Copayments

Section 125.310  Copayments a)         Effective July 1, 2012, copayments may be charged to the family by a health care professional whenever the service is performed in an office or home setting, except for visits scheduled for well-baby care, well-child care or age-appropriate immunizations. Copayments may also be charged to the family by hospitals, for inpatient hospitalization or outpatient encounter.  No copayment is permitted for visits to health care professionals or hospitals made solely for speech, occupational or physical therapy, audiology, radiology or laboratory.  Families with an enrolled individual who is an American Indian or Alaska Native shall not be charged copayments. b)         Effective July 1, 2012, copayment requirements are as follows, subject to federal approval: 1)         Practitioner office visit: A)        All Kids Share copayment: the nominal copayment amount as defined in federal regulations at 42 CFR 447.54, which, for dates of service beginning July 1, 2012 through March 31, 2013, is $3.65. Beginning April 1, 2013, the nominal copayment amount is $3.90.  Specific copayment amounts are described and updated on the Department's Web site. B)        All Kids Premium Level 1 copayment: $5 per visit. 2)         Inpatient hospitalization: A)        All Kids Share copayment: a copayment amount as defined in federal regulations at 42 CFR 447, which, for dates of service beginning July 1, 2012 through March 31, 2012, is $3.65 per admission. Beginning April 1, 2013, the nominal copayment amount is $3.90 per day.  Specific copayment amounts are described and updated annually on the Department's Web site. B)        All Kids Premium Level 1 copayment: $5 per day. 3)         Outpatient hospital encounter: A)        All Kids Share copayment: the nominal copayment amount as defined in federal regulations at 42 CFR 447.54, which, for dates of service beginning July 1, 2012 through March 31, 2013, is $3.65. Beginning April 1, 2013, the nominal copayment amount is $3.90.  Specific copayment amounts are described and updated annually on the Department's Web site. B)        All Kids Premium Level 1 copayment: $5 per visit. 4)         Prescription drugs: A)        All Kids Share copayment: $2 for a 1-day to 30-day supply of generic drugs, including over-the-counter drugs and the nominal copayment amount as defined in federal regulations at 42 CFR 447.54, which, for dates of service beginning July 1, 2012 through March, 31, 2013 is $3.65. Beginning April 1, 2013, the nominal copayment amount is $3.90 for a 1-day to 30-day supply of brand name drugs.  Specific copayment amounts are described and updated on the Department's Web site. B)        All Kids Premium Level 1 copayment: $3 for a 1-day to 30-day supply of generic drugs or $5 for 1-day to 30-day supply of brand name drugs. 5)         Nonemergency visit to an emergency room: A)        All Kids Share copayment: $0 per visit. B)        All Kids Premium Level 1 copayment: $25 per visit. 6)         Emergency room visit: A)        All Kids Share copayment:  $0 per visit. B)        All Kids Premium Level 1 copayment:  $5 per visit. c)         The maximum out-of-pocket expense a family will incur for copayments during a 12-month eligibility period is $100. d)         Once the family has satisfied the copayment cap, the family is responsible for submitting receipts, to the Department, documenting the payment of copayments.  The Department may return partial documentation received on copayments to the family. e)         Upon the Department determining that the copayment cap has been satisfied, the following will occur: 1)         A notice stating that the copayment cap has been satisfied, and the date satisfied, will be sent to the family. 2)         REV will be updated to reflect that the copayment cap has been reached. f)         Providers will be responsible for collecting copayments under the All Kids Health Plan. g)         Providers may elect not to charge copayments.   If copayments are charged, the copayment must comply with the requirements in this Section. h)         Providers shall be responsible for refunding to the family copayments they collect after the family has reached the copayment cap. i)          The Department will not require providers to deliver services when copayments properly charged under the All Kids Health Plan are not paid.