Plan Administration Guide

Transcription

1 Cardinal Innovations Healthcare Plan Administration Guide State Funded Member Financial Eligibility Criteria

2 Table of Contents 1. Service Snapshot Service Categories Policy References 4 4. Service Documentation References/Version Control 7 6. Appendices. 8 2

3 1. Service Snapshot Area: Plan Administration Guide Number: Service: Departments: Finance, Service Center, Utilization Management Objective: To clarify expectations around financial eligibility for state funded services. Service Partners: Kathy Tuttle, Emma Morris, Christine Beck, Renee Snipes, Ashley Fischer, Patrice Lewis Process Manager: Ashley Fischer Creation Date: 4/5/2017 Review Date: 6/2/2017 Documentation Notes 3

4 2. Service Categories Crisis Services Outpatient Services All Other Services Diagnosis Groups Consumers are eligible to receive crisis services regardless of financial eligibility. Consumers will be enrolled and given 24 hour period (1 day) of eligibility if their household income is above the financial eligibility threshold. Outpatient Services may require a copay based on the sliding fee schedule. Copays are required for consumers whose family income falls between 138% and 288% of the federal poverty guideline. Providers are required to use the Cardinal Innovations sliding fee schedule. This fee schedule must be used in lieu of any sliding fee schedule the provider otherwise uses. More information on the Cardinal Innovations sliding fee schedule can be found below (See Policy References). All other behavioral health services covered by Cardinal Innovations are provided without consumer financial contribution for consumers who meet the financial and residential eligibility requirements. The above service categories and consumer financial contribution requirements apply to all diagnosis groups (SU, MH, IDD). 3. Policy References (if applicable) Provider Manual Sliding Fee Scale Monthly Income Sliding Fee Scale Yearly Income Federal Register Poverty Guidelines

5 4. Service Documentation What are the financial criteria for State Funded Eligibility? Family income must be at or below 288% of the federal poverty line to qualify for State funding (see Appendix A). Family includes immediate family only adults and children. Income equals the gross income for all adults (18 and over) in the household. Please see Appendix B regarding How To Define Family Income. The consumer is not eligible for State funding of service cost when: The consumer s household income is over 288% of the federal poverty line. The consumer is not a Cardinal Innovations county resident (exception for special regional CASP service recipients). The consumer refuses to complete the financial intake form. The consumer does not meet diagnostic and clinical criteria. Note: Eligible consumers may not receive authorization if funding is unavailable or there is a waiting list for services. Provider Requirements for Collecting Financial Information? Providers are required to collect financial information for all consumers seeking State funded services. These financial requirements do not apply to Medicaid consumers. Providers are required to collect financial information annually, or more often if a known change in financial status is determined, including but not limited to: o Change in Medicaid status o Change in Employment status o Change in Family size Consumer/ Guardian must sign to attest financial information is accurate. Cardinal Innovations has provided the attached form (Appendix C) for provider use in collecting financial eligibility information. Providers may use their own forms or collection methods; however if audited, providers must be able to provide the following data elements: o Consumer Name o Consumer Address o Consumer County of Residence o Consumer Social Security Number and Date of Birth o Consumer Employment Status o Financial Eligibility Information Gross Annual Household Income o Providers should ask for some form of financial verification or proof that it was requested (i.e. Paystubs, SSI/Disability statement, tax documents, bank statement) Family Size Primary insurance information, including: Insurance company name, address and phone number 5

6 Policyholder name, Policy ID, date of birth and social security number Copy of Insurance card, front and back Generally, if a member is unwilling to give the financial information they are ineligible for services. If the situation is emergent but does not require Crisis Services, Providers may call the Access Line ( ) to request an exception on a case by case basis. Exceptions will be granted for 30 days, but the Providers are expected to verify the financial information during that time period. Consumers can call the Access line directly if they are uncomfortable giving their financial information to the office staff of the Providers. However, this should be a rare occurrence. Cardinal Sliding Fee Scales The sliding fee schedule only applies to Outpatient services. Monthly Sliding Fee Scale: Yearly Sliding Fee Scale: 6

7 References/Version Control DEFINITIONS REFERENCES Board and/or Cardinal Operational Policy References Cardinal Procedure(s) References APPENDICES Date Superseded: Revision Reason: Procedures Superseded: NOTE: Consumer Individual receiving services State Funded Services historically called IPRS REVISION CHRONOLOGY All text in red and blue indicate updates/changes to be made when additional process change information is available. All text in purple indicates data elements that must be identified in the handoff in order to execute this SOP. 7

8 Appendix A: 2016 Poverty Guidelines 2016 Poverty Guidelines for the 48 Contiguous States and the District of Columbia Persons in family/household Poverty guideline 138% of Poverty guideline 288% of Poverty guideline 1 $11,880 $16,394 $34,264 2 $16,020 $22,108 $46,205 3 $20,160 $27,821 $58,145 4 $24,300 $33,534 $70,086 5 $28,440 $39,247 $82,027 6 $32,580 $44,960 $93,967 7 $36,730 $50,687 $105,937 8 $40,890 $56,428 $117,935 For families/households with more than 8 persons add $4,160 for each additional person. 8

9 Appendix B: Family Income and Family Size Definitions How to Define Annual Family Income Income equals the gross income for all adults (18 and over) in the household. This includes total annual cash receipts before taxes from all sources and includes: Money, wages and salaries before any deductions. Net receipts from non-farm self-employment (receipts from a person's own unincorporated business, professional enterprise, or partnership, after deductions for business expenses). Net receipts from farm self-employment (receipts from a farm which one operates as an owner, renter, or sharecropper, after deductions for farm operating expenses). Regular payments from social security, railroad retirement, unemployment compensation, strike benefits from union funds, workers' compensation, veterans' payments, public assistance (including Temporary Assistance for Needy Families, Supplemental Security Income, and non-federally-funded General Assistance or General Relief money payments), and training stipends. Alimony, child support, and military family allotments or other regular support from an absent family member or someone not living in the household; private pensions, government employee pensions (including military retirement pay), and regular insurance or annuity payments. College or university scholarships, grants, fellowships, and assistantships. Dividends, interest, net rental income, net royalties, periodic receipts from estates or trusts, and net gambling or lottery winnings. Income does not include non-cash benefits, such as the employer-paid or union-paid portion of health insurance or other employee fringe benefits, food or housing received in lieu of wages, the value of food and fuel produced and consumed on farms, the imputed value of rent from owner-occupied non-farm or farm housing, and such Federal non-cash benefit programs as Medicare, Medicaid, food stamps, school lunches, loans, and housing assistance. If there is no annual income, enter zeroes. Enter the dollar amount only, (no cents), which represents the total combined annual income of the consumer and any individuals with which the consumer is financially interdependent. NOTE: In the case of an adult consumer living with his/her parents or family, such as grandparents, aunts/uncles or brothers/sisters, only the income of the consumer should be listed. The income of the parents or family members providing a home to the adult consumer should not be included in this total. A spouse or adult child living with the consumer and providing income would be included in the income total. 9

10 How to Define Family Size Number contributing to and/or dependent upon the income (as defined in the preceding section) For family size enter the number (01-99) of individual's dependent upon or contributing to the income of the consumer. This should reflect the consumer, family members, or significant others who are interdependent financially. IT SHOULD INDICATE THE NUMBER OF PEOPLE WHO MUST LIVE ON THE INCOME REPORTED IN THE ANNUAL INCOME FIELD. NOTE: In the case of an adult consumer living with his/her parents or other family, where only the income of the consumer was listed, then the family size should be listed as "01" to indicate the consumer only and not the parents. However, if the adult consumer has dependents also living with him/her in the parents' household, then the dependents should be reported in the number while still excluding the parents of the adult consumer. 10

11 Appendix C: Standardized Financial Intake Form Name Record # Address City/State ZIP Code County of Residence Financial Intake Form Date Provider Name Person Receiving Services Identifying Information: Social Security # Date of Birth Primary Insurance Information: Insurance Co. Name Insurance Co. Address Insurance Co. Phone Policyholder s Name Policyholder s Employer MH Carrier (if applicable) MH Carrier (if applicable) MH Carrier (if applicable) Relationship: Self Dependent Spouse Policyholder s Social Security # Policy # Group # Effective Date of Insurance Referring Doctor (if any) Doctor s Phone # Secondary Insurance Information: Insurance Co. Name Insurance Co. Address Insurance Co. Phone Policyholder s Name Policyholder s Employer MH Carrier (if applicable) MH Carrier (if applicable) MH Carrier (if applicable) Relationship: Self Dependent Spouse Policyholder s Social Security # Policy # Group # Effective Date of Insurance Referring Doctor (if any) Doctor s Phone # 11

12 Sliding Scale Benefit: Gross Monthly Household Income Sliding Fee Scale % (staff use only) Family Size Signature of Consumer/Guardian 12