Health, Health Care Financing, Coverage and Reimbursement Policy

Section R414-200-4

Cost Sharing

Notice of Proposed Rule

(Amendment)

DAR File No.: 33419
Filed: 03/01/2010 04:17:19 PM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this change is to update the rule to be consistent with the cost sharing policy found in the 1115 Demonstration Waiver, 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 updates the cost sharing policy for Non-Traditional Medicaid clients and also 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:

The explanation of impact to the state budget is detailed in the companion filing to this proposed change (Rule R414-1). (DAR NOTE: The proposed amendment to Rule R414-1 is under DAR No. 33414 in this issue, March 15, 2010, of the Bulletin.)

local governments:

The explanation of budget impact to local governments is detailed in the companion filing to this proposed change (Rule R414-1).

small businesses:

The explanation of budget impact to small businesses is detailed in the companion filing to this proposed change (Rule R414-1).

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

The explanation of budget impact to persons other small businesses, businesses, or local government entities is detailed in the companion filing to this proposed change (Rule R414-1).

Compliance costs for affected persons:

The explanation of compliance costs for affected persons is detailed in the companion filing to this proposed change (Rule R414-1).

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.

R414-200. Non-Traditional Medicaid Health Plan Services.

R414-200-4. Cost Sharing.

(1) An enrollee is responsible to pay to the:

(a) hospital a $220 co-insurance payment for each inpatient hospital admission;

(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, physician-related, mental health services, physical therapy, and occupational therapy services; except, no copayment is due for preventive services, immunizations and health education; and

(d) pharmacy a $3 copayment per prescription for prescription drugs.

(e) physician costs for services that include family planning purposes. Pharmacy products related to family planning purposes are exempt from copayment requirements.

(2) The out-of-pocket maximum payment for copayments or co-insurance is limited to $500 per enrollee per calendar 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 requirements:

(a) American Indians; and

(b) individuals whose total gross income, before exclusions or deductions, is below the Temporary Assistance to Needy Families (TANF) standard payment allowance. These individuals must indicate their income status to their eligibility case worker on a monthly basis to maintain their exemption from the copayment requirements.

 

KEY: Medicaid, non-traditional, cost sharing

Date of Enactment or Last Substantive Amendment: [July 1, 2009] 2010

Notice of Continuation: May 24, 2007

Authorizing, and Implemented or Interpreted Law: 26-18