(a) Financial assessment. The LMHA must conduct and document a financial assessment for each person within the first 30 days of services. The LMHA must update each person's financial assessment at least annually and whenever a significant financial change (as defined) occurs as long as the person continues to receive services. The financial assessment is accomplished using the financial documentation listed in §412.105(d) of this title (relating to Accountability), which represents the finances of the:
  (1) person who is age 18 years or older and the person's spouse; or
  (2) parents of the person who is under age 18 years.
(b) Maximum monthly fee. A person's maximum monthly fee is based on the financial assessment and calculated using the Monthly Ability-To-Pay Fee Schedule, referenced as Exhibit A in §412.113 of this title (relating to Exhibit). The calculation is based on the number of family members and annual gross income, reduced by extraordinary expenses paid during the past 12 months or projected for the next 12 months. No other sliding scale is used.
  (1) A maximum monthly fee that is greater than zero is established for persons who are determined as having an ability to pay. If two or more members of the same family are receiving services, then the maximum monthly fee is for the family.
  (2) A maximum monthly fee of zero is established for persons who are determined as having an inability to pay.
(c) Third-party coverage.
  (1) Third-party coverage that will pay. A person with third-party coverage that will pay for needed services is determined as having an ability to pay for those services.
  (2) Third-party coverage that will not pay.
    (A) If the person's third-party coverage will not pay for needed services because the LMHA does not have an approved provider on its network, then the LMHA will propose to refer the person to his/her third-party coverage to identify a provider for which the third-party coverage will pay unless:
      (i) the LMHA is identified as being responsible for providing court-ordered outpatient services to the person;
      (ii) the LMHA is able to negotiate adequate payment for services with the person's third-party coverage; or
      (iii) the person (or parent) voluntarily agrees to pay the standard charge(s) for the needed service(s).
    (B) If the LMHA proposes to refer the person to his/her third-party coverage as described in paragraph (2)(A) of this subsection, then the LMHA will provide written notification to the person (or parent) in accordance with §412.109(e)(1) of this title (relating to Payments, Collections, and Non-payment), which provides an opportunity to appeal. The LMHA must also comply with §412.109(e)(2) - (3) as initiated by the person (or parent).
    (C) If the LMHA refers the person to his/her third-party coverage, then the LMHA will assist the person (or parent) in identifying a provider for which the third-party coverage will pay.
    (D) If a person who has been referred to his/her third-party coverage is unable to identify or access needed services from an approved provider or if access will be unduly delayed, then the LMHA will:
      (i) assist the person (or parent) in resolving the matter with the third-party coverage (e.g., contacting customer service at the third-party coverage, filing a complaint with the third-party coverage or the Texas Department of Insurance); and
      (ii) if clinically indicated, ensure the provision of the needed services to the person pending resolution.
    (E) The LMHA will maintain documentation of:
      (i) all referrals as described in paragraph (2)(C) of this subsection;
      (ii) all assistance as described in paragraph (2)(D)(i) of this subsection; and
      (iii) whether the person received services pending resolution as described in paragraph (2)(D)(ii) of this subsection.
(d) Social Security work incentive provisions. A person who identified payment for specific needed services in his/her approved plan utilizing Social Security work incentive provisions (i.e., Plan to Achieve Self-Sufficiency; Impairment Related Work Expense ) is determined as having an ability to pay for the specific services. Persons are not required to identify payment for any service for which they may be eligible as part of their approved plan for utilizing the Social Security work incentive provisions.
(e) Notification. After a financial assessment is conducted, the LMHA must provide written notification to the person (or parents) that includes:
  (1) the determination of whether the person (or parent) has an ability or an inability to pay;
  (2) a copy of the financial assessment form that is signed by the person (or parent) and a copy of the Monthly Ability-to-Pay Fee Schedule, with the applicable areas indicated (i.e., annual gross income, number of family members);
  (3) the amount of the maximum monthly fee;
  (4) the name and phone number of at least one LMHA staff who the person (or parent) may contact during office hours to discuss the information contained in the written notification; and
  (5) a statement that the person (or parent) may voluntarily pay more than the maximum monthly fee.

Source Note: The provisions of this §412.106 adopted to be effective September 1, 2002, 27 TexReg 2041; amended to be effective September 15, 2005, 30 TexReg 5806