DAR File No. 41914

Health, Health Care Financing, Coverage and Reimbursement Policy

Section R414-100-4

Cost Sharing Provisions

Notice of Proposed Rule

(Amendment)

DAR File No.: 41914
Filed: 07/10/2017 10:41:23 AM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this change is to implement new cost-sharing policy in accordance with the Affordable Care Act.

Summary of the rule or change:

This amendment removes cost-sharing provisions from the rule to defer implementation of the cost-sharing policy to the Medicaid State Plan. The Department 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:

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

Anticipated cost or savings to:

the state budget:

The Department estimates annual savings to the state budget based on the new cost-sharing policy. The total savings amount can be found in the companion filing to this rulemaking (Section R414-1-28, published in the May 15, 2017, Utah State Bulletin). (EDITOR'S NOTE: The proposed amendment to Section R414-1-28 was published under Filing No. 41498 in the May 15, 2017, issue of the Utah State Bulletin on page 75.)

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 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 is offset by a decrease in reimbursement and does not affect total annual revenue. Medicaid members, however, may see an annual increase in out-of-pocket expenses with the policy's implementation. The total out-of-pocket cost can be found in the companion filing to this rulemaking (Section R414-1-28, published in the May 15, 2017, Utah State Bulletin).

Compliance costs for affected persons:

A single Medicaid member may share a portion of the annual increase in out-of-pocket expenses with the policy's implementation. The total out-of-pocket cost can be found in the companion filing to this rulemaking (Section R414-1-28, published in the May 15, 2017, Utah State Bulletin).

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

After conducting a thorough analysis, it was determined that this proposed rule will not result in a fiscal impact to businesses.

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 [email protected]

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:

08/31/2017

This rule may become effective on:

09/07/2017

Authorized by:

Joseph Miner, Executive Director

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

R414-100. Medicaid Primary Care Network Services.

[R414-100-4. Cost Sharing Provisions.

(1) Emergency department visits require a $30 copayment.

(2) Outpatient office visits require a $5 copayment for physician and physician-related visits. There is no copayment for preventive services, immunizations and health education.

(3) Dental office visits require a $5 copayment.

(4) Laboratory and x-ray services:

(a) laboratory services costing less than $50 require no copayment or co-insurance;

(b) laboratory services costing more than $50 require a co-insurance of 5% of the Medicaid allowed amount;

(c) x-ray services costing less than $100 require no copayment or co-insurance; and

(d) x-ray services costing more than $100 require a co-insurance of 5% of the Medicaid allowed amount.

(5) Pharmacy services require:

(a) a $5 copayment per prescription for generic drugs;

(b) a 25% of the estimated acquisition cost co-insurance for brand name drugs for which there is no generic equivalent; and

(c) a 100% copay for brand name drugs for which there is a generic equivalent.

(6) Durable medical equipment and supplies require a co-insurance of 10% of Medicaid allowed amount.

(7) The out-of-pocket maximum payment for copayments or co-insurance is limited to $1000 per enrollee per enrollment year.

(8) Tribal members utilizing the federal Indian Health Care or tribal health care systems will not pay copayments, co-insurance or deductibles.

(9) Vision services require a $5 copayment per office visit.]

 

KEY: Medicaid, primary care network

Date of Enactment or Last Substantive Amendment: [May 5], 2017

Notice of Continuation: May 14, 2012

Authorizing, and Implemented or Interpreted Law: 26-18