DAR File No. 41915

Health, Health Care Financing, Coverage and Reimbursement Policy

Section R414-200-4

Cost Sharing

Notice of Proposed Rule

(Amendment)

DAR File No.: 41915
Filed: 07/10/2017 10:52:53 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.

R414-200. 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: [May 5], 2017

Notice of Continuation: May 14, 2012

Authorizing, and Implemented or Interpreted Law: 26-18