Pennsylvania Code › Title 55 - HUMAN SERVICES › Part VI - Mental Health/Intellectual Disability/Autism Manual › Subpart C - Administration and Fiscal Management › Chapter 4310 - CLIENT LIABILITY-STATE MH/ID FACILITIES › BILLING AND COLLECTION › Appendix A - LLR MONTHLY LIABILITY SCALE

Current through Register Vol. 54, No. 28, July 13, 2024
Annual Discretionary Income
Monthly Liability for Institutional Care
Annual Discretionary Income
Monthly
								Liability for Institutional Care
0-249
-3-
9000-9499
329.
250-499
11.
9500-9999
356.
500-999
22.
10,000-10,499
384.
1000-1499
36.
10,500-10,999
413.
1500-1999
50.
11,000-11,499
443.
2000-2499
65.
11,500-11,999
474.
2500-2999
79.
12,000-12,499
506.
3000-3499
94.
12,500-12,999
540.
3500-3999
108.
13,000-13,499
574.
4000-4499
122.
13,500-13,999
610.
4500-4999
137.
14,000-14,499
646.
5000-5499
151.
14,500-14,999
684.
5500-5999
170.
15,000-15,499
723.
6000-6499
189.
15,500-15,599
763.
6500-6999
210.
16,000-16,499
804.
7000-7499
231.
16,500-16,999
846.
7500-7999
254.
17,000 and
								over
1/20 of
8000-8499
278.
discretionary
8500-8999
303.
income +$23.00
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Dear
Under Sections 501, 502 and 503 of the Mental Health and
						Intellectual Disability Act of 1966, you are liable for services provided the
						client mentioned above. According to the Department of Human Service's
						Regulations promulgated as Chapter 4310 your monthly liability has been
						assessed in the maximum amount specified above. You will be billed monthly for
						services provided in accordance with charges established by the Department of
						Human Services or the amount of your liability, whichever is the lesser amount.
						It is your responsibility to report significant changes in income which may
						effect the amount of your liability.
If payment of the liability will cause a hardship for
						you, you may request an abatement or modification of liability by completing
						the form on the reverse side of this notice with a full explanation of the
						hardship created. Forward the PW-83 and a copy of the Determination of
						Liability - PW-833 to the Secretary of Public Welfare, Box 2675, Harrisburg,
						Pennsylvania 17105. If you need assistance, the facility providing the service
						will assist you in completing this request.
The basis for granting an abatement or modification of
						liability are detailed in the Notice of Rights - S1-83 provided with the Notice
						of Assessment - PW-83.
Debts that cannot be considered in granting abatement or
						modification of liability include:
(a) mortgage or rent on principal residence;
(b) utility payments;
(c) payments on first automobile;
(d) medical expenses already considered;
(e) debts incurred after treatment has begun;
(f) any other debt or payment for which the client has
						not incurred a legal obligation to pay;
(g) retail charge purchases for personal use items, food
						and/or commodities.
Any request for review must be made within 30 days from
						receipt of this notice. The time limit will not apply where hardship has been
						caused by unforeseen circumstances over which you have no control.
____________________________________
____________________________________
INSTITUTIONAL COLLECTIONS OFFICER
DATE
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To appeal a decision regarding the assessment of
						liability, a written request for a fair hearing must be submitted to the Office
						of Hearings and Appeals, Department of Public Welfare, P. O. Box 2675,
						Harrisburg, Pa. 17120, within 30 days of the date from which this decision was
						mailed.
In your request for a fair hearing you must state the
						reason(s) why you are appealing the Department's decision. It is also necessary
						that you list your name, address and telephone number, with area code, and
						whether or not you will be represented by counsel. If you are represented by
						counsel, list counsel's name, address, and telephone number, with area code, as
						the Office of Hearings and Appeals may elect to hold the hearing by
						telephone.
At the hearing, the appellant may represent himself or be
						represented by counsel, and has the following rights:
1. To present evidence on his own behalf, to bring
						witnesses, and to confront and cross-examine witnesses the Department will
						produce to support its decision or action.
2. To examine prior to the hearing, as well as during
						the hearing, that material from the patient's records that the Department will
						introduce as evidence in the hearing to support its decision or action.
3. To be provided with the names, addresses and
						telephone numbers of the Department's staff members and witnesses who will be
						present at the hearing.
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The provisions of this Appendix A amended under
						  sections 201(2) and (8) and 202 of the Mental Health and Intellectual
						  Disability Act of 1966 (50 P.S. §§
														4201(2) and
						  (8) and
						  4202).