Okla. Admin. Code § 450:1-7-6

Current through Vol. 42, No. 4, November 1, 2024

Section 450:1-7-6 - Liability of Consumer for care and treatment - Eligibility for Waiver of Liability

(a) A consumer at a facility within the Department is responsible for payment and liable for his care and treatment unless he or she has received a waiver of the indebtedness from the Department.

(b) A consumer at a facility within the Department shall be granted a waiver from payment for services if the following criteria are met:

(1) The individual must be in need of behavioral health services. An individual shall be considered to be in need of behavioral health services if treatment is needed to stabilize, reduce or eliminate the symptoms of, or prevent worsening of any of the following conditions for which a facility within the Department offers treatment needed based on the diagnosis and level of care:

(A) A diagnosable behavioral health condition as defined by the current DSM, excluding a sole diagnosis of developmental disorders or dementia disorders;

(B) A presenting problem(s) that indicates a behavioral health illness or condition;

(C) A level of functioning that indicates the need for behavioral health treatment based on a standard assessment instrument; or

(D) A behavioral health crisis.

(2) The individual must be uninsured. An individual shall be considered uninsured if one of the following applies:

(A) The individual is not covered by private or public insurance and receives no insurance benefits for behavioral health services;

(B) The individual has used all available benefits or coverage allowed for behavioral health services;

(C) The individual has limited benefits for behavioral health services, but the service(s) needed by the individual are not covered by the individual's insurance or plan; or

(D) Except for housing and vocational services, persons receiving behavioral health services through a health maintenance organization are considered to be fully covered for behavioral health services and are not eligible for a waiver of liability.

(3) The individual is indigent. An individual shall be considered indigent if he or she is at or below 200% of the Federal Poverty Guidelines based solely on the individual's applicable income. The indigence requirement does not apply to persons receiving emergency services or to persons seventeen (17) years of age or younger.

(A) "Income" is total annual cash receipts before taxes from all sources, and includes money wages and salaries before any deductions, net receipts from self-employment, 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 and Supplemental Security Income), training stipends; alimony, child support, military family allotments or other regular support from an absent family member or someone not living in the household, private pensions, government employee pensions, 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.

(B) "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 federal non-cash benefit programs such as Medicare, Medicaid, food stamps, school lunches, loans and housing assistance.

(C) Adjustments to "income" are allowed for the following:

(i) Child care allowance for dependent children under the age of fourteen (14). The amount of $200 for each child under the age of two (2), and $175 for each child under the age of fourteen (14) can be deducted from "income" to calculate total adjusted "income". If the family has children, there is no verification requirement.

(ii) Working adult allowance for working adults in the household. The amount of $240 for each working adult can be deducted from "income" to calculate total adjusted "income". "Working adult" is defined as a person age eighteen (18) or older with earned income (adult children in the household are not eligible to be counted for this deduction). There is no verification requirement for this deduction.

(c) Before any waiver of liability is granted, a report or questionnaire must be prepared which indicates the demographic information including the consumer's name, address if any, telephone number if any, and social security number, the consumer's income, number of dependents and third-party insurance or payer information. Income must be verified by the facility obtaining one of the following:

(1) The consumer's Internal Revenue Service Form W-2 from the previous year;

(2) The consumer's federal or state income tax return from the previous year;

(3) Two recent, consecutive paycheck stub(s) showing the pay date, hours worked, types of pay and gross rate of pay;

(4) A Medicaid card; or

(5) Any government document that verifies income.

If the facility is unable to verify the consumer's income by an independent source, the consumer or a family member of the consumer must sign an income verification statement before a waiver of liability may be granted.

(d) The executive director of the facility within the Department or his or her designee shall make a determination of whether the consumer meets the criteria for waiver of liability and sign a statement, which must be placed in the consumer's record at the facility, of the reasons for the waiver.

Okla. Admin. Code § 450:1-7-6

Added at 20 Ok Reg 2100, eff 7-1-03; Amended at 27 Ok Reg 2200, eff 7-11-10