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Section
3.4 Co-payments
3.4.1
Introduction
3.4.2 References
3.4.3 Scope
3.4.4 Did you know…?
3.4.5 Objectives
3.4.6 Procedures
3.4.6-A. Co-payments for Non-Title XIX/XXI Persons
3.4.6-B. Co-payments for Title XIX/XXI eligible
persons
3.4.6-C. Housing subsidies, Mental Health
Services NOS (Room and Board) co-payments and other fees
3.4.1
Introduction
At times, it may be necessary for persons to contribute to the cost
of behavioral health services. A co-payment is a fixed fee for services,
based on the person’s ability to pay and never exceeds the
actual cost of services. For persons who are not eligible for Title
XIX or Title XXI services, ADHS/DBHS has established a sliding co-payment
schedule that determines the amount to be charged to a person for
a covered behavioral health service. In a set of limited circumstances,
a co-payment may also be collected from a Title XIX or Title XXI
eligible person.
This section
describes:
- How and
when behavioral health providers calculate a person’s co-payment;
- The behavioral
health services that must not be assessed a co-payment; and
- The limited
situations in which a Title XIX/XXI eligible person may be assessed
a co-payment.
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3.4.2
References
The following citations can serve as additional resources for this
content area:
3.4.3
Scope
To whom does this apply?
All persons
referred to, or enrolled with, a behavioral health provider to receive
publicly funded behavioral health services.
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3.4.4
Did you know…?
- Arizona
state law (A.R.S.
§ 36-3409) requires the assessment of a co-payment
to Non-Title XIX/XXI persons and requires the use of a sliding
fee schedule for the assessment of co-payments based on ability
to pay.
- Title XIX/XXI
eligible persons must never be assessed a co-payment for interpreter
services. When needed for the appropriate delivery of behavioral
health services, interpreter services must be provided free of
charge to Title XIX/XXI eligible persons.
- The Non-Title
XIX/XXI Co-payment Assessment (see
PM
Form 3.4.1) is based on Federal Poverty Guidelines
and may be amended annually. ADHS/DBHS will notify the T/RBHAs
when changes occur.
3.4.5
Objectives
Identify when and how providers must assess a co-payment,
address the collection of co-payments and the actions to take for
nonpayment of co-payments.
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3.4.6
Procedures
Co-payments must be assessed and collected consistent with state
law and Arizona Administrative Code requirements. Behavioral health
providers must not bill, nor attempt to collect payment directly
or through a collection agency from a person claiming to be AHCCCS
eligible without first receiving verification from AHCCCS that the
person was ineligible for AHCCCS on the date of service, or that
services provided were not Title XIX/XXI covered services.
3.4.6-A.
Co-payments for Non-Title XIX/XXI Persons
A co-payment is:
- A fixed
dollar amount that varies depending on whether the service is
a support or rehabilitation service; treatment, medical or day
program service; or residential or inpatient service;
- Based on
a person’s ability to pay;
- Assessed
using the Non-Title XIX/XXI Co-payment Assessment (except Mental
Health Services Not Otherwise Specified (NOS) (Room and Board);
see subsection 3.4.6-C); and
- Does not
exceed the cost of services.
The Non-Title
XIX/XXI Co-payment Assessment (PM
Form 3.4.1) is used to calculate a person’s co-payment.
WHEN
IS A CO-PAYMENT AMOUNT DETERMINED? |
HOW
ARE CO-PAYMENTS DETERMINED? |
WHAT
SERVICES REQUIRE CO-PAYMENTS? |
WHAT
SERVICES ARE EXCLUDED FROM CO-PAYMENTS? |
| -At
the initiation of services
-When
there are significant changes in the person’s financial
circumstances (assessed prospectively only)
-When requested by the person
-At least annually thereafter |
-Apply
the gross family income and family household size to the Non-Title
XIX/XXI Co-payment Assessment (PM
Form 3.4.1) |
-Support/Rehabilitation
Services* -Treatment/Medical/ Day Program Services*
-Inpatient/Residential Services (per day)* |
-Crisis
services
-Case management services
-Housing support services
-Flex funds |
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* See specific
services of each category in the ADHS/DBHS
Behavioral Health Covered Services Guide.
Other Payment
Sources
- T/RBHAs
or their providers must follow the requirements set forth in Section
3.5, Third Party Liability and Coordination of Benefits,
and collect third party payments for behavioral health services
when applicable. If a person has third party liability coverage,
co-payments are collected when there is a portion of the cost
of services that is not reimbursed through the third party payer.
Collection
of Co-payments
Behavioral health providers may:
- Require payment
of co-payments at the time that the person receives a service;
or
- Provide
for individually determined installment payments of co-payments;
and
- Take reasonable
steps to collect on delinquent accounts.
Also know that:
- For multiple
services received on the same day, the person is only required
to pay the co-payment of the most costly service. (For example,
if a person receives peer support and counseling services on the
same day, the co-payment for the counseling service is the only
charge assessed.)
- The fixed
dollar amount is assessed per service received, regardless of
the number of units encountered
- Any co-payments
collected are retained by the provider. Provider claims submitted
to the Gila River RBHA for covered services to Non-Title XIX/XXI
persons must include information regarding co-payments collected,
if any. Total billed charges submitted by the provider are to
be reduced by the amount of the co-pay.
Non-payment
of Co-payments
- Behavioral
health providers may terminate services for non-payment of co-payments
only after other options (e.g., informal discussions) do not result
in resolution. All efforts to resolve the issue must be documented
in the person’s comprehensive clinical record.
- Persons determined
to have a serious mental illness must not be terminated or denied
services because of non-payment of co-payments. See Section
3.10, SMI Eligibility Determination.
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3.4.6-B.
Co-payments for Title XIX and Title XXI eligible persons
Under certain conditions, a behavioral health provider may collect
a co-payment from a Title XIX/XXI eligible person.
Co-payments
for behavioral health services not covered under Title XIX or Title
XXI
A behavioral health provider may collect a co-payment for the following
Non-Title XIX/XXI services:
- Mental Health
Services NOS (Room and Board);
- Traditional
healing services; and
- Auricular
acupuncture services.
With the exception
of Mental Health Services NOS (Room and Board), co-payments for
the above services not covered under Title XIX or Title XXI must
be calculated using the Non-Title XIX/XXI Co-payment Assessment
Form (PM
Form 3.4.1). To calculate co-payments for Mental Health
Services NOS (Room and Board), see subsection 3.4.6-C.
Co-payments
for Title XIX covered behavioral health services
Who is exempt from co-payments?
- There are
no co-payments for Title XIX or Title XXI eligible behavioral
health recipients under the age of 19.
- There are
no co-payments for Title XIX covered behavioral health services
delivered to persons determined to have a serious mental illness.
When can
co-payments be assessed to Title XIX/XXI eligible persons?
- Co-payments
may only be collected for Title XIX covered behavioral health
services from Title XIX eligible persons who are assigned to general
mental health or substance abuse program categories (See Section
7.5, Enrollment, Disenrollment and other Data Submission Section)
in the following circumstance:
- A $1.00
co-payment may be charged for doctor’s visits (including
all diagnostic and rehabilitative x-ray and laboratory services
associated with the visit).
- A behavioral
health provider must ensure that a Title XIX eligible person
is not denied services because of the person’s inability
to pay a co-payment.
Other considerations
for Title XIX and Title XXI eligible persons
T/RBHAs or their providers must follow the requirements set forth
in Section
3.5, Third Party Liability and Coordination of Benefits,
and collect third party payments for behavioral health services
when applicable. This includes services that are rendered to Medicaid
(Title XIX)/Medicare (Title XVIII) dually eligible persons.
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3.4.6-C.
Housing subsidies, Mental Health Services NOS (Room and Board) co-payments
and other fees
The co-payments and fees described in this subsection may be applied
to all populations.
Housing
Subsidy
There may be occasions when a person is referred to a housing subsidy
entity (e.g., HUD) for assistance with housing needs. If a person
is receiving aid from a housing subsidy entity, that entity may
sometimes establish fees that are independent of the co-payment
requirements described in this section.
Co-payments
for Mental Health Services NOS (Room and Board) and Other Fees
Behavioral health providers may assess a co-payment for Mental Health
Services NOS (Room and Board) independent of the Non-Title XIX/XXI
Co-payment Assessment Form (see
PM
Form 3.4.1). Behavioral health providers may also establish
operating fees for other expenses (e.g., cable television, travel
that is not related to the provision of behavioral health services).
When assessing co-payments for Mental Health Services NOS (Room
and Board) and/or operating fees, behavioral health providers must
ensure that:
- Any applicable
co-payments and/or operating fees are disclosed and reviewed with
the person before the person is charged;
- Persons are
left with a reasonable amount of personal spending money;
- Persons are
not charged co-payments/fees in excess of their income;
- Operating
fees are not inclusive of Title XIX/XXI or Non-Title XIX/XXI covered
behavioral health services; and
- The process
for determining co-payments and/or operating fees is consistent
for all persons.
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3.4
Co-payments
Last Revised: 04/27/2006
Effective Date: 05/01/2008 |
