Targeted Case Management Services Sliding Scale Payment Schedules

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1 Office of the City Manager CONSENT CALENDAR April 18, 2006 To: From: Honorable Mayor and Members of the City Council Phil Kamlarz, City Manager Submitted by: Fred Medrano, Director, Health and Human Services Subject: Targeted Case Management Services Sliding Scale Payment Schedules RECOMMENDATION Adopt a Resolution establishing sliding scale payment rate schedules for targeted case management services provided in Seniors Programs. FISCAL IMPACTS OF RECOMMENDATION In order for the Department of Health and Human Services to bill the federal government for services provided under the Medi-Cal billing program, Targeted Case Management (TCM), the Federal Health Care Financing Administration has determined that a sliding scale of rates for payment for targeted case management services for non Medi-Cal clients must be in place. TCM provides Federal reimbursement for a portion of costs associated with case management services to Seniors Programs clients enrolled in the Medi-Cal program. The total amount of revenue to be generated as a result of this program is unknown. However, to date, Seniors Programs has received over $400,000 in Medi-Cal reimbursements. In order to comply with state and federal regulations and retain the ability to bill for TCM services, the City must adopt a sliding fee schedule in Seniors Programs for non Medi-Cal clients. CURRENT SITUATION AND ITS EFFECTS The TCM program involves documenting existing reimbursable services to existing clients. No new services will be provided as a result of this program. Allowable TCM services include assessment, development of case plans, linkage and consultation with service providers, assistance in accessing services, crisis assistance planning, and periodic review of case plans and related services. Required Sliding Scale Payment Rate Schedule - The State Plan Amendment requires the use of a sliding scale payment rate schedule to ensure that the Federal government is not billed for services provided free to non Medi-Cal Clients. We are recommending that an existing sliding schedule in use by the Public Health Division be used as the payment schedule for this program. The proposed schedule calls for a sliding fee to be paid if income exceeds $143,078 for a family of four or more, or if income exceeds $75,248 for an individual. Sliding scale payment rates will be factored by costs 2180 Milvia Street, Berkeley, CA Tel: (510) TDD: (510) Fax: (510) manager@ci.berkeley.ca.us Website:

2 TCM Sliding Scale Payment Schedules CONSENT CALENDAR April 18, 2005 established through the TCM reimbursement rate. The proposed sliding scale payment rate schedules are Exhibits A, B and C. We are also requesting authorization to waive required fees for individuals unable to pay in those cases where the health and well-being of the client or public are deemed to be at risk. These schedules apply only to the Seniors Programs case management and TCM programs, and not to any other services provided by the Department of Health and Human Services. BACKGROUND On November 21, 1995 by Resolution No. 58,272-N.S., the City Council approved the establishment of sliding scale payment rate schedules for public health activities provided as targeted case management services in the Public Health Division. This action brought the Public Health Division into compliance with federal regulations. Approval of the recommended action will bring Seniors Programs into compliance with State and Federal regulations. CONTACT PERSON William Rogers, Seniors Program Administrator, Attachments: 1. Resolution Exhibit A: TCM Schedule for Individual or Family of Two Exhibit B: TCM Schedule for Family of Three Exhibit C: TCM Schedule for Family of Four or More Exhibit D: TCM Fee Waiver Form 2

3 RESOLUTION NO. - N.S. ESTABLISHING SLIDING SCALE PAYMENT RATE SCHEDULES FOR TARGETED CASE MANAGEMENT SERVICES PROVIDED IN THE SENIORS PROGRAMS WHEREAS, the Federal Health Care Financing Administration has determined that a sliding scale of rates for payment for targeted case management services for non Medi-Cal clients must be in place; and WHEREAS, implementation of the Medi-Cal billing program, Targeted Case Management, provides Federal reimbursement for a portion of costs associated with case management services to Seniors Programs clients enrolled in the Medi-Cal program. NOW THEREFORE, BE IT RESOLVED by the Council of the City of Berkeley that the sliding scale payment rate schedules of maximum charges used to determine service payments for Seniors Programs activities provided as targeted case management services is hereby established, attached hereto as Exhibits A, B, and C, and made a part hereof. BE IT FURTHER RESOLVED that this Resolution shall be in full force and effect on and after April 19, BE IT FURTHER RESOLVED that the City Manager is hereby authorized to waive fees generated through the sliding scale payment rate schedules for individuals unable to pay in those cases where the health and well being of the client or public are deemed to be at risk.

4 EXHIBIT A Seniors Programs Targeted Case Management Sliding Scale Payment Rate Schedule Individual or Family of Two For families of one or two persons, including the client and all members of the same household: ADJUSTED GROSS INCOME (amount reported by liable party on most recent federal income tax return) Fee Factor (% of the cost of services provided) $ 1 - $ 75,248 0% $ 75,249 - $ 79,487 5% $ 79,488 - $ 84,786 10% $ 84,787 - $ 90,086 15% $ 90,087 - $ 95,385 20% $ 95,386 - $100,684 25% $100,685 - $105,983 30% $105,984 - $111,282 35% $111,283 - $116,582 40% $116,583 - $121,881 45% $121,882 - $127,180 50% $127,181 - $132,479 55% $132,480 - $137,778 60% $137,779 - $143,078 65% $143,079 - $148,377 70% $148,378 - $153,676 75% $153,677 - $158,975 80% $158,976 - $164,275 85% $164,276 - $169,574 90% $169,575 - $174,873 95% $174,874 and over 100%

5 EXHIBIT B Seniors Programs Targeted Case Management Sliding Scale Payment Rate Schedule Family of Three For families of three persons, including the client and all members of the same household: ADJUSTED GROSS INCOME (amount reported by liable party on most recent federal income tax return) Fee Factor (% of the cost of services provided) $ 1 - $111,282 0% $111,283 - $116,582 5% $116,583 - $121,881 10% $121,882 - $127,180 15% $127,181 - $132,479 20% $132,480 - $137,778 25% $137,779 - $143,078 30% $143,079 - $148,377 35% $148,378 - $153,676 40% $153,677 - $158,975 45% $158,976 - $164,275 50% $164,276 - $169,574 55% $169,575 - $174,873 60% $174,874 - $180,172 65% $180,173 - $185,471 70% $185,472 - $190,771 75% $190,772 - $196,070 80% $196,071 - $201,369 85% $201,370 - $206,668 90% $206,669 - $211,967 95% $211,968 and over 100%

6 EXHIBIT C Seniors Programs Targeted Case Management Sliding Scale Payment Rate Schedule Family of Four or More For families of four or more persons, including the client and all members of the same household: ADJUSTED GROSS INCOME (amount reported by liable party on most recent federal income tax return) Fee Factor (% of the cost of services provided) $ 1 - $143,078 0% $143,079 - $148,377 5% $148,378 - $153,676 10% $153,677 - $158,975 15% $158,976 - $164,275 20% $164,276 - $169,574 25% $169,575 - $174,873 30% $174,874 - $180,172 35% $180,173 - $185,471 40% $185,472 - $190,771 45% $190,772 - $196,070 50% $196,071 - $201,369 55% $201,370 - $206,668 60% $206,669 - $211,967 65% $211,968 - $217,267 70% $217,268 - $222,566 75% $222,567 - $227,865 80% $227,866 - $233,164 85% $233,165 - $238,464 90% $238,465 - $243,763 95% $243,764 and over 100% 6

7 EXHIBIT D Annual Gross Income Senior Programs Targeted Case Management Fee Waiver TCM Fee Schedule REIMBURSEMENT RATE: $ Family of 1 or 2 Family of 3 Family of 4 or More Fee % Client Annual Fee % Client Annual Fee % Fee Gross Fee Gross Client Fee Income Income 75,249 5% ,283 5% ,079 5% ,488 10% ,583 10% ,378 10% ,787 15% ,882 15% ,677 15% ,087 20% ,181 20% ,677 20% ,882 50% ,976 50% ,772 50% ,378 75% ,472 75% ,268 75% , % , % , % The percentage stated is the amount of TCM reimbursable encounter rate that would be collected if not waived. TCM Fee was waived for the following reason: Client has Medi-Cal Client has applied for Medi-Cal and eligibility determination is pending Client is unemployed or on leave of absence from work Client has been employed for less than six months Client s employment is seasonal of temporary in nature Client has no medical insurance Client assessment was done at the request of another agency of health provider Client would refuse case management visit if required to pay and in the case manager s judgment would fail to seek necessary health and social services without case management assistance Client has private insurance that does not pay for Comprehensive Case Management Case Manager Signature Approved Date Not Approved Case Manager Supervisor Signature Date Client Name: Chart No.: 7