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    v1.0.30
    OpenPayerPolicy UpdatesAdministrative/Operational PolicyDelaware DHSS Ability-to-Pay Policy Update | OpenP…
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    CurrentDelaware Department of Health and Social ServicesPolicy 37

    Standard Ability to Pay Fee Schedule

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    Establishes a uniform process for determining and collecting fees from persons who owe DHSS for care or services but cannot pay the full cost, including ability-to-pay adjustments, sliding-scale charges, collection, and appeals.

    Policy Summary
    PayerDelaware Department of Health and Social Services
    PolicyStandard Ability to Pay Fee Schedule
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateMarch 1, 2022
    Next Review DateN/A
    Key ActionCalculate the maximum annual fee as 10% of disposable income and divide the annual amount by 12 to establish the monthly payment.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    230%-290%Sliding-scale income range
    0%No-charge threshold
    100%Full-charge threshold
    $15,049Automatic waiver threshold
    10%

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Maximum annual fee

    Eligibility, Fee Determinations, and Appeals

    Payer Exclusions

    The policy does not apply to persons supported by the payers listed below, subject to the stated exception.

    EXCLUSION

    • Person is supported by Medicaid, Medicare, CHAMPUS, or private insurance.

    • EXCEPTION

      • The payer has a contract with a DHSS facility and the charge is a deductible or coinsurance amount.
      • The payer has a contract with a DHSS facility and the charge is for a service not covered by that payer.

    Inpatient Ability-to-Pay Determination

    When a written agreement to recover the full cost of services cannot be obtained, complete the DHSS Ability to Pay Worksheet for the person receiving care and for each other person liable under 29 Del. C. § 7940(a).

    ALL of the following

    • Complete the DHSS Ability to Pay Worksheet for the patient and, when applicable, each other liable person.
    • Use the worksheet to determine disposable income and the minimum annual fee due based on ability to pay.
    • Automatically waive liability when disposable income is less than $15,049.
    • Provide written notice of the person's liability, payment due dates, and appeal procedures.
    • Payment agreements in force before implementation of this schedule must be phased out for conformance at the time of automatic review, which occurs at least every two years.

    Community-Based and Outpatient Sliding Scale

    Divisions determine and record ability to pay for community-based and outpatient services using a sliding scale applied to the fees established by the individual DHSS divisions.

    ALL of the following

    • Determine the client's gross income as a percentage of the applicable federal poverty level and maintain the ability-to-pay record at all service locations.
    • Apply the sliding scale across the range from 230% through 290% of the poverty level, using the actual income thresholds in Table A for family or household sizes 1 through 10.
    • Apply the resulting percentage to the division-established fee for each service.

    • CHARGE LEVEL

      • Gross income is at or below 230% of the poverty level: service is free of charge.

    Ability-to-Pay Fee Calculation

    Use the DHSS Ability to Pay Worksheet to calculate the maximum annual fee and monthly payment.

    ALL of the following

    • Line 1 — Gross income: obtain income from a filed tax return or, for nontaxable income, documentation of payment sources such as welfare or pension payments.
    • Line 2 — Standard deduction: apply the amount for the family or household size; for families with more than eight persons, add $4,720 for each additional person.
    • Line 3 — Taxes withheld: document FICA, federal income, state income, and city wage taxes from W-2 forms.
    • Line 4 — Tax refunds or payments: use amounts from federal and state tax returns.
    • Line 5 — Total deductions = Line 2 + Line 3 + Line 4.

    Appeal Requirements

    Written notice must state the calculated payment, due date, and the requirements and destination for an appeal.

    ALL of the following

    • Send written notice identifying the patient and stating the calculated minimum monthly payment under 29 Del. C. § 7940 and DHSS Policy Memorandum Number 37.
    • Enclose a copy of the calculation.
    • State that payments are due by the 20th of the month for the previous month's care.
    • Advise that the person may appeal the determination in writing to the Appeals Committee.
    • Require the written appeal to state the substance of the decision being appealed, the facts supporting the appeal, and the relief sought.

    Fee Thresholds, Rates, and Payment Rules

    Inpatient Fee Thresholds
    Automatic waiver thresholdDisposable income less than $15,049
    Community-Based and Outpatient Sliding Scale
    No-charge thresholdGross income at or below 230% of the poverty level; services are free of charge
    Community-Based and Outpatient Sliding Scale
    Full-charge thresholdGross income above 290% of the poverty level; the person pays 100% of the applicable charge
    Community-Based and Outpatient Sliding Scale

    Operational Responsibilities and Processing Steps

    Documentation Required

    Obtain Payment Agreement and Ability-to-Pay Worksheet

    Before or, in an emergency, after admission or treatment, obtain a written agreement from the patient and, when applicable, legally liable person(s) for recovery of the full cost of care. If the full-cost agreement cannot be obtained, complete the DHSS Ability to Pay Worksheet for the patient and each person liable under 29 Del. C. § 7940(a).

    • Use Appendix A for the written full-cost payment agreement.
    • Use Appendix B and its instructions to determine disposable income and the minimum annual fee.
    Documentation Required

    Provide Liability Notice and Financial Documentation

    Notify the patient and all legally liable persons of the service liability, payment due dates, and appeal procedures, and obtain the financial records needed to evaluate an inability to pay. Advise that adjustments cannot be made if the requested information is not submitted.

    • Request the most recent federal and state income-tax returns.

    Policy Terms and Calculation Definitions

    Definitions
    Cost of Services RenderedThe cost of care as used in Delaware Code, Title 29, Section 7940 and DHSS Policy Memorandum Number 12
    Definitions
    Disposable incomeGross income less a standard deduction and taxes paid
    Definitions
    Standard deductionA deduction based on 100% of the poverty level
    Definitions
    Gross income
    Policy Summary
    PayerDelaware Department of Health and Social Services
    PolicyStandard Ability to Pay Fee Schedule
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateMarch 1, 2022
    Next Review DateN/A
    Key ActionCalculate the maximum annual fee as 10% of disposable income and divide the annual amount by 12 to establish the monthly payment.
    SourceLink
    On This Page
    Eligibility, Fee Determinations, and AppealsFee Thresholds, Rates, and Payment RulesOperational Responsibilities and Processing StepsPolicy Terms and Calculation Definitions
    Gross income is above 230% and through 245% of the poverty level: pay 20% of the charge.
  1. Gross income is above 245% and through 260% of the poverty level: pay 40% of the charge.
  2. Gross income is above 260% and through 275% of the poverty level: pay 60% of the charge.
  3. Gross income is above 275% and through 290% of the poverty level: pay 80% of the charge.
  4. Gross income is above 290% of the poverty level: pay 100% of the charge.
    5. Line 6 — Disposable income = Line 1 gross income − Line 5 total deductions.
  5. Line 7 — Maximum annual fee = 10% of disposable income (Line 6 × 0.1). Automatically waive the maximum annual fee when disposable income is less than $15,049.
  6. Line 8 — Monthly payment = Line 7 annual fee ÷ 12.
    7. Direct the appeal to the Appeals Committee Administrator at the applicable facility name and address.
    Sliding-scale incrementThe charge percentage increases 20% for each 15% increase in poverty-level income between 230% and 290%
    Inpatient Fee Calculation
    Maximum annual inpatient fee10% of disposable income
    Inpatient Fee Calculation
    Monthly inpatient paymentMaximum annual fee divided by 12
    Review Requirements
    Automatic review intervalAt least every two years
    Appeals
    Appeals Committee hearing deadlineWithin 60 days
    Ability-to-Pay Fee Calculation
    Maximum annual fee rate10% of disposable income
    Ability-to-Pay Fee Calculation
    Automatic fee-waiver thresholdDisposable income less than $15,049
    Ability-to-Pay Fee Calculation
    Monthly payment calculationAnnual fee divided by 12
    Standard Deduction
    Additional household deduction$4,720 for each family member over eight
    Payment Requirements
    Payment due dateThe 20th of the month for the previous month's care
  7. Request all W-2 forms submitted with those returns.
  8. Obtain other documents showing current income, including applicable insurance information.
    9. Documentation Required

    Maintain Outpatient Ability-to-Pay Records

    For community-based and outpatient services, determine each client’s ability to pay using the applicable sliding scale and maintain the ability-to-pay record at all service locations.

    • Apply the 230%–290% of poverty-level range.
    • Clients with gross income at or below 230% of the poverty level receive services free of charge.
    • Increase the percentage of charges by 20% for each 15% increase in the poverty-level measure; clients above 290% pay 100% of the charge.
    • Apply the scale to fees developed and implemented by the responsible DHSS Division.
    Billing Rule

    Process Ability-to-Pay Appeals

    When a written appeal of an ability-to-pay determination is received, notify the individual and forward the appeal request to the Division Director’s office within five working days. The Review Panel must review appeals at least monthly and notify the facility and appellant of its determination within five working days of review.

    • Establish a three-member Review Panel consisting of the Division Director or Deputy Director, an Institutional Representative, and a Community-Based Representative.
    • If the Review Panel concurs with the original determination, forward the appeal to the Appeals Committee for final review.
    • The Appeals Committee must hold a hearing within 60 days and its decision is final and binding.
    Billing Rule

    Follow Collection and Write-Off Policy

    Conduct collection efforts and write-off activities in conformance with DHSS Policy Memorandum Number 19.

    Note

    Administer Fee Adjustments and Oversight

    Division Directors may administratively adjust the monthly fee instead of submitting the matter to the Appeals Committee when circumstances justify an adjustment. Use this authority only when the individual has extraordinary expenses beyond the individual’s control, such as medical bills, and maintain the required oversight structure.

    • Maintain a permanent Ability to Pay Committee to monitor and administer the fee schedule and resolve implementation or interpretation issues.
    • The committee consists of two representatives each from Substance Abuse and Mental Health, Developmental Disabilities Services, and Public Health, plus one representative from Management Services, who serves as chair.
    Billing Rule

    Calculate Disposable Income

    Calculate disposable income by subtracting the standard deduction, taxes withheld, and applicable federal and state tax refunds or payments from gross income.

    • Gross income may be taken from a tax return or other payment-source documentation, including nontaxable welfare or pension payments.
    • Use the standard deduction for household size; for families with more than eight persons, add $4,720 for each additional person.
    • Taxes withheld include FICA, federal income, state income, and city wage taxes.
    • Total deductions equal the sum of Lines 2 through 4; disposable income equals gross income less total deductions.
    Billing Rule

    Determine Annual and Monthly Payment

    Calculate the maximum annual fee as 10% of disposable income, then calculate the monthly payment by dividing the annual fee by 12.

    • Maximum annual fee = disposable income × 0.10.
    • Monthly payment = maximum annual fee ÷ 12.
    Billing Rule

    Apply Low-Income Waiver

    Automatically waive the maximum annual fee when the individual’s disposable income is less than $15,049.

    • Apply the waiver when the disposable-income threshold is not met.
    Documentation Required

    Issue Payment Determination

    Issue written notice of the payment determination after reviewing the submitted information. Provide the worksheet calculation, state the required minimum monthly payment, and require payment by the 20th of the month for the prior month’s care.

    • Enclose a copy of the calculation worksheet.
    • Identify the patient, monthly amount due, and services covered.
    • Include written appeal rights and the submission address.
    Billing Rule

    Process Payment Appeals

    Accept written appeals concerning the payment determination and route them to the Appeals Committee Administrator at the designated facility address. The appeal must state the substance of the decision being appealed, the supporting facts, and the relief sought.

    • Provide the appellant’s written appeal to the Appeals Committee process.
    • The Secretary’s Office receives appeal information, schedules the hearing, and notifies the Appeals Committee and the individual.
    Obtained from a filed tax return or documentation of other payment sources, including nontaxable welfare payments, pension payments, or other income
    Definitions
    Standard deductionBased on family or household size; for households with more than eight persons, add $4,720 for each additional person
    Definitions
    Disposable incomeGross income minus the total deductions listed on the worksheet
    Definitions
    Maximum annual fee10% of disposable income; automatically waived when disposable income is less than $15,049
    Definitions
    Monthly paymentThe maximum annual fee divided by 12