Standard Means Test

PURPOSE: This rule prescribes a standard means test as required by section 630.210, RSMo, to determine amounts to be charged for services provided or procured by the Department of Mental Health. (1) Definitions. The terms defined in section 630.005, RSMo, are incorporated by reference as though set out in this rule. The following other terms used in this rule, unless the text clearly requires otherwise, shall mean: (A) Adjusted gross monthly income—the income remaining after allowable deductions permitted by this rule; (B) Community psychiatric rehabilitation center (CPR provider or CPR program)—an organization which provides or arranges for, at the minimum, the following core services: intake and annual evaluations, crisis intervention and resolution, medication services, consultation services, medication administration, community support, and psychosocial rehabilitation in a nonresidential setting for individuals with serious mental illness in conjunction with standards set forth in 9 CSR 30-4.031–9 CSR 30-4.047; (C) Community services—any services purchased or provided by the department that are not included in the definition of “longterm care”; (D) Community support services—for the Division of Developmental Disabilities (DD), this means all Purchase of Service (POS) services, case management services for clients residing in Community Placement Program (CPP) facilities and in their natural homes, Choices for Families services, and all voucher services; for the Division of Comprehensive Psychiatric Services (CPS), this means Family Preservation services, Intensive Case Management services for children and adults, Supported Housing Voucher Program or Housing and Urban Development (HUD) Housing Voucher Program services, and Intergrated Employment Support services; for the Division of Alcohol and Drug Abuse (ADA), this applies to drug-free counseling services provided to clients participating in a methadone maintenance program who have become drug-free; (E) Early intervention services—developmental services provided by qualified personnel to meet infant’s or toddler’s developmental needs in one (1) or more of the following areas: physical development, cognitive development, language and speech development, psychosocial development, or self-help skills. Early intervention services must be provided in conformity with an individualized family service plan. Early intervention services may include, but are not limited to: 1. Family training, counseling, and home visits; 2. Special instructions; 3. Speech pathology and audiology; 4. Occupational therapy; 5. Physical therapy; 6. Transportation; 7. Psychological services; 8. Social work; 9. Case management services; 10. Nursing services; 11. Nutrition services; 12. Medical services for diagnostic or evaluation purposes; 13. Early identification, screening, and assessment services; and 14. Health services which enable infants or toddlers to benefit from other early intervention services; (F) Financially responsible person—the individual who is obligated by law or this rule to pay charges for services; (G) Gross monthly income (earned and unearned)—the total monthly income from all sources before payroll deductions, other withholdings, and expenses incurred in earning the income. Examples would include salaries and wages, dividends, annuities, interest, rents, pensions, disability and survivor benefits, Workers’ Compensation, unemployment compensation, maintenance and child support payments, bonuses, tips and gratuities, income from business or profession, and any other taxable and nontaxable income; (H) Household size—the number of persons dependent upon the income of the financially responsible person including the person (recipient) receiving services, except for a blended family situation. Dependency for family members, other than the recipient, must meet the dependency test in the federal Internal Revenue Code; (I) Long-term care—continuous residential care (excluding supportive housing) which meets any of the following conditions: 1. Admission to a habilitation center; 2. Admission to a community placement facility; 3. A statement signed by a physician or a qualified mental health professional that the care is for an indeterminate period; or 4. The care has been provided for at least twenty-four (24) months without any documentation in the recipient’s individualized treatment, habilitation, or rehabilitation plan indicating discharge is imminent (within ninety (90) days); (J) Monthly rate—the amount determined by application of the sliding fee scale to be charged for services provided in a month; (K) Provider—a public or private agency offering services to individuals approved for Department of Mental Health (DMH)-funded services; (L) Recipient-client, patient, or resident— the person receiving services; (M) Representative payee—guardian, trustee, conservator, or other fiduciary appointed to receive a beneficiary’s benefits (for example, Social Security, Railroad Retirement); (N) Sliding fee scale—a table for determining the monthly rate to be charged to a financially responsible person for services; and (O) Unearned income—income that is not derived from employment. Examples would include maintenance and child support monies, interests, pensions, unemployment benefits, Workers’ Compensation, and benefits from the Social Security Administration, Railroad Retirement Board, Civil Service Commission, Veterans Administration, and other similar types of income. (2) Charges Not to Exceed Costs. The charges determined by the application of this rule shall not exceed costs. For providers operated by the department, the costs are determined annually as required by section 630.210, RSMo. For other providers, the costs are authorized by contract with the department. If more than one (1) source of reimbursement is being charged, then collectively the charges shall not exceed costs. (3) Community Support Incentives/POS. The following financial incentives shall be provided to clients and families receiving less costly community support services: (A) Clients or their financially responsible parties shall be assessed at a rate of one-fourth (1/4) their monthly ability to pay, for community support services which are received by the client, except for the case management services specified in subsection (3)(B). Insurance companies and other third-party payers shall be billed at actual cost for all community support services, including the case management services specified in subsection (3)(B); and (B) For case management services reimbursed by the Division of Developmental Disabilities and intensive case management services reimbursed by the Division of Comprehensive Psychiatric Services, only clients or their financially responsible parties with annual adjusted gross incomes exceeding one hundred thousand dollars ($100,000) in 1991 dollars, adjusted annually for inflation using the Consumer Price Index (CPI), shall be assessed a charge, and the charge shall be the lesser of actual cost or one-fourth (1/4) their monthly ability to pay. (4) Health Insurance. The provider shall apply to the costs incurred for providing services to the recipient the benefits received or available on behalf of or to the recipient from private and public health insurance, health services corporation and health maintenance organization plans, policies and contracts including individual, company, fraternal, group, Medicare, Medicaid, and similar plans to the extent and limits of the coverage for the recipient. If a federal program requires the department to accept federal reimbursement as full payment as a condition of participation in the program for certain services, the provider shall not charge the financially responsible person for the services except the federally permitted deductibles or coinsurances. (5) Financial Responsibility. As set out in section 630.205, RSMo, the following are jointly and severally liable to pay under this rule for services rendered to a recipient: (A) The recipient; (B) The recipient’s estate only to the extent of the assets in the estate, if the recipient has a conservator or is deceased; (C) The recipient’s spouse unless otherwise provided for in a separation agreement or dissolution order approved by a court of competent jurisdiction; (D) The recipient’s natural parents’ ability to pay is based separately on their own income with each claiming the children from that marriage as dependents. All child support, even if it is for other children that were a result of that marriage that are not our clients, will be considered in total income; (E) Any fiduciary, such as a trustee, only to the extent of the assets the fiduciary is holding on behalf of or for the recipient, which assets may be used according to law; except for any assets held in the Missouri Family Trust Fund on behalf of or for the recipient; (F) Any representative payee to the extent of the benefits and assets under the law governing and permitting payment of benefits and assets for the recipient; (G) The recipient’s parents if the recipient is a minor (under age eighteen (18)), except the following: 1. The parents of a minor recipient who has been emancipated; 2. The parents of a minor recipient if the parents have relinquished parental responsibility through legal adoption or have had parental rights terminated by an action of a juvenile court; 3. The parents of a recipient age three to eighteen (3–18), a recipient age three to twenty-one (3–21), or the spouse or estate of a recipient age three to twenty-one (3–21) are not liable for the cost of education, special education, or related services. The parents of a recipient age birth to three (0–3) are not liable for the cost of prevention and early intervention services provided through P.L. 102-119 Part H First Steps. The term special education, as used in this rule, is defined in 34 CFR Section 300a.14. The term related services, as used in this rule, is defined in 34 CFR 300a.13; 4. The adoptive parents of a minor recipient who had been, before the adoption, court committed to the legal custody of the department, the Department of Social Services, or a charitable organization; and 5. Stepparents’ income; (H) If two (2) or more members of a household receive services in the same month, the provider shall charge no more than the amounts determined by application of the sliding fee scale for one (1) recipient. Before this shall apply, the financially responsible person shall notify the provider when services are provided to more than one (1) member of the household in the same month; (I) If the recipient is eligible for Medicaid (under any state entitlement program), Supplemental Security Income (SSI), General Relief (GR), or Food Stamps, the Standard Means Test (SMT) is not required to be implemented, with the exceptions that are found in other parts of this rule. Documentation of the eligibility must be placed in the financial file in lieu of an SMT; (J) If the recipient is eligible for Title IVA, the SMT will not need to be implemented. Documentation of eligibility must be placed in the financial file in lieu of an SMT; (K) If it appears from the application of the SMT that the recipient could be assessed under more than one (1) client identifier, the formula which requires the least amount of client pay will be used; and (L) The department shall consider noncustodial parents court orders regarding support payments and medical coverage obligations. (6) Charges for Nonresidents. If a recipient of any age is not domiciled in this state, as defined in 9 CSR 10-31.016, then those responsible to pay, the parents, school district, special district or state department or agency of the recipient’s domicile, under this rule are liable to pay the full cost of the services. (7) Sliding Fee Scale. The scale determines the monthly rate to be charged to a financially responsible person for services. The scale was developed using three hundred percent (300%) of the federal poverty guidelines for the year 2009 and income withholding tables for federal and state taxes. The scale shall be updated annually when changes have occurred in the federal poverty guidelines or the tax withholding tables. The adjusted gross monthly income on the sliding fee scale is determined by deducting the following expenses from gross income: (A) Business expenses and expenses incurred on income-producing property when the income is included in gross income under this rule and the expenses were deducted on the federal income tax return; (B) Business expenses which have no history and are now being claimed will be based on federal tax guidelines; if a review finds business expenses were invalid, then the rate will be adjusted to their ability to pay, retroactively; (C) Medical expenses deducted by the taxpayer (financially responsible person) on the most recent filed tax year that exceed the federal percentage rate allowable of the federal adjusted gross income in (1996) or medical expenses that exceed the federal percentage and cannot be claimed on the federal tax return due to inability to itemize deductions, proof of payment must be presented; (D) Medical expenses, anticipated or unanticipated, that will be scheduled as a monthly payment. Documentation must be presented that the payments have been or are being made. If a review finds that payments were not or are not being made, then the rate will be adjusted to their actual ability to pay, retroactively; and (E) Child support paid by a parent, whether the parent can claim the child as a dependent or not, shall be a deduction to income. Documentation must be provided that payments are being made. (8) Charges for Long-Term Care. The charges shall be determined under this section, and only under this section, when the recipient requires long-term care. (A) If the recipient is with his/her spouse or dependents, the provider shall charge the recipient, his/her estate, fiduciary, or representative payee as follows: If the recipient is with his/her spouse or dependents, all unearned income should be treated as earned income and assessed according to the sliding fee scale, except in those cases where the spouses are estranged. (B) If the recipient in a residential care or inpatient facility purchased or operated by DMH is without spouse or dependents, then the provider shall consider all of a recipient’s real and personal property when the provider has obtained and filed an annual statement from a licensed physician or a qualified mental health professional indicating that the recipient requires full-time residential services or, if the recipient has been in full-time residential services, twenty-four (24) or more continuous months previously. The provider shall charge all costs until the recipient’s estate is reduced to the allowable amount for Medicaid eligibility, except cash and securities shall not exceed ninety-five percent (95%) of the Medicaid limit on cash and securities. The provider (DMH-operated or purchased facility) shall apply all unearned income to the cost of services, except that the provider shall make an allowance of thirty dollars ($30) or more per month for personal spending as specified in the recipient’s individualized treatment, habilitation, or rehabilitation plan. If the representative payee is the conservator, then the court-ordered costs shall be a reduction in the amount assessed upon the recipient’s benefits. (C) Subsections (8)(A) and (B) of this rule may be waived whenever the release of the recipient is imminent (within ninety (90) days), the unmet needs of the recipient have been documented and the recipient’s existing funds are inadequate to pay the costs of the needs documented in the recipient’s individualized habilitation, rehabilitation, or treatment plan. (9) Charges for Community Services. Only financially responsible persons whose income is equal to, or greater than, three hundred percent (300%) of the federal poverty guidelines shall be assessed a monthly rate using the sliding fee scale, except that no financially responsible person shall be assessed a monthly rate for services received through a Community Psychiatric Rehabilitation Center or Compulsive Gambling services as defined in 9 CSR 30-3.134(1). (10) Working Clients. If the recipient is a working client and is without a spouse, dependents, or both, the provider shall apply to costs of services forty percent (40%) of all net earned income exceeding one hundred dollars ($100) per month, except in cases where DMH is not paying room and board costs. In these cases, the sliding fee scale shall be applied. (11) Documentation Requirements. For community services, the financially responsible persons shall certify their income to the provider. If the provider has reasons to believe that the income certified by the financially responsible persons is inaccurate, then the provider shall request the documentation required below for individuals receiving longterm care. For long-term care, the financially responsible persons shall furnish the provider written statements of their income (for example, most recent year’s filed complete federal tax return) or other supporting documentation requested by the provider for income verification. If the provider applies the longterm care provisions under this rule, then the provider shall obtain a statement of the recipient’s personal and real assets and other supporting documentation. Documentation must be provided for any deductions to gross income. (12) Failure to Comply. The provider shall have the recipient or financially responsible person apply for benefits and entitlements described in this rule if it appears the recipient is eligible. The provider may charge the financially responsible person all costs of providing or procuring the services when the recipient or financially responsible person— (A) Deliberately fails to divulge financial resources upon request of the provider; (B) Fails to apply or permit the provider to apply for benefits; or (C) Fails to assign benefits. (13) Failure to Pay. The provider may take action to collect any unpaid amounts charged based on the sliding fee scale or the full cost based on the failure to comply. These actions may include, but are not limited to, Missouri State Income Tax Intercept and any further action allowable under state and federal law. (14) Voluntary Payments. The provider may accept voluntary payments from individuals not legally obligated to pay and payments made in addition to the amounts determined by application of this rule. Providers operated by the department shall receive gifts, donations, devises, or bequests as set out in section 630.330, RSMo. For services to clients, vendors or department-operated providers may set a minimal charge for services to clients which may exceed the monthly charge applicable under this rule. The charge shall not exceed five dollars ($5) per visit and shall be an offset against any charges determined as otherwise applicable under this rule, per program, per provider. If one (1) client is assessed a minimal charge, all clients in that program must be assessed the same minimal charge. The provider can determine that an urgent need for immediate services overrides any inability or refusal to pay. (15) Test Application Procedures. The director delegates his/her authority to complete the SMT to any provider operated by the department. Other providers (for example, nonstate community mental health centers or substance abuse programs) which serve recipients directly without having them go through department case management shall apply the test if the providers agree to do so under the terms of contracts with the department. (A) The provider shall apply the SMT contained in this rule at admission, annually after admission if the recipient is still receiving services, upon request from the recipient or responsible party, or by the initiative of the provider or the department director due to any significant change in financial status. (B) The provider shall apply the test in this rule on all recipients as of February 26, 1993. (C) Upon request for review, the provider shall change the monthly rate, if warranted, effective to the first day of the month of the date of request. (D) As other substantial changes occur in income or asset status, the provider shall reapply the test and the changes shall be effective as of the first day of the month following the date of the reapplication of the test. If inaccurate or fraudulent information was provided for determining charges, or if the recipient is entitled to retroactive benefits, the provider shall retroactively change the amount charged. (16) Appeal Procedures. The application of the SMT may be appealed by the financially responsible person to the chief administrative officer of the provider and then the department director as follows: (A) The chief administrative officer of the provider shall review upon appeal the application of the test as to the verification of financial resources, the determination of charges, and issue a decision to the financially responsible person; (B) The decision of the chief administrative officer of the provider may be appealed to the department director within fifteen (15) days of the receipt of the decision. The director will review appeals only if the recipient or responsible party alleges the incorrect application of the test. Upon completion of the review, the director shall issue a decision which may alter application of the test; (C) As set out in section 630.210, RSMo, the decision of the director may be reviewed in the circuit court of Cole County or the circuit court in the county where the financially responsible person legally obligated to pay resides according to the procedure set out in Chapter 536, RSMo; and (D) Pending the decision upon appeal by the provider’s chief administrative officer, the decision of the department director, if appealed, or decision of a court of competent jurisdiction, if judicially reviewed, whichever is later, the department shall hold the provider harmless and shall pay disputed amounts to the provider, if necessary, to continue services to the recipient. If the financially responsible person is deemed obligated to pay any of the disputed amounts after the appeal is completed, then the financially responsible person shall pay the amounts to the provider as an offset to the department’s future support or to the department if no future department support is to be provided. (17) Probation and Parole Clients. For services provided under terms and conditions of probation and parole, the provider may determine charges related to income and consistent with the treatment and rehabilitation goals of the terms and conditions of probation and parole as approved in writing by the department and the supervising court. (18) Waiver Authority. The director may waive the application of the SMT to specific services, programs, or populations, or for specific purposes, or in specific situations, when the director determines that it is in the best interests of the state, the department, and the individuals served by the department to do so. Examples of situations in which waivers may be deemed appropriate include natural or man-made disasters, temporary services or programs which are not suited to the current SMT process, specific situations in which collections do not justify the administrative burden of applying the SMT, and situations in which the cost of providing services is fully covered by another funding source. AUTHORITY: sections 630.050 and 630.210, RSMo Supp. 2009.* Original rule filed May 12, 1981, effective Jan. 1, 1982. Emergency amendment filed March 19, 1982, effective April 1, 1982, expired July 11, 1982. Amended: Filed April 14, 1982, effective July 11, 1982. Emergency amendment filed Dec. 20, 1982, effective Jan. 1, 1983, expired April 1, 1983. Emergency amendment filed June 20, 1983, effective July 1, 1983, expired Nov. 1, 1983. Amended: Filed June 20, 1983, effective Nov. 1, 1983. Emergency amendment filed Sept. 13, 1983, effective Oct. 1, 1983, expired Jan. 1, 1984. Amended: Filed Sept. 13, 1983, effective Jan. 1, 1984. Amended: Filed Oct. 11, 1984, effective Jan. 14, 1985. Amended: Filed Aug. 15, 1985, effective Nov. 11, 1985. Emergency amendment filed June 17, 1986, effective June 27, 1986, expired Oct. 15, 1986. Amended: Filed July 14, 1986, effective Nov. 28, 1986. Emergency amendment filed Dec. 20, 1990, effective Dec. 30, 1990, expired April 28, 1991. Amended: Filed Dec. 21, 1990, effective April 29, 1991. Emergency amendment filed May 21, 1991, effective July 1, 1991, expired Oct. 28, 1991. Amended: Filed Feb. 15, 1991, effective Aug. 30, 1991. Emergency rule filed Oct. 13, 1992, effective Oct. 23, 1992, expired Feb. 19, 1993. Emergency amendment filed Oct. 23, 1992, effective Nov. 2, 1992, expired Feb. 19, 1993. Rescinded and readopted: Filed May 15, 1992, effective Feb. 26, 1993. Emergency rule filed Feb. 10, 1993, effective Feb. 20, 1993, expired June 19, 1993. Amended: Filed Nov. 4, 1992, effective May 6, 1993. Amended: Filed July 17, 1995, effective Jan. 30, 1996. Amended: Filed Dec. 1, 2009, effective May 30, 2010. *Original authority: 630.050, RSMo 1980, amended 1993, 1995, 2008 and 630.210, RSMo 1980, amended 1981, 1982, 1993, 2004.