Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 206 - BEHAVIORAL HEALTH SERVICES › Chapter 5 - CONSUMER ELIGIBILITY › Section 206-5-002 - CONSUMER ELIGIBILITY AND PAYMENT FOR SERVICES

Current through June 17, 2024
The Division will reimburse the Regional Behavioral Health Authorities
	 for behavioral health services for consumers who are in Nebraska voluntarily
	 and intend to make Nebraska his or her home and who meet:
(A) The clinical eligibility criteria for the
  services specified in the contract;
(B) The financial eligibility criteria as
  specified in the Region's Financial Eligibility Policy and Financial
  Eligibility Fee Schedule. For the fiscal year July 1, 2012 through June 30,
  2013, the Financial Eligibility Policy is based on the 2012 United States
  Department of Health and Human Services Federal Poverty Guidelines. For future
  fiscal years, the Financial Eligibility Policy and Financial Eligibility Fee
  Schedule will be adjusted based on changes to the annual United States Federal
  Poverty Guidelines and will not be specified in the regulations; and
(C) Lawful presence requirements set forth in
  Neb. Rev. Stat. §§
									4-108
  to
  4-114.
002.01
FINANCIAL ASSESSMENT OF
  ELIGIBILITY.
The assessment of a consumer's financial eligibility
  is an ongoing process. The consumer's financial eligibility status must be
  re-assessed annually or when known changes occur that increase or decrease the
  copayment obligations of the consumer.
002.02
REFUSAL TO PROVIDE
  FINANCIAL INFORMATION.
Consumers who refuse to provide financial
  information shall be charged the full cost of services. The provider may not
  bill the Division for any service for which the consumer is responsible due to
  the failure of the consumer to provide financial information or attest to the
  financial information.
002.03
POLICIES AND FEE SCHEDULES.
Regional Behavioral Health
  Authority's Financial Eligibility Policy and Financial Eligibility Fee Schedule
  shall be adopted pursuant to Neb. Rev. Stat. §
										71-809.
  The Financial Eligibility Policy and Financial Eligibility Fee Schedule shall
  be approved by the Division.
002.04
REIMBURSEMENT.
For a consumer who meets the clinical
  eligibility, financial eligibility, and lawful presence criteria, the Regional
  Behavioral Health Authority will be reimbursed:
(A) At the rate set by the Division for
  services provided which are pre-authorized;
(B) The Region-determined rate of
  reimbursement for allowable uncompensated expenses for services provided;
  and
(C) Not more than the actual
  cost of the service less any co-payment and third party payment received for
  the service.
002.05
PAYOR OF LAST RESORT.
The Division reserves the right
  to be the payer of last resort for consumers who meet the Division's clinical
  criteria for an identified level of care and who are without the financial
  resources to pay for care. The Division will not reimburse:
(A) For Medicaid reimbursable services
  provided to Medicaid consumers. If the consumer has accrued personal needs
  allowance and created savings that disqualify him or her from a benefit such as
  Medicaid, the full cost of the service must be assessed to the consumer until
  he or she qualifies for the Medicaid benefit.
(B) For any portion of services required to
  be paid by a Medicaid recipient to meet a share of cost obligation.
(C) For services eligible for, or covered
  under, other health insurance benefits that were:
(i) Denied by an insurance company due to
  provider error, insufficient documentation, or lack of medical
  necessity;
(ii) That were not
  submitted to the insurance company in accordance with the policy; or
(iii) That were not submitted to the
  insurance company at the request of the consumer.
(D) For any service in which the consumer is
  deemed eligible to pay the cost of the service.
002.06
DETERMINATION OF FINANCIAL
  ELIGIBILITY.
To determine if a consumer meets financial
  eligibility on the Financial Eligibility Policy and Financial Eligibility Fee
  Schedule:
(A) Complete the eligibility
  worksheet to determine the adjusted monthly income. To determine the adjusted
  monthly income:
(i) Add up wages, alimony,
  tips or other money received for a good or service in the past 12 month period.
  Divide this number by 12 to determine the taxable monthly income of the
  consumer.
(ii) Determine the
  monthly amount for housing, utilities, transportation, or daycare paid by the
  consumer. Actual cost claimed cannot exceed the maximum amounts listed on the
  worksheet for each item. Total the amounts listed for housing, utilities,
  transportation, and daycare to determine total allowable liabilities.
(iii) Subtract the total allowable
  liabilities from the taxable monthly income to determine the adjusted monthly
  income amount to be used to determine eligibility for funded
  services.
(B) Locate the
  adjusted monthly income amount on the appropriate fee schedule;
(i) The Financial Eligibility Fee Schedule is
  used for consumers who do not meet the requirements for the hardship or
  emergency access fee schedules.
(ii) Hardship fee schedule is used for:
(1) Consumers who meet criteria for severe
  and persistent mental illness; or
(2) Consumers who meet criteria for serious
  emotional disorder in youth 19 or under; or
(3) Medical bills or medical debt in excess
  of 10% of the taxable annual income.
(iii) Emergency access fee schedule is used
  for:
(1) Consumers receiving assistance from
  crisis response team, emergency community support, housing related assistance;
  or
(2) The hospital diversion
  services where consumers stay less than 24 hours.
(C) Locate the total number of
  family members dependent on the taxable income; and
(D) Only those consumers who fall within the
  shaded areas on the fee schedules are eligible for services funded by the
  Division.
002.07
CO-PAYMENT.
In addition to payments made by the
  Division, the Regional Behavioral Health Authority may assess consumers a
  co-payment fee based upon the Financial Eligibility Fee Schedule. To determine
  the maximum co-payment:
(A) Locate the
  adjusted monthly income amount on the appropriate schedule.
(B) Locate the total number of family members
  dependent on the taxable income.
(C) Locate the box in which the column and
  row intersect is the maximum co-payment fee to be charged to the consumer for
  each appointment or unit of service.
002.08
RESIDENTIAL LEVELS OF
  CARE.
Residential levels of care will receive payment based on the
  Division's established rates. In addition to room and board fees, co-payment
  fees may also be assessed. The room and board fee may not be in excess of
  actual costs incurred for these services by the provider. All co-payments
  charged must be in compliance with the Region's Financial Eligibility Policy
  and Financial Eligibility Fee Schedule.
002.09
SUBSTANCE USE DISORDER
  EDUCATION AND DIVERSION.
Fees and copayments for substance use
  disorder education and diversion services are determined by the Region or other
  providers and are not subject to the provisions of the Region's Financial
  Eligibility Policy and Financial Eligibility Fee Schedule.
002.10
ELIGIBILITY
  VERIFICATION.
The Division or the Regional Behavioral Health
  Authority may request from the provider verification of a consumer's
  eligibility for service.