form.
Amount of Debt
a. b. c. d. e. f. g. h. i. j. k. l. ANY OTHER UNUSUAL EXPENSES OR CIRCUMSTANCES THAT WOULD SUPPORT REQUEST FOR ABATEMENT OR MODIFICATION OF LIABILITY
I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF.
SIGNATURE…DATE
DETERMINATION OF CLIENT LIABILITY
A. NAME OF FACILITY
B. CLIENT’S NAME(S) CASE
NUMBER(S)SERVICE(S) TO BE PROVIDED EFF. DATE OF ASSES. C. THIRD PARTY PAYMENT FOR CLIENT’S CARE MEDICAL/GENERAL ASST. (If yes, case no.)
PRIVATE HEALTH INSURANCE (If yes, company name)
POLICY NO.
SOCIAL SECURITY (If yes, number) VETERAN’S BENEFITS (If yes, claim no.) MEDICARE (If yes, number)
OTHER (specify)
D. NAME(S) OF LEGALLY RESPONSIBLE RELATIVES RELATIONSHIP EMPLOYER E. COMPUTATION OF LIABILITY
ANNUAL INCOME:
1. Salary and/or wages$ 2. Interest and/or dividends 3. Benefits (social security, VA, Pensions) 4. Other (support payments, etc.) 5. TOTAL INCOME [lowbar] [lowbar] [lowbar] [lowbar] [lowbar] [lowbar] $ DEDUCTIONS:
1. Federal Income Tax2. State Income Tax 3. Local Income Tax 4. FICA (self employment tax) 5. Mandatory Retirement 6. Extensive Medical Expenses (Exceeding 5% of Gross Income) 8. Real Estate Taxes 9. Work Privilege Tax 10. Child Care Costs 11. Other (Specify) F. TOTAL DEDUCTIONS [lowbar] [lowbar] [lowbar] [lowbar] [lowbar] [lowbar] $ G. Net Annual Income [lowbar] [lowbar] [lowbar] [lowbar] [lowbar] [lowbar] H. Household Allowance [lowbar] [lowbar] [lowbar] [lowbar] [lowbar] [lowbar] I. Dependency Allowance [lowbar] [lowbar] [lowbar] [lowbar] [lowbar] [lowbar] J. DISCRETIONARY INCOME [lowbar] [lowbar] [lowbar] [lowbar] [lowbar] [lowbar] $
K. DEPENDENT’S NAME(S) AGE RELATIONSHIP L. LIABILITY $
I have read the information in items A through E and find them to be true to the best of my knowledge and belief.
NOTICE OF RIGHTS
HOSPITAL
NAME OF PATIENT/CLIENT CASE NUMBER
INSTRUCTIONS: Upon completion, retain in patient/client file
This is to inform you that you have the right to seek the advice of an attorney or other person of your choice not employed by the Commonwealth regarding the attached Notice of Assessment for services provided to you.
The advisor of your choice may be present at any conference you may wish to arrange with the revenue agent or other Commonwealth employe in connection with the settlement of this bill as indicated in the Notice of Assessment.
You also have the right to request a hearing from the Secretary of Human Services for the purpose of modifying your liability if any questions remain unresolved after 1) conference with the revenue agent, and 2) review by the Department of the revenue agent’s assessment.
In addition, you have the right to petition the Secretary under 50 P.S. § 4504 and to obtain a hearing regarding abatement, modification or discharge of assessed liability on the basis that:
(i) Imposition of liability would result in loss of financial payments of benefits from any public or private source to which he or she might be entitled, 50 P.S. § 4504(a)(1)(i); or (ii) Imposition of liability would result in a substantial financial hardship upon him, her or a person owing a legal duty of support to him or her, 50 P.S. § 4504(a)(1)(ii); or (iii) Imposition of liability would result in greater financial burden upon the people of the Commonwealth, 50 P.S. § 4504(a)(1)(iii); or
(iv) Imposition of liability would result in a financial burden upon him or her that would nullify the results of care and treatment for mental disability, 50 P.S. § 4505(a)(1)(iv); or (v) State and federal benefits may be insulated from claims of the Commonwealth for care and maintenance; or
(vi) The patient/resident is entitled to the reasonable value of unpaid work benefiting the Commonwealth in reduced costs of maintenance and operation of the facility to which he or she was admitted or committed, performed by him or her, by way of offset; or
(vii) The care and maintenance is less than that assessed by the Commonwealth; or (viii) Any other defenses or offsetting claims in law and equity.
…
Witness Signature…Authorized Signature
Date
Commonwealth of Pennsylvania…Department of Human Services…SI 83 - 2-76NOTICE OF DECISION
BY THE DEPARTMENT
To:
In Re:
Client’s Name
Client’s Case Number
The Department of Human Services has acted on your request for review of your liability. As a result of this review:
If you disagree with the results of this review you have the right to request a fair hearing before the Department of Human Service’s Hearing and Appeals Unit. If you wish to request such a hearing, you must complete the back of this form and mail it along with the other information required on the back to the Office of Hearings and Appeals, P.O. Box 2675, Harrisburg, Pa. 17105 within 30 days of receipt of this notice. Appeals will be considered within 30 days of the mailing date of this decision. More details on the hearing process may be obtained from Institutional Collections Officer.
…
Date…DHS Representative
PW 1073I wish to have a fair hearing before the Department’s Office of Hearings and Appeals. The attached letter explains the reasons why I am appealing this decision.
…
Date…Liable Person’s Signature
* * * * *
APPEAL PROCEDURE
To appeal a decision regarding the assessment of liability, a written request for a fair hearing must be submitted to the Office of Hearings and Appeals, Department of Human Services, P. O. Box 2675, Harrisburg, Pa. 17120, within 30 days of the date from which this decision was mailed.
In your request for a fair hearing you must state the reason(s) why you are appealing the Department’s decision. It is also necessary that you list your name, address and telephone number, with area code, and whether or not you will be represented by counsel. If you are represented by counsel, list counsel’s name, address, and telephone number, with area code, as the Office of Hearings and Appeals may elect to hold the hearing by telephone.
At the hearing, the appellant may represent himself or be represented by counsel, and has the following rights:
1. To present evidence on his own behalf, to bring witnesses, and to confront and cross-examine witnesses the Department will produce to support its decision or action.
2. To examine prior to the hearing, as well as during the hearing, that material from the patient’s records that the Department will introduce as evidence in the hearing to support its decision or action.
3. To be provided with the names, addresses and telephone numbers of the Department’s staff members and witnesses who will be present at the hearing.REQUEST FOR DEPARTMENTAL REVIEW
CLINICAL ABATEMENT
Client’s Name
Hospital Case #
Liable Person’s Name
I hearby request the review by the Department of this liable person’s/client’s assessed liability. I request that the liability be:
Abated in full
Modified to
per year
I hereby certify that to the best of my knowledge and belief, the imposition of liability would be likely to negate the effectiveness of treatment, or prohibit the client’s continuing treatment. I further certify that, to the best of my knowledge and belief, the failure to provide such treatment would result in serious harm to the client’s welfare or in greater cost to the Commonwealth due to deterioration in the client’s condition. The grounds for such belief are fully spelled out in the client’s case record and are summarized as follows:
…
Date…Signature of MH/ID Professional
PW 1075
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 adopted December 3, 1982, effective December 4, 1982, 12 Pa.B. 4149; amended June 17, 2016, effective June 18, 2016, 46 Pa.B. 3177. Immediately preceding text appears at serial pages (375699) to (375706).
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