Policy and procedure regarding Payer & Financial Information and UMDAP

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City and County of San Francisco Department of Public Health Population Health and Prevention Community Behavioral Health Services CBHS Billing Office 1380 Howard Street, 3 rd Floor San Francisco, CA

255-3400 Policy and procedure regarding Payer & Financial Information and UMDAP Issued By: Jo Robinson Director, Community Behavioral Health Services Date: January 20, 2015 Manual Number: 2.

1 City and County of San Francisco Department of Public Health Population Health and Prevention Community Behavioral Health Services CBHS Billing Office 1380 Howard Street, 3 rd Floor San Francisco, CA Tel: Policy and procedure regarding Payer & Financial Information and UMDAP Issued By: Jo Robinson Director, Community Behavioral Health Services Date: January 20, 2015 Manual Number: References: Welfare & Institutions Code Section ; MHP Contract with CA Dept of Health Care Services; SCOPE: The California Welfare & Institutions Code requires County Behavioral Health Systems to obtain Payer and Financial Information (PFI) for all Clients receiving mental health and/or substance use disorder treatment services. The PFI establishes the Client /Family s healthcare benefits and insurance coverages and, Patient Fee amounts payable for the cost of treatment services they receive. This policy/procedure describes the process that is used by Community Based Organizational Providers and by the San Francisco Mental Health Plan for obtaining CBHS Clients Payer and Financial Information. POLICY Payer and Financial Information is obtained for all Mental Health and Substance Use Disorder Clients at the beginning of his/her episode; and annually thereafter, if continuing to receive services during the Client/Family s account anniversary date. The PFI is also required whenever there has been a significant change in the Client s healthcare benefits or insurance coverage, or in the family s financial status. This requirement facilitates the updating of CBHS Patient Accounts information to keep it current. Clients or Responsible Parties who refuse to provide accurate and complete PFI information are billed the full cost of services received from CBHS, in accordance with State DHCS Revenue Policy & Procedures. Episode Guarantor Information CBHS Providers use the Episode Guarantor Information process to meet the State s PFI requirements. Providers complete the Episode Guarantor Information (EGI) form in Avatar/CalPM when the Client is admitted to their Mental Health or Substance Abuse Treatment Program; and, at least annually thereafter, if the Client continues to receive CBHS services. A paper EGI form (optional) can be used to gather a Client s financial and eligibility coverage

2 information prior to entering data into the Avatar system at a later time. The form corresponds to the fields of the EGI form in the Avatar system. The EGI provides information to CBHS Billing about Clients guarantor or funding sources for the Program s episode services. Different agencies may have different funding sources, or the Client s funding source may change during different periods; therefore, a separate EGI is needed for each agencies episode and when Clients have different admission periods with an agency. A single EGI can be completed if the same agency opens different episodes for a Client within the same period, i.e. for Outpatient and for Day Treatment. The Client or their Responsible Party s signature on the Client s Authorization for Billing form is obtained when the EGI is completed. This is their consent for billing and authorization for CBHS to release healthcare information for billing purposes, to record the Assignment of Healthcare Benefits payable to the San Francisco Dept of Public Health, and agreement to pay their Coinsurance and/or deductible amounts, or their UMDAP Patient Fee, or their Per visit Co-payment amounts payable. The Client Authorization for Billing form is available at 1380 Howard, 2 nd Floor Forms Room.. Advanced Beneficiary Notice CMS requires Providers to notify their Medicare Clients in advance about medically necessary services that are not covered by Medicare. Rehabilitation services, particularly those rendered by non-medicare Clinicians or Programs, and Substance Abuse treatment services are not covered by Medicare. For this reason, Medicare Clients who will/ are receiving services from CBHS Organizational Providers, must sign an ABN Form annually as part of the PFI process. The CMS Advanced Beneficiary Notice form and Instructions are available in the following website. CBHS Reports Providers must have a designated Staff person responsible for generating and reviewing the Missing Guarantor Report and PFI Due Report in Avatar, at least once a month. The Missing Guarantor Report is generated to confirm Clients have guarantor information in Avatar so that Provider services can be posted and billed. Please complete the EGI for Clients whose names appear on this report. The PFI Due Report lists Clients whose annual Payer and Financial Information or UMDAP will expire within 45 days or, has expired. Providers are responsible for updating their Clients annual UMDAP and for determining their Medi-Cal eligibility and/or healthcare coverages are current and accurate. Please note, CBHS policy now requires MH and SA programs to complete Clients annual Periodic CSI data (for mental health Clients) or the annual periodic CalOMS (for substance abuse program Clients) data reporting when Providers renew their Clients annual PFI. Uniform Method for Determining Ability to Pay UMDAP stands for Uniform Method for Determining Ability to Pay, which is based on the DMH 1989 Sliding Fee schedule, still in use today. Clients UMDAP dates are determined when their Patient Account was first created. Their UMDAP is valid for a one year period and must be

3 reassessed every year. There can be only one annual UMDAP liability period regardless of the number of service providers within the county. The UMDAP process is used for determining the Sliding Fee Amount for Clients or their Responsible Parties (RP) when they are unable to pay the regular Published Fee amounts charged for Services or, instead of their normal portion of the cost of treatment services received from CBHS and its Providers. Per State PFI policy/procedures, the Client pays the UMDAP amount determined, or the cost of services received less any third party payments and adjustments, during their annual (one-year) UMDAP period, whichever is less. UMDAP is the maximum amount Clients pay as their share of the cost of mental health or substance abuse treatment services they receive from CBHS programs during their one-year UMDAP period. The annual UMDAP amount may be divided by twelve to arrive at a monthly UMDAP amount payable. The UMDAP amount may be adjusted for clinical reasons, however, it is against Federal laws, State regulations, and the CBHS Code of Conduct to automatically waive, or reduce Patient Fees. Under the Affordable Care Act, everyone is required to obtain healthcare insurance coverage. The SFDPH policy requires Uninsured clients to be referred to a Health Access Program so they may complete an application for healthcare benefits or insurance coverage. Please refer Uninsured persons to Healthy San Francisco, Covered California, or to their local Human Service Agency to obtain low or no cost healthcare coverage that includes primary care, prescription drug, mental health and substance use disorder treatment benefits. Uninsured persons are not eligible for UMDAP. Who does not have an UMDAP? The following Clients do NOT have an UMDAP liability, and are not required to complete the UMDAP form. They have no Patient Fee liability. There is no need to complete the Avatar/CalPM/ Family Registration form for: 1. Clients who have Full-scope Medi-Cal and no monthly Share-of-Cost obligation. 2. Clients who are Homeless Clients who pay a Per-visit Copayment amount 4. Healthy San Francisco and SF PATH Enrollees who have incomes that are less than 133% of Federal Poverty Level (FPL). 5. Clients who are receiving ERMHS services that are included in their annual Individualized Education Plan (IEP). For them, any additional services received that are not included their IEP, are subject to UMDAP requirements. 6. Special Funded Program Clients CBHS designated programs that have been approved as exempt from Patient Billing and UMDAP; examples include: MHSA, IHBS, SB785, etc. AVATAR Family Registration Substance Abuse Providers use the same DHCS UMDAP Fee Schedule for determining their Clients sliding fees and are responsible for collecting patient amounts payable. However, SA Providers do NOT enter UMDAP information into the My Avatar/CalPM/ Family Registration 1 Refer to the Federal definition on Homelessness, Title 42, Chapter 119, Section 11302

4 form. Medi-Cal Share-of-Cost, UMDAP and Non-Medi-Cal Patient fees collected by SA Providers are reported on their FY Cost Reports. Therefore, SA Providers maintain a Patient Fee tracking, collection and payment process for their Clients accounts. Mental Health Providers enter their Clients UMDAP information into the Avatar/ CalPM/ Family Registration form. One CBHS Patient Account is created for all Family members receiving Mental Health services from CBHS. The CBHS Billing Office is responsible for processing Patient Fee Payments received from Clients, and for sending monthly Client billing statements listing services received and patient amounts due. Please see the CBHS Policy/procedures for Client Billing Statements and for Handling Patient Payments received in Clinics. SFHP Co-payments and Healthy San Francisco Point-of-Service Fees San Francisco Health Plan (SFHP) enrollees have a Per Visit Co-pay amount that is due at the time of service. If the Client forgets to pay or is unable to pay their Co-pay, please make a note on their Patient record or Progress Note. If the Client is unable to pay the Co-pay because of financial hardship, please refer the Client to the SF Health Plan to have their Co-pay amounts reduced or eliminated. The Client may be eligible for an entitlement program or another program that does not include a patient fee. Otherwise, it is a SFHP, CBHS, and a State requirement for these per-visit Copayment amounts to be collected. Healthy San Francisco (HSF) enrollees include working individuals whose Employers chose the City s plan for their employees and SF residents who have signed up for low or no cost healthcare coverage. HSF enrollees who have incomes above 150% FPL (Federal Poverty Level) have a Point-of-Service (POS) Fee that is payable at time of service. HSF enrollees who have income levels above FPL, and receive specialty services from CBHS are assessed a POS fee amount that is different than POS fees charged in Primary Care Clinics because the CA Dept of Health Care Services (DHCS) requires CBHS to use UMDAP. Further, DHCS allows SFDPH - CBHS to deduct the Clients HSF Participation Fee (i.e., the annual premium paid for HSF coverage) from their UMDAP annual liability amount. This adjusted annual UMDAP amount is divided by 12 (months). The resulting amount is the HSF Client s monthly POS fee for CBHS services. HSF Clients Point of Service fee amounts are determined based on information provided by SFHP to CBHS. Please contact the CBHS Billing - HSF Specialist at (415) for assistance. The Client or their Account Responsible Party signs the completed Client Authorization for Billing form. Patient Co-pay amounts, Co-insurance and/or deductible, or UMDAP payments that are collected by Mental Health Service Providers are processed and reported to the CBHS Billing Office, per CBHS Policy/Procedure Contact Person: CBHS Patient Accounts Billing Manager, (415) Distribution: CBHS Policies and Procedures are distributed by the Health and Information Management Department under the DPH Compliance Office Administrative Manual Holders

5 CBHS Programs SOC Program Managers BOCC Program Managers CDTA Program Managers CBHS Billing

Episode Guarantor Information

Episode Guarantor Information Guide Purpose: The Episode Guarantor Information form collects healthcare and benefit coverage information for Mental Health and Substance Abuse Clients for SFDPH Community