Patient Liability

1
Patient Liability

• June 18, 2008
• Debbie Hoffine
• Division of Fiscal Administration, ODMRDD

2
What is Patient Liability?

• Patient Liability is the amount an individual is
  required to contribute (pay) each month for
  Medicaid-eligible services in order to maintain
  his/her Medicaid eligibility.
• Ohio Administrative Code 51011-39-24 defines
  Patient Liability as the individuals financial
  obligation toward the Medicaid cost of care.

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How is Patient Liability Determined?

• Patient Liability is determined by the county
  Department of Job and Family Services in the
  county in which the individual resides.
• The amount is calculated based on a formula that
  considers the individuals available resources,
  such as income and assets.

4
How often is PL Determined?

• Patient Liability is determined at least once per
  year in connection with the individuals annual
  Medicaid redetermination.
• If the individuals resources change
  significantly during the course of the year,
  however, the individual is required to report
  such changes to the county Department of Job and
  Family Services, so that his/her Patient
  Liability can be recalculated.

5
How is PL Information Communicated?

• County boards of mrdd are responsible for sharing
  Patient Liability information with providers.
• The county board is notified by ODMRDD if an
  individual has been assigned a Patient Liability.
  The county board is then responsible to
  determine which provider will be responsible for
  deducting the amount of the Patient Liability
  from their billing for the month and collecting
  the Patient Liability from the individual.

6
How is PL Information Communicated?

• Monthly reports are mailed both to county boards
  and providers, advising them of the amount of
  Patient Liability for the individual, and the
  amount that has been reported on the providers
  claims.

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How is PL Deducted from Billing?

• The provider includes the appropriate Patient
  Liability amount on the waiver claims that are
  submitted each month.
• Specific information pertaining to this process
  is contained in the ODMRDD Medicaid Waiver
  Billing Instructions which can be found ODMR/DDs
  website at www.mrdd.ohio.gov.

8
How is PL Deducted from Billing?

• The Other Source and Other Source Amount
  fields on the claims are used to report PL
  information.
• Providers can use the Single Line Entry
  Application on ODMRDDs website or use their own
  software to submit their claims.

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How is PL Deducted from Billing?

• The number 1 is entered into the Other Source
  field on the claims to represent Patient
  Liability.
• The number 1 is the code that indicates that
  Patient Liability is being reported for the
  individual receiving services.

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How is PL Deducted from Billing?

• The amount of the Patient Liability that is
  attributable to the specific claim line is
  entered into the Other Source Amount field.
• The process is repeated until the amounts entered
  into the Other Source Amount fields total the
  required Patient Liability for the month.

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Single Line Entry Screen

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Single Line Entry Example

This claim along with the claim from the next
page satisfies the 127.00 Patient Liability for
the month of December 2007. The provider is
entitled to collect this amount from the
individual receiving services.
13
Single Line Entry Example

This claim along with the claim from the previous
page satisfies the 127.00 Patient Liability for
the month of December 2007. The provider is
entitled to collect this amount from the
individual receiving services.
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What If the Required Patient Liability is not
Deducted from Waiver Claims?

• ODMRDD reviews all Patient Liability cases on a
  regular basis. If the appropriate amounts have
  not been deducted, ODMRDD notifies the provider
  to make the necessary corrections (adjustments)
  to the previously paid claims, which causes the
  Patient Liability amounts to be deducted from
  current claims.
• If the provider does not make the necessary
  corrections within an established time period,
  ODMRDD will make the necessary corrections on
  behalf of the provider, which causes the Patient
  Liability amounts to be deducted from current
  claims.

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What If Too Much Patient Liability is Deducted
from Waiver Claims?

• ODMRDD reviews all Patient Liability cases on a
  regular basis. If more than the required amount
  has been deducted, ODMRDD notifies the provider
  to make the necessary corrections (adjustments)
  to the previously paid claims, which causes the
  excess amount that was deducted to be paid to the
  provider.
• If the provider does not make the necessary
  corrections within an established time period,
  ODMRDD will make the necessary corrections on
  behalf of the provider, which causes the excess
  amount that was deducted to be paid to the
  provider.

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Questions

• Questions regarding how to submit claims for
  individuals with Patient Liability should be
  directed to Provider Support.
• Phone [phone]
• Email provider.support_at_odmrdd.state.oh.us
• Questions regarding the Monthly Update of Patient
  Liability reports, or claims adjustments made to
  recoup/refund PL should be addressed to Laura
  Morris.
• Phone [phone]
• Email laura.morris_at_dmr.state.oh.us
• Questions related to the calculation of the
  amount of Patient Liability for an individual
  should be directed to the county Department of
  Job and Family Services.