Section 1.03. Billing rates and ability to pay.

 

(1)   Applicable insurance. Where applicable insurance exists, the insurer shall be billed an amount equal to the fee, as determined pursuant to these rules, times the number of units of service provided.

(2)   Clients residing in facilities (medical or non-medical) with unearned income. A client receiving room and board with care or services and who is the beneficiary of monthly payments intended to meet maintenance needs and/or accrues unearned income (including but not limited to interest from assets such as savings and investments), shall be expected to pay the lesser of the monthly liability for that care or the total amount of unearned income that month less an amount sufficient to satisfy the client's unmet personal needs and any court-ordered payments or support of legal dependents. The monthly amount of interest income is determined by dividing the current annual interest income by 12. If payments of unearned income are made to a representative payee or guardian, that person shall be expected to pay from the resources of the client as specified for the client but subject to further possible reductions according to other prerequisite uses of the benefit payments a payee may be required or permitted to make as established by the payer. For clients in full-care, non-medical facilities receiving SSI benefits, no attempt shall be made to collect from any responsible party any remaining liability for those months that SSI payments are applied to the cost if such collections would reduce the SSI payment.

(3)   Clients residing in facilities (medical or non-medical) with earned income. Except for clients who are full time students or part-time students who are not full time employees, clients receiving room and board with care or services who have earned income shall be expected to pay any remaining liability for that care each month from earnings as follows: after subtraction of the first $65 of net earnings (after taxes) and any unmet court-ordered obligations or support of legal dependents, up to one-half the remaining amount of earnings.

(4)   Payment adjustment from client's earned income. The appropriate payment approval authority may authorize the following modification to sub. (3) for clients whose care-treatment plans provide for economic independence within less than one year: subtract up to $240 of net earnings after taxes and proceed under the provisions of sub. (3) provided that any amounts subtracted beyond $65 per month under this subsection are used for the following purposes:

(a) Savings to furnish and initiate an independent living arrangement for the client upon release from the facility. Under this provision, earnings shall not be conserved beyond the point that the client would no longer meet the asset eligibility limits for SSI or Medicaid.

(b) Purchase of clothing and other reasonable personal expenses the client will need to enter an independent living arrangement.

(c) Repayment of previously incurred debts.

(5)   Payment adjustment from client's unearned and earned income. When a client resides in a facility less than 15 days in any calendar month, payments expected under subs. (2) and (3) may be prorated between the days the client spends in and out of the facility. A daily payment rate may be calculated by multiplying the monthly amount determined under subs. (2) and (3) by 12 and dividing by 365. The daily payment rate times the days the client spends in the facility determines the amount of the payment expected from the client's income. The provisions for determining the client's "available income" in billing Medicaid shall take precedence over this procedure wherever applicable.

(6)   Clients residing in facilities (medical or non-medical) with liquid assets in excess of eligibility for ssi or medicaid. Clients residing in facilities shall be expected to pay any remaining liability for that care until their assets are reduced to eligibility limits for SSI or Medicaid except as follows:

(a) As protected by law or an order of the court.

(b) As may be protected in full or in part by a written agreement approved by the appropriate payment approval authority upon presentation in writing by the client or client's guardian, trustee or advocate, any specific and viable future plans or uses for which the excess assets are intended. Such documentation shall include the extent to which the client's funds need to be protected for purposes of preventing further dependency of the client upon the public and/or of enhancing development of the client into a normal and self-supporting member of society.

(7)   Notification. The payment approval authority shall assure that clients and responsible parties are informed as early as administratively and clinically feasible of their rights and responsibilities under the uniform fee system. The department shall provide sample brochures for the various service categories to assist payment approval authorities with this requirement.

(8)   Refusal to provide full financial information. A responsible party who is informed of his or her rights and knowingly refuses to provide full financial information and authorizations for billing all applicable insurance shall not be eligible under s. DHS 1.02 (6) to discharge liability other than by means of full payment.

(9)   Intake process. In conjunction with appropriate notification, the intake process for each client who receives fee-chargeable or third-party billable services shall include sufficient time and capability to complete all necessary information for billing including an application for ability to pay considerations.

(10)   Financial information form.

(a) Except as otherwise provided in this chapter, the Financial Information Form (DMT 130) is mandatory when a responsible party chooses to be considered for ability to pay provisions.

(b) County agencies may use their own forms in place of DMT 130 subject to the prior approval of the department. Any substitute form must be capable of fulfilling the same provisions as the current DMT 130.

(11)   Billing on the basis of ability to pay.

(a) A responsible party who provides full financial information and authorizations for billing all applicable insurance shall be billed on the basis of the family's ability to pay.

(b) For each family, ability to pay shall be determined in the following manner:

1. The annual gross income of all family members shall be determined and totaled except that the earned income of a child who is a full-time student or a part-time student but not a full-time employee shall be excluded. Income from self-employment or rent shall be the total net income after expenses. Depreciation on farm, business or rental property and wages paid to members of the family shall not be treated as expenses for this purpose. Actual principal payments on capital equipment and depreciated property shall be allowed as an expense. The income of any family member in a residential setting is treated separately under this section.

2. The monthly average income shall be computed by dividing the annual gross income by 12.

3. Monthly payments from court ordered obligations shall be subtracted from monthly average income.

4. For services other than care to minors in state institutions, the department may permit a payment approval authority to add an amount based on the value of assets to monthly income. This amount may not exceed 1/6 of the assets that would be considered excess assets for the purpose of determining eligibility for the medical assistance program.

(12)   Maximum monthly payment. A family providing full financial information shall be billed at a monthly rate that does not exceed the maximum amount computed by means of the following formulas:

(a) Long-term support for adults. For long-term support for adults in the department's community options program and similar programs, an amount not to exceed the monthly income computed according to sub. (11) less the following:

1. Estimated income taxes, social security or federal retirement obligations; and

2. An amount determined annually by the department which is no less than current income limits for medically needy persons in the Wisconsin medical assistance program.

(b) Child day care. For child day care, the monthly payment when income computed under sub. (11) is less than 50% of the state median income as defined by the department shall be zero. For income at 50% of the state median income, the maximum payment shall be $5.00 per month. For income at 60% of the state median income, the payment shall be $30.00 per month. The maximum payment for income at 100% of the state median income shall be $266 per month. The department shall annually publish a schedule which prorates the day care payments for income levels for each one percent increase in income from 50% to 100% of the state median income. Parental payment limits in sub. (18) (a) do not apply to this paragraph.

(c) Other services for children. Except as provided in s. DHS 1.065 , for other services to children, the maximum monthly payment for a parent shall be computed as follows:

1.

a. Subtract the appropriate minimum family budget in Table 1.03 (12) from the family's monthly income computed under sub. (11) . - See PDF for table

b. For years after calendar year 1985, the department shall update the allowances in Table DHS 1.03 (12) by the same percentage used to update family budgets in the aid to families with dependent children program.

2. If remaining income is:

a. Less than $1.00, the maximum monthly payment is zero;

b. At least $1.00 but less than $543, the maximum monthly payment is 28% of the income in excess of $1.00;

c. At least $543, the maximum monthly payment is $152 plus 7% of the income in excess of $543.

3. The department shall publish a schedule annually for agencies to compute maximum monthly payment rates under this paragraph.

(d) All other services. For all other services, the department shall publish maximum monthly payment schedules or formulas that require payments no higher than those computed under par. (a) .

(12m)   Maximum monthly payment for a child in a court-ordered out-of-home placement. The maximum monthly payment of parents for court-ordered out-of-home placements of their children under chs. 48 and 938 , Stats., shall be determined according to procedures in s. DHS 1.07 .

(13)   Minimum payment. The appropriate payment approval authority may establish a minimum payment rate up to $25.00 per month or 3% of gross income across-the-board for all persons or families incurring liability for a fee chargeable service whose maximum monthly payment as calculated according to subs. (2) through (6) or (12) is less than the minimum rate. Where minimum rates are used, all persons or families shall be expected to pay the applicable minimum rate except where liability is waived according to s. DHS 1.02 (7) or where a minimum payment exceeds the available income of the responsible party or parties. Minimum charges under this section may also be set on a per unit basis, for instance, per hour or per day, provided the charges do not accumulate to exceed $25.00 per month or 3% of monthly income.

(13m)   Special payment schedules. The department may establish special payment schedules, to be used in place of schedules determined according to sub. (12) or (13) , for designated providers and types of services on a pilot basis for periods not to exceed 3 years. Special payment schedules shall be directed toward goals which include, but are not limited to, increasing revenue to expand or maintain service levels, improving administration of the fee system and assessing the impact of different fee approaches on service. Beyond the pilot period, the payment schedule for the designated type of service shall be established according to sub. (12) or (13) or any other applicable provision of law. Special payment schedules shall incorporate standards for income and may incorporate standards for assets. These standards may not be more stringent than the income and assets provisions of the Wisconsin medical assistance program described in ss. DHS 103.04 and 103.05 . However, where income is less than the limit for medical assistance eligibility, the department may approve schedules where assets are not considered and payments for a month of service do not exceed 3% of the family's gross monthly income.

(14)   Adjustments. The maximum monthly payment rate calculated under sub. (12) or (13) is adjustable in the following situations:

(a) In cases where family members who contribute to the family income are not responsible parties for the liability being charged to the family, the maximum monthly payment rate shall not exceed the sum of the unearned and one-half the earned income of responsible party or parties, less an amount equal to that used by the Wisconsin AFDC program for work related expenses.

(b) When payment at the maximum monthly payment rate, as calculated in sub. (12) or (13) , would create a documentable hardship on the family, (such as the forced sale of the family residence or cessation of an education program), a lower maximum monthly payment rate may be authorized by the appropriate payment approval authority under the following provisions:

1. Hardship adjustments are normally restricted to situations where services extend more than one year, and sufficient relief is not afforded to the family through an extended or deferred payment plan.

2. Each hardship adjustment shall be documented by additional family financial information. Such documentation shall become part of the client's collection file as provided in s. DHS 1.06 .

3. Responsible parties shall be informed in writing of approval or denial with approval taking the form of a written agreement.

4. Hardship adjustments shall be reviewed annually and, if necessary, renegotiated.

(15)   Extended payment plans. Agencies may work out an extended payment plan with any responsible party who indicates that payment at the monthly payment rate would place a burden on the responsible party's family. This payment plan has the effect of the responsible party paying a lesser monthly amount over a longer period of time but with the total expected amount to equal the full application of the monthly payment rate under s. DHS 1.02 (6) . Authority to approve extended payment plans may be placed at whatever staff level the payment approval authority determines is appropriate.

(16)   Shortcuts to document no ability to pay for services not covered by third-party payers.

(a) Family income information in form DMT 130 is not required where no family member receives earned income and the family is supported in full or in part by income maintenance benefits.

(b) The financial information form (DMT 130) is not required for fee-chargeable services when zero ability to pay can be documented. The following families making application for services are automatically considered to have no ability to pay when the following financial information is documented on other forms required by the department.

1. Recipients of SSI.

2. When the family has no earned income and are recipients of AFDC, Medical Assistance, Food Stamps or General Relief.

3. Families whose income is lower than the point at which payment begins according to the maximum monthly payment rate schedule for families of similar size.

(17)   Relationship to extent of services. When full financial information is provided, the monthly payment rate established according to sub. (12) or (13) and adjusted according to sub. (14) (a) is the total ceiling amount that the family may be billed a month regardless of the number of family members receiving services, the number of agencies providing services, or the magnitude or extent of services received.

(18)   Exceptions.

(a) Parental payment limits set according to sub. (21) shall be applied to billings to parents for each child who receives care or services in a state center for the developmentally disabled. The department may also approve parental payment limits set according to sub. (21) which are requested by payment approval authorities for any other care or services provided to children. When parents of a child are divorced or separated, the total billed to both parents for the care of a child may not exceed the one billing limit used for the care or services received by the child. When a minor child and an adult from one family receive services, the parental payment limit may not be applied to billings for services to the adult. When used, parental payment limits shall be applied as follows:

1. For outpatient psychotherapy normally covered by health insurance and purchased or provided by county agencies, parents who provide full insurance information and necessary authorizations for billing all applicable insurance may not be billed a total amount per child per month greater than the monthly parental payment limit per month for each child who receives services;

2. For other services normally covered by health insurance, parents who provide full insurance information and necessary authorizations for billing all applicable insurance may not be billed more than the daily parental payment limit per day for each child who receives service;

3. For residential care not normally covered by health insurance, the following applies:

a. When a child is in care for less than 21 days in a calendar month, the parents may not be billed more than the daily parental payment limit per day for that child's care;

b. When a child is in care for more than 20 days in a calendar month, the payment approval authority shall adopt an agency policy for parental payment limits according to either the daily or monthly limit. The limit chosen shall apply uniformly to all parents;

c. When the daily limit is used, the agency may prorate daily billings for all families served by the agency according to their ability to pay. Under this prorating approach, the billing shall be the lesser of the daily limit or the family's monthly payment amount determined by s. DHS 1.03 (12) or (13) multiplied by 12 and divided by 365; and

d. As an alternative to subd. 3. c. , when the daily limit is used, an agency may bill all parents the daily limit for each day of care up to their monthly payment rate determined according to sub. (12) or (13) .

(b) The appropriate payment approval authority may bill a responsible party a minimum payment for therapeutic reasons for a fee chargeable service. The therapeutic charge may be a per month amount or a per visit or per unit of service charge and may result in a higher amount than the maximum monthly payment rate. A charge for "no-show" is considered a therapeutic charge. Therapeutic charges may not exceed the maximum monthly payment by more than $25.00 per month. Therapeutic charges and minimum charge(s) established under sub. (13) may not total more than $25.00 per family nor may a therapeutic charge exceed the responsible party's available income.

(c) When residential care is provided under ch. 48 , Stats. , and there is a support order under s. 49.90 , Stats., or ch. 767 , Stats. , which was in existence before the ch. 48 , Stats. , disposition, the billing amount to parents for residential care shall not be less than the previously ordered amount attributable to the child client. This provision supersedes maximum billing limitations in subs. (12) , (13) , (13m) , (18) (a) and (21) .

(19)   Redetermination of maximum monthly payment rate. The maximum monthly payment rate established upon entry into the system shall be reviewed at least once per year. A redetermination shall be made at any time during the treatment or payment period that a significant change occurs in available income. The redetermined maximum monthly payment rate may be applied retroactively or prospectively.

(20)   Payment period. Monthly billing to responsible parties with ability to pay shall continue until:

(a) Liability has been met or

(b) A waiver of remaining liability is obtained or

(c) Third-party sources have been exhausted and the responsible parties have a permanent inability or unlikely future ability to pay.

(21)   Parental payment limit. Except as provided in s. DHS 1.065 , parental payment limits shall be determined as follows:

(a) For care in the department's centers for the developmentally disabled, the daily parental limit shall be $6.00, subject to adjustment by the department under par. (b) . For all other care or services the department may approve daily parental payment limits at amounts which the department determines to be administratively feasible, but not higher than the cost-based fee for the service;

(b) The daily parental payment limit for care in the department's centers for the developmentally disabled shall be adjusted upward or downward in direct proportion to movement in the Milwaukee all-urban consumer price index for food and beverages, published by the U.S. department of labor. The adjustment shall be rounded downward to the nearest whole dollar. The base date for computing the adjustments shall be the date of the last published consumer price index for Milwaukee in 1982. The base dollar amount shall be $6.00 per day. This adjustment shall be computed at the end of each calendar year and shall be effective the following July 1; and

(c) The monthly parental payment limit shall be determined by multiplying the appropriate daily limit by 365 and dividing the product by 12.

History: Cr. Register, August, 1978, No. 272 , eff. 9-1-78; am. (2) to (6), renum. (7) to (14) to be (8), (11), (12), (14), (17) to (20) respectively and am. (8), (11), (14), (17), (18) (b) and (20), r. and recr. (18) (a), cr. (7), (9), (10), (13), (15) and (16), Register, November, 1979, No. 287 , eff. 1-1-80; emerg. am. (18) (a), eff. 7-1-80; am. (18) (a), Register, October, 1980, No. 298 , eff. 11-1-80; r. and recr. (18) (a), cr. (18) (c) and (21), Register, December, 1980, No. 300 , eff. 1-1-81; cr. (13m), Register, June, 1981, No. 306 , eff. 7-1-81; am. (8), (10), (13), (13m), (14) (a), (15) and (18) (c), r. and recr. (11) (b) 4. and (12), r. (11) (b) 5., Register, September, 1984, No. 345 , eff. 10-1-84; am. (11) (b) 1., (13) and (18) (c), r. (16) (b) 3., renum. (16) (b) 4. to be 3., r. and recr. (18) (a) and (21), Register, December, 1987, No. 384 , eff. 1-1-88; emerg. cr. (12m), eff. 1-22-97; cr. (12m), Register, August, 1997, No. 500 , eff. 9-1-97; correction in (13m) made under s. 13.93 (2m) (b) 7., Stats., Register, June, 2001, No. 546 ; CR 08-017 : am. (12) (c) (intro.) and (21) (intro.) Register June 2008 No. 630 , eff. 7-1-08; correction in (13m) made under s. 13.92 (4) (b) 7., Stats., Register November 2008 No. 635 ; CR 10-146 : r. and recr. (20) (c) Register May 2011 No. 665 , eff. 6-1-11.

Note

Form DMT 130 may be ordered from: Microsoft Windows NT 6.1.7601 Service Pack 1   Department of Health Services
  Forms Center P.O. Box 7850
  Madison, Wisconsin 53707 Microsoft Windows NT 6.1.7601 Service Pack 1 $152 is assumed to represent a basic allowance to provide support for a child living in a family, and 7% of gross income above support is assumed to represent added support above basic needs that a family with higher income would provide for a child in the home. Microsoft Windows NT 6.1.7601 Service Pack 1 For example, if the maximum monthly payment for a family is $80, the daily rate would be $2.63 ($80 × 12 ÷ 365 days = $2.63). Microsoft Windows NT 6.1.7601 Service Pack 1 Before October 1, 1984 this subsection included the following limits on the amount that parents were expected to pay each month for care or services provided or purchased for their minor children. Microsoft Windows NT 6.1.7601 Service Pack 1 For outpatient psychotherapy purchased or provided by county agencies, the maximum billing rate to qualified parents for outpatient psychotherapy was $4.00 per day per child client for such care from September 1, 1977 through December 31, 1979. For care from January 1, 1980 through June 30, 1980, the maximum rate for this service was $120 per month per child client. From July 1, 1980 through June 30, 1983, the maximum rate was $152 per month per child client. Since July 1, 1983 the maximum was $183 per month per child client. Microsoft Windows NT 6.1.7601 Service Pack 1 For all other services, the maximum billing rate for care from September 1, 1977 through June 30, 1980 was $4.00 per day per child client; from July 1, 1980 through June 30, 1983, $5.00 per day per child client; since July 1, 1983, $6.00 per day per child client. Since January 1, 1981 county departments of social services were permitted to convert the daily amounts for residential care to average monthly amounts. Microsoft Windows NT 6.1.7601 Service Pack 1