SECTION 275.201. Determining an Individual's Co-payment

(a) An individual's co-payment is a percentage of the monthly cost of services provided to the individual. To calculate an individual's co-payment, a provider must:

(1) determine the individual's total net monthly income in accordance with subsections (f) - (i) of this section;

(2) determine the individual's co-payment percentage by using the individual's net monthly income and the CMPAS co-pay schedule located in the DADS Consumer Managed Personal Assistance Services Provider Manual;

(3) inform the individual of the individual's estimated monthly co-payment by multiplying the authorized hours of service per month by the hourly reimbursement rate, multiplied by the co-payment percentage;

(4) calculate the amount of the individual's actual monthly co-payment each month by multiplying the individual's co-payment percentage amount by the reimbursement rate, multiplied by the number of hours of service actually provided during the month.

(b) An individual who suffers undue hardship as a result of legal financial obligations for reasons such as a catastrophic illness of the individual or a family member may request that his or her co-payment be temporarily reduced or waived. To request a reduction or waiver of a co-payment, the individual must make the request to the assessor of need and document the legal financial obligation that necessitates the reduction or waiver.

(1) The provider may approve a reduction or waiver for a three-month period. The individual must resubmit a new request to receive three-month extensions to the waiver or reduction.

(2) If the provider does not approve a reduction or waiver, the provider must offer the individual orally and in writing an informal dispute resolution (IDR) process which includes a meeting of the IDT and notify the individual of the right to a fair hearing as provided by §44.503 of this subchapter (relating to Fair Hearing).

(c) The provider must bill a co-payment amount to an individual by or on the 15th day of the month following the month in which services were provided. The bill must show the co-payment percentage, the reimbursement rate, the total number of hours of service for the month, the total cost, and the actual amount of the co-payment due. If payment is not made within 15 days after billing, the provider must send a second notice to the individual within 10 days after the bill was due. If the individual does not pay the amount due by the 20th day of the month after the month in which the second notice was sent, the provider must suspend services.

(d) A provider must not charge an individual a fee for late payment.

(e) In collecting monthly co-payments, a provider must:

(1) provide the individual a receipt containing the provider's name, individual's name, amount paid, and the date of the payment;

(2) retain a copy of the receipt;

(3) deduct the co-payment from reimbursement claims submitted to DADS under §44.505 of this subchapter (relating to Reimbursement); and

(4) maintain a current individual co-payment ledger system, in accordance with generally accepted accounting principles, that reflects all charges to and all payments by an individual.

(f) A provider must calculate an individual's total monthly income by adding:

(1) the gross monthly earnings of the individual and the individual's spouse, including:

(A) employee wages or salary; and

(B) commissions, tips, piece-rate payments, and cash bonuses;

(2) the net monthly receipts of the individual and the individual's spouse from non-farm self-employment, calculated by subtracting business expenses from gross receipts, as described in subsection (g) of this section;

(3) the net monthly receipts of the individual and the individual's spouse from farm self-employment, calculated by subtracting business expenses from gross receipts, as described in subsection (h) of this section;

(4) the gross monthly benefits received by the individual and the individual's spouse, including:

(A) pensions, retirement, disability, and survivors' benefits;

(B) education loans, scholarships, and grants to the extent funds are or may be applied to living costs;

(C) payments from annuities, insurance, and irrevocable trust funds;

(D) public assistance payments, such as Temporary Assistance to Needy Families or Supplemental Security Income, and including general assistance from a local government source;

(E) court-ordered support payments, such as alimony and child support payments for a minor child;

(F) unemployment compensation and union strike payments;

(G) workers' compensation payments or other compensation for work injuries;

(H) Veterans Administration payments, such as subsistence allowances and refunds of GI insurance premiums; and

(I) other monthly support, such as allotments or payments from friends or relatives; and

(5) the net monthly income from property of the individual or the individual's spouse, calculated by averaging receipts over a 12-month period, including:

(A) dividends and interest payments;

(B) receipts from a life estate, other estate, or trust fund;

(C) income from a mortgage, promissory note, or other negotiable instrument;

(D) income from lease of mineral rights, calculated by subtracting the following prorated payments from gross royalties or lease payments:

(i) property taxes (not including windfall profit taxes); and

(ii) excise taxes; and

(E) income from rental property, including rent from boarders, calculated by subtracting the following prorated payments from gross receipts:

(i) mortgage interest;

(ii) property repair and maintenance expenses (not including improvements or depreciation charges);

(iii) property insurance; and

(iv) property taxes.

(g) For purposes of calculating net monthly receipts from non-farm self-employment in accordance with subsection (f)(2) of this section:

(1) gross receipts means the value of all goods sold and services provided by the non-farm self-employment enterprise; and

(2) business expenses means the actual operating expenses of the non-farm self-employment enterprise, including:

(A) purchased goods or services;

(B) rent;

(C) utilities;

(D) depreciation charges;

(E) wages and salaries; and

(F) business taxes, which do not include personal income taxes.

(h) For purposes of calculating net monthly receipts from farm self-employment in accordance with subsection (f)(3) of this section:

(1) gross receipts means the value of all goods sold and services provided by the farm self-employment enterprise, except for goods and services used for family living. Gross receipts include receipts from:

(A) the sale of crops;

(B) the rental of farm equipment;

(C) the sale of wood, sand, gravel, and similar items; and

(D) government crop loans;

(2) business expenses means the actual operating expenses of the farm self-employment enterprise, including:

(A) the cost of feed, fertilizer, seed, and other farming supplies;

(B) wages and salaries;

(C) depreciation charges;

(D) rent;

(E) interest on farm mortgages;

(F) farm building repairs; and

(G) farm taxes, which do not include personal income taxes.

(i) A provider must calculate an individual's income exclusions by adding:

(1) payments to satisfy a judgment of the Indian Claims Commission or its successor agency, the U.S. Court of Claims;

(2) any payment received under the federal Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970;

(3) education loan, grant, and scholarship funds that are not or cannot be applied to living costs;

(4) Veterans Administration payments, such as aid-and-attendance benefits, homebound elderly benefits, and payments for purchase of medications;

(5) in-kind credits, such as rent subsidies;

(6) infrequent or irregular payments from any source that occur no more often than once a quarter and that do not exceed $20 a month;

(7) reimbursements from an insurance company for health insurance claims; and

(8) grants, such as those made through the DADS In-Home and Family Support Program.

(j) A provider must calculate an individual's income deductions by adding:

(1) the prorated monthly cost of tuition and books when enrolled in an accredited institution of higher education or skills training program;

(2) $93 for the individual's spouse;

(3) $93 for each dependent of the individual;

(4) $93 for the individual;

(5) funds the law requires be withheld, such as deductions for income taxes or to comply with the Federal Insurance Contributions Act (FICA);

(6) amounts spent on disability-related equipment that cost more than $500, such as wheelchair-compatible vans, vehicle modifications, and power wheelchairs (not including transportation costs);

(7) amounts dedicated to be spent on disability-related equipment that costs more than $500, such as wheelchair-compatible vans, vehicle modifications, and power wheelchairs (not including transportation costs), in accordance with the following requirements:

(A) the individual must identify to the provider the equipment to be purchased and must submit to the provider a written estimate of the cost of the equipment including a dealer's estimate or an advertisement with a listed purchase price of comparable equipment;

(B) the individual must open a dedicated account for the exclusive purpose of purchasing identified equipment;

(C) the first $500 deposited does not reduce the monthly income;

(D) the individual must provide an estimate of the amount deposited each month to the dedicated account, the date the deposit is made each month, and the estimated date of the purchase;

(E) the individual must report each month to the provider the actual amount deposited in the dedicated account for that month and the accumulated total in the account;

(F) based on the individual's report, the provider must make the corresponding deduction from the individual's monthly income and any interest earned on the dedicated account will not be included as income if the interest payments are eventually used to purchase the equipment;

(G) the individual must report to the provider when any funds are withdrawn from the account for any purpose other than for the purchase of the equipment and the provider must include this amount as income for the month in which these funds are withdrawn;

(H) the individual must report to the provider when the funds are withdrawn from the account at the time the purchase is made and furnish a sales receipt showing the purchase price and date of purchase; and

(I) the individual must close the account after the purchase of the equipment and report to the provider the amount of any remaining funds, which the provider must include as income for the month in which the account is closed;

(8) child-care costs (actual expenses the individual paid to someone to care for his or her child, not including child support payments) up to $350 per month for each child through age 5, and up to $200 per month for each child age 6-12;

(9) annualized costs of expenditures for health insurance premiums for the individual and the individual's spouse and dependents, and for medical treatment and prescriptions for the individual, the individual's spouse and the individual's dependents that are not reimbursed by insurance; and

(10) annual contributions to a retirement plan in an amount up to 20 percent of the individual's total income as calculated in accordance with subsection (f) of this section.

(k) To determine an individual's net monthly income for co-payment purposes, a provider must:

(1) determine the individual's total monthly income in accordance with subsection (f) of this section;

(2) subtract from that amount the income exclusions calculated in accordance with subsection (i) of this section; and

(3) subtract from that amount the income deductions calculated in accordance with subsection (j) of this section.

Source Note: The provisions of this §275.201 adopted to be effective October 1, 2013, 38 TexReg 6606; transferred effective August 1, 2022, as published in the Texas Register July 8, 2022, 47 TexReg 3983