Health, Health Care Financing, Coverage and Reimbursement Policy

Section R414-1-28

Cost Sharing

Notice of Proposed Rule

(Amendment)

DAR File No.: 33414
Filed: 03/01/2010 03:45:52 PM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this change is to consolidate all copayment policies into one administrative rule and to list American Indians as a cost sharing-exempt group in accordance with the American Recovery and Reinvestment Act of 2009.

Summary of the rule or change:

This change adds a section to the rule text that consolidates all Medicaid copayment policies into one administrative rule and lists American Indians as a cost sharing-exempt group.

State statutory or constitutional authorization for this rule:

• Section 26-1-5
• Section 26-18-3

Anticipated cost or savings to:

the state budget:

There is an annual cost of approximately $12,441 to the General Fund and $31,489 in federal dollars that results from the cost sharing exemption for American Indians.

local governments:

There is no impact to local governments because they do not fund or provide Medicaid services.

small businesses:

There is no impact to Medicaid providers who work in smaller clinics because the Department will reimburse them the full amount for services to cover the cost of the exemption.

persons other than small businesses, businesses, or local governmental entities:

There is no impact to Medicaid providers who work in hospitals, clinics, or other health care centers because the Department will reimburse them the full amount for services to cover the cost of the exemption. On the other hand, American Indians who qualify for the cost sharing exemption will save some portion of the total amount ($43,930) calculated under the state budget.

Compliance costs for affected persons:

There are no compliance costs because there are only savings to an American Indian who qualifies for the cost sharing exemption. In addition, a Medicaid provider does not lose any annual revenue as a result of this change because the Department will reimburse the provider in full to cover the cost of the exemption.

Comments by the department head on the fiscal impact the rule may have on businesses:

This rule change implements requirements of the American Recovery and Reinvestment Act of 2009 and will have no fiscal impact on business since the Medicaid program will absorb the cost.

David N. Sundwall, MD, Executive Director

The full text of this rule may be inspected, during regular business hours, at the Division of Administrative Rules, or at:

Health
Health Care Financing, Coverage and Reimbursement Policy
288 N 1460 W
SALT LAKE CITY, UT 84116-3231

Direct questions regarding this rule to:

• Craig Devashrayee at the above address, by phone at 801-538-6641, by FAX at 801-538-6099, or by Internet E-mail at cdevashrayee@utah.gov

Interested persons may present their views on this rule by submitting written comments to the address above no later than 5:00 p.m. on:

04/14/2010

This rule may become effective on:

04/21/2010

Authorized by:

David Sundwall, Executive Director

R414. Health, Health Care Financing, Coverage and Reimbursement Policy.

R414-1. Utah Medicaid Program.

R414-1-28. Cost Sharing.

(1) An enrollee is responsible to pay the:

(a) hospital a $220 coinsurance per year;

(b) hospital a $6 copayment for each non-emergency use of hospital emergency services;

(c) provider a $3 copayment for outpatient office visits for physician and physician-related mental health services except that no copayment is due for preventive services, immunizations, health education, family planning, and related pharmacy costs; and

(d) pharmacy a $3 copayment per prescription up to a maximum of $15 per month;

(2) The out-of-pocket maximum payment for copayments for physician and outpatient services is $100 per year.

(3) The provider shall collect the copayment amount from the Medicaid client. Medicaid shall deduct that amount from the reimbursement it pays to the provider.

(4) Medicaid clients in the following categories are exempt from copayment and coinsurance requirements;

(a) children;

(b) pregnant women;

(c) institutionalized individuals;

(d) American Indians; and

(e) individuals whose total gross income, before exclusions and deductions, is below the temporary assistance to needy families (TANF) standard payment allowance. These individuals must indicate their income status to their eligibility caseworker on a monthly basis to maintain their exemption from the copayment requirements.

 

KEY: Medicaid

Date of Enactment or Last Substantive Amendment: [January 27,]2010

Notice of Continuation: April 16, 2007

Authorizing, and Implemented or Interpreted Law: 26-1-5; 26-18-3; 23-34-2