department of health and social services
Division of Social Services
PROPOSED
PUBLIC NOTICE
Client Cost Sharing for Pharmaceutical Services: Cumulative Maximum
In compliance with the State's Administrative Procedures Act (APA - Title 29, Chapter 101 of the Delaware Code) and under the authority of Title 31 of the Delaware Code, Chapter 5, Section 512, Delaware Health and Social Services (DHSS) / Division of Social Services is proposing to amend the Division of Social Services Manual (DSSM) regarding the Pharmaceutical Services Program.
Any person who wishes to make written suggestions, compilations of data, testimony, briefs or other written materials concerning the proposed new regulations must submit same to Sharon L. Summers, Policy & Program Development Unit, Division of Social Services, P.O. Box 906, New Castle, Delaware 19720-0906 by August 31, 2005.
The action concerning the determination of whether to adopt the proposed regulation will be based upon the results of Department and Division staff analysis and the consideration of the comments and written materials filed by other interested persons.
Citation
Amending the Following Title XIX Medicaid State Plan Pages
Amending the Following Sections of the Division of Social Services Manual
Summary of Amendment Provisions
To ensure that the state delivers an accessible medical assistance prescription drug program, the following describes the proposed change for pharmacy co-payments, effective July 1, 2005:
Once a client has met the individual monthly maximum co-payment for his or her prescriptions, the Point of Sale (POS) System will NOT indicate a co-payment is due. Medicaid will keep track of the cumulative number of prescriptions for a client with co-payments. Any prescriptions dispensed after the cumulative maximum monthly co-payment amount is met are not subject to a co-payment. Reversal of a previously filled prescription with a co-payment will require a refund of the co-payment to the individual, and will cause the next prescription filled for that client to be adjudicated with a co-payment.
By implementing this process, the Department ensures that a cumulative maximum is likely to benefit all eligible Medicaid clients with continued access to prescription medications.
The proposed cumulative maximum pharmacy requirements are subject to approval by the Centers for Medicare and Medicaid Services (CMS).
DSS PROPOSED REGULATION #05-37a
Page 56a
Revision: HCFA-PM-91-4 (BPD) OMB No.: 0938-AUGUST 1991
State/Territory: DELAWARE
Citation 4.18 (b) (3) (Continued)
42 CFR 447.51 (iii) For the categorically needy
and qualified through 447.58
Medicare beneficiaries,
ATTACHMENT 4.18-A
specifies the:
A. Service(s) for which a
charge(s) is applied;
B. Nature of the charge
imposed on each service;
C. Amount(s) of and basis for
determining the charge(s);
D. Method used to collect the
charge(s);
E. Basis for determining
whether an individual is
unable to pay the charge and
the means by which such an
individual is identified to
providers;
F. Procedures for implementing
and enforcing the exclusions
from cost sharing contained
in 42 CFR 447.53 (b); and
G.. Cumulative maximum that
applies to all deductible,
coinsurance or co-payment
charges imposed on a
specified time period.
X Not applicable. There is
no maximum.
Not applicable. There is
no maximum.
DSS PROPOSED REGULATION #05-37b
ATTACHMENT 4.18-A
Page 3
State Plan Under Title XIX of the Social Security Act
State: DELAWARE
E. Cumulative maximums on charges:
State policy does not provide maximums.
X Cumulative maximum has been established as described below:
$15.00 cumulative monthly maximum co-payment amount aggregated for pharmacy services.
Once a client has met the individual monthly maximum co-payment for his or her prescriptions, the Point of Sale (POS) System will NOT indicate a co-payment is due. Medicaid will keep track of the cumulative number of prescriptions for a client with co-payments. Any prescriptions dispensed after the cumulative maximum monthly co-payment amount is met are not subject to a co-payment. Reversal of a previously filled prescription with a co-payment will require a refund of the co-payment to the individual, and will cause the next prescription filled for that client to be adjudicated with a co-payment.
14960.1 Co-Payment Requirement
Effective January 10, 2005, clients have a nominal co-payment will be imposed for generic and brand name prescription drugs as well as over-the-counter drugs prescribed by a practitioner.
The co-payment is based upon the cost of the drug as follows:
|
Medicaid Payment for the Drug |
Co-payment |
|
$10.00 or less |
$ .50 |
|
$10.01 to $25.00 |
$1.00 |
|
$25.01 to $50.00 |
$2.00 |
|
$50.01 or more |
$3.00 |
The co-payment is imposed for each drug that is prescribed and dispensed.
149601.1 Cumulative Maximum Monthly Co-payment
Effective July 1, 2005, there is a cumulative maximum monthly co-payment amount equal to $15.00 for each recipient. Any prescriptions dispensed after the cumulative maximum monthly co-payment amount is met are not subject to a co-payment.
