MAXIMUM LIABILITY FOR SERVICES PROVIDED
§ 4310.6. Maximum liability—payors/liable persons.
The maximum liability for services provided is established by the institutional collections officer for both payors and liable persons within the following:
(1) Maximum charge to Medicare.
(i) The maximum monthly charge to Medicare shall be the product of the per diem rate multiplied by the number of client days.
(ii) Medicare reimbursement includes only covered charges and shall be accepted by the facility as payment in full for the number of Medicare-eligible days billed, excluding deductibles and coinsurances.
(iii) If Medicare deductibles and coinsurances have been deducted from the Medicare reimbursement, the deductibles and coinsurances shall be billed to MAMIS if the client is Medical Assistance eligible.
(iv) If the client is not Medical Assistance eligible, deductibles and coinsurances are the responsibility of the client or LLR up to his maximum liability.
(2) Maximum charges to third-party payors.
(i) The maximum charge to third-party payors shall be the product of the per diem rate multiplied by the number of client days.
(ii) If the costs of services are to be paid in whole or in part by a third-party payor, that resource must be fully used. If the third-party payor coverage is limited, any costs of services in excess of the payment are the responsibility of the client and LLR up to his maximum liability if these costs cannot be billed to another third party or to MAMIS.
(iii) If the sum of third-party payments and client/LLR liability exceed the total charges, the overpayments shall be refunded to the client/LLR if the imposition of liability resulted in the overpayment, or to the third-party payor, if no client/LLR liability have been established.
(3) Legally liable relative maximum liability.
(i) LLR liability for services provided to a client is based on the LLR’s monthly discretionary income. LLR liability may not exceed the facility monthly per diem rate.
(ii) LLR liability for services to a client is imposed in excess of amounts paid by third-party payors or other agencies, but may not exceed the LLR’s maximum monthly liability or the facility monthly per diem rate.
(4) Spouse for spouse liability.
(i) The liability of one spouse for services to the other is limited to 120 days of continuous inpatient care.
(ii) If the client is discharged for 120 consecutive days and is subsequently readmitted after 120 days to the facility, spouse for spouse liability recurs.
(iii) If there is court-ordered support, the amount of the court order must be considered the maximum liability for the costs of service.
(5) Parental liability.
(i) Parental liability is limited to the cost of services for children under the age of 18 who are not Supplemental Security Income (SSI) eligible. If a child under 18 years of age becomes eligible for SSI, parental liability ceases.
(ii) If there is a court order for support, the amount of the court order must be considered the maximum liability for the costs of services.
(6) Client/resident maximum liability.
(i) Maximum client liability is based on income or assets of the client, or both, in excess of amounts paid by third party payors or other agencies, up to the per diem rate established for the facility. Monthly charges for services provided to mental health and intellectual disability clients may not exceed the product of the per diem rate multiplied by the number of days in the month.
(ii) If the client is responsible for maintaining a spouse or children, client liability is determined by the scale for LLR monthly liability.
(7) Charges equal to maximum liability.
(i) If the cost of service (that is, client days multiplied by the per diem rate) exceeds the maximum liability, the client shall be billed for the amount of the maximum liability.
(ii) If the cost of service (that is, client days multiplied by the per diem rate) is less than the client’s maximum liability, the client shall be billed for the amount of the maximum liability.
(iii) If the cost of service (that is, client days multiplied by the per diem rate) exceeds the LLR’s maximum liability, the LLR shall be billed for the amount of the maximum liability.
(iv) If the cost of service (that is, client days multiplied by the per diem rate) is less than the LLR’s maximum liability, the LLR shall be billed for the amount of the maximum liability.
(8) Maximum charges for services to MAMIS.
(i) The maximum charge for service billed to MAMIS is the product of the per diem rate times the client days in the month. If client and/or LLR liability has been established by the County Assistance Office, the maximum monthly billing to MAMIS must be the monthly rate minus the client/LLR liability.
(ii) No portion of the charges to MAMIS except the liability imposed on the client/LLR by Medical Assistance may be billed to the client or his LLR.
(iii) Institutional collections officers shall compute and bill client/LLR liability based on this chapter.
(iv) The difference between the Medical Assistance liability assessment and the assessment determined within this chapter may not be billed or collected from the client/LLR or invoiced to MAMIS.
Authority The provisions of this § 4310.6 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 § 4310.6 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 (251377) to (251379).
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