DAR File No. 41498

Health, Health Care Financing, Coverage and Reimbursement Policy

Section R414-1-28

Cost Sharing

Notice of Proposed Rule

(Amendment)

DAR File No.: 41498
Filed: 04/26/2017 09:31:06 AM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this change is to implement new cost-sharing policy, effective 07/01/2017, in accordance with the Affordable Care Act.

Summary of the rule or change:

This amendment removes the cost sharing section of the rule to defer implementation of the cost sharing policy to the Medicaid State Plan. The Department of Health will adopt the new cost sharing policy in Section R414-1-5 when it incorporates the Medicaid State Plan by reference to 07/01/2017.

Statutory or constitutional authorization for this rule:

• Section 26-1-5
• 42 CFR 447.50 through 447.57
• Section 26-18-3

Anticipated cost or savings to:

the state budget:

The Department estimates annual savings of about $410,000 to the state budget based on the new cost sharing policy that becomes effective 07/01/2017.

local governments:

There is no impact to local governments because they neither fund Medicaid services nor receive cost sharing amounts from Medicaid members.

small businesses:

There is no impact to small businesses because the cost sharing increase projected for 07/01/2017 is offset by a decrease in reimbursement and does not affect total annual revenue.

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

There is no impact to Medicaid providers because the cost sharing increase projected for 07/01/2017 is offset by a decrease in reimbursement and does not affect total annual revenue. Medicaid members, however, may see an annual increase of about $410,000 in out-of-pocket expenses with the policy's implementation.

Compliance costs for affected persons:

A single Medicaid member may share a portion of the cost of $410,000 with the policy's implementation.

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

There is no fiscal impact to business because the cost sharing increase will be offset by the decrease in reimbursement to Medicaid providers.

Joseph K. Miner, MD, Executive Director

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

Health
Health Care Financing, Coverage and Reimbursement Policy
CANNON HEALTH BLDG
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:

06/14/2017

This rule may become effective on:

07/01/2017

Authorized by:

Joseph Miner, 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: [February 15], 2017

Notice of Continuation: February 15, 2017

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