DEPARTMENT OF HEALTH AND SOCIAL SERVICES

Division of Social Services

Statutory Authority: 31 Delaware Code,

Section 512 (31 Del.C. §512)

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.

Summary Of The Provisions

Citation

• 42 CFR §447.54(d)

Amending the Following Title XIX Medicaid State Plan Pages

• Page 56a

• Attachment 4.18-A, Page 3

Amending the Following Sections of the Division of Social Services Manual

• 14960.1

• 14960.1.1

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:

• A cumulative maximum is 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.

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.

c 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:

c 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.

DSS PROPOSED REGULATION #05-37c

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.

9 DE Reg. 173 (08/01/05) (Prop.)