department of health and social services
Division of Social Services
final
Client Cost Sharing for Pharmaceutical Services
ORDER
Nature Of The Proceedings
Delaware Health and Social Services (“Department”) / Division of Social Services initiated proceedings to amend the Title XIX Medicaid State Plan and the Division of Social Services Manual (DSSM) to establish the provisions relating to imposing and collecting co-payments for pharmaceutical services from Medicaid/Medical Assistance clients. The Department’s proceedings to amend its regulations were initiated pursuant to 29 Delaware Code Section 10114 and its authority as prescribed by 31 Delaware Code Section 512.
The Department published its notice of proposed regulation changes pursuant to 29 Delaware Code Section 10115 in the November 2004 Delaware Register of Regulations, requiring written materials and suggestions from the public concerning the proposed regulations to be produced by November 30, 2004 at which time the Department would receive information, factual evidence and public comment to the said proposed changes to the regulations.
Summary Of The Pharmacy Services Co-payment Policy
Title of Notice:
Medicaid/Medical Assistance Client Cost Sharing
Overview:
42 USC 1396a(a)(14) permits state Medicaid programs to require certain clients to share some of the costs of Medicaid by imposing enrollment fees, premiums, deductibles, coinsurance, co-payments, or similar cost sharing charges. The Delaware Medicaid/Medical Assistance Program (DMAP) exercises this option to impose a co-payment for prescription drugs for Medicaid clients. Having elected to impose this co-payment, DMAP must comply with the specific provisions of 42 U.S.C. 1396o, 42 CFR §§447.15, 447.21, 447.53, 447.54, 447.55 and, 447.57.
Summary of Pharmacy Services Co-Payment Policy
This notice is being given to provide information of public interest with respect to the intent of DSS to amend the Division of Social Services Manual (DSSM) and to submit to the Centers for Medicare and Medicaid Services (CMS) an amendment to the Title XIX Medicaid State Plan to establish and implement co-payments for pharmacy services. The following provisions of this amendment shall be implemented on January 10, 2005:
Medicaid Fee Co-Pay Amount
$10.00 or less $ .50
$10.01-$25.00 $1.00
$25.01-$50.00 $2.00
$50.01 or more $3.00
The proposed amendment applies to Medicaid clients and shall be implemented on January 10, 2005.
The proposed cost sharing requirements are subject to approval by the Centers for Medicare and Medicaid Services (CMS)
Summary Of Comments Received With Agency Response and Explanation Of Any Change(S)
DSS received comments from the following organizations: the Governor's Advisory Council for Exceptional Citizens (GACEC) and the State Council for Persons with Disabilities (SCPD).
A summary of all the comments and agency response follows:
Agency Response: This was a publication formatting problem. Under 14960.2 Exclusions from Co-payment Requirement, the list should read from “a” to “f”, not “h”. What is listed under “d” is actually a continuation of “c”. In this case, letters were dropped when the word document was imported. The final order regulation shows the correct text. DSS intends to exempt actual nursing home residents. GA and waiver participants are not exempt from the co-pay requirement.
Agency Response: DSS expects to notify affected beneficiaries prior to implementation.
Agency Response: The requested information will be made available once finalized.
Agency Response: Federal regulations require states to exempt persons in institutions.
Agency Response: Co-pays have been implemented and are working in many other states.
Agency Response: At present, the policy will remain as is.
Findings Of Fact:
The Department finds that the proposed changes as set forth in the November 2004 Register of Regulations should be adopted.
THEREFORE, IT IS ORDERED, that the proposed regulation to establish the provisions relating to imposing and collecting co-payments for pharmaceutical services from Medicaid/Medical Assistance clients is adopted and shall be final effective January 10, 2005.
Vincent P. Meconi, Secretary, DHSS
Date of Signature 12.15.2004
DSS FINAL ORDER REGULATION #04-31a
Page 54
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State/Territory: DELAWARE
Citation 4.18 Recipient Cost Sharing and
42 CFR 447.51 Similar Charges
through 447.58 (a) Unless a waiver under 42 CFR
431.55(g) applies deductibles,
coinsurance rates, and co
payments do not exceed the
maximum allowable charges
under 42 CFR 447.54.
1916 (a) and (b) (b) Except as specified in items 4.18
of the Act (b) (4), (5) and (6) below, with
respect to individuals covered as
categorically needy or as
qualified Medicare beneficiaries
(as defined in section 1905 (p) (1)
of the Act) under the plan:
(1) No enrollment fee, premium,
or similar charge is imposed
under the plan.
(2) No deductible, coinsurance,
co-payment, or similar
charge is imposed under the
plan for the following:
(i) Services to individuals
under age 18, or under--
Age 19
Age 20
X Age 21
Reasonable categories
of individuals who are
age 18 or older, but
under age 21, to whom
charges apply are listed
below, if applicable.
(ii) Services to pregnant
women related to the
pregnancy or any other
medical condition that
may complicate the
pregnancy.
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Citation 4.18 (b) (2) (Continued)
42 CFR 447.51 (iii) All services
through furnished to pregnant
447.58 women.
Not applicable.
Charges apply for
services to pregnant
women unrelated to
the pregnancy.
(iv) Services furnished to
any individual who is an
inpatient in a hospital,
long-term care facility,
or other medical
institution, if the
individual is required, as
a condition of receiving
services in the
institution, to spend for
medical care costs all
but a minimal amount of
his or her income
required for personal
needs.
(v) Emergency services if
the services meet the
requirements in 42 CFR
447.53 (b) (4).
(vi) Family planning
services and supplies
furnished to individuals
of childbearing age.
(vii) Services furnished
by a health maintenance
organization in which
the individual is
enrolled.
1916 of the Act, (viii) Services furnished
P.L. 99-272, to an individual
(Section 9505) receiving hospice care,
as defined in section
1905 (o) of the Act.
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Citation 4.18(b) (Continued)
42 CFR 447.51 (3) Unless a waiver under
through 42 CFR 431.55 (g)
447.48 applies, nominal deductible,
coinsurance, co-payment, or
similar charges are imposed
for services that are not
excluded from such charges
under item (b) (2) above.
Not applicable. No such
charges are imposed.
(i) For any service, no more
than one type of charge
is imposed.
(ii) Charges apply to
services furnished to the
following age groups:
18 or older
19 or older
20 or older
X 21 or older
Charges apply to
services furnished
to the following
reasonable
categories of
individuals listed
below who are 18
years of age or
older but under age
21.
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Citation 4.18 (b) (3) (Continued)
42 CFR 447.51 (iii) For the categorically
through 447.58 needy and qualified
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.
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State/Territory: DELAWARE
Citation
1916 (c) of 4.18 (b) (4) A monthly premium is
the Act imposed on pregnant
women and infants who
are covered under
section 1902 (a)(10)(A)
(ii) (IX) of the Act and
whose income equals or
exceeds 150 percent of
the Federal poverty level
applicable to a family of
the size involved. The
requirements of section
1916 (c) of the Act are
met ATTACHMENT
4.18-D specifies the
method the State uses
for determining the
premium and the criteria
for determining what
constitutes undue
hardship for waiving
payment of premiums
by recipients.
1902 (a) (52) 4.18 (b) (5) For families
and 1925 (b) receiving extended
of the Act benefits during a second
6-month period section
1925 of the Act, a
monthly premium is
imposed in accordance
with sections 1925 (b)
(4) and (5) of the Act.
1916 (d) of 4.18 (b) (6) A monthly premium,
the Act set on a sliding
scale, imposed on
qualified disabled and
working individuals
who are covered under
section 1902 (a) (10) (E)
(ii) of the Act and whose
income exceeds 150
percent (but does not
exceed 200 percent) of
the Federal poverty level
applicable to a family of
the size involved.
The requirements of
section 1916 (d) of the
Act are met.
ATTACHMENT4.18-E
Specifies the methods
and standards the State
uses for determining the
premium.
DSS FINAL ORDER REGULATION #04-31c
Division of Social Services Manual (DSSM)
14960 Cost Sharing
Section 1902(a)(14) of the Social Security Act permits states to require certain recipients to share some of the costs of Medicaid by imposing upon them such payments as enrollment fees, premiums, deductibles, coinsurance, co-payments, or similar cost sharing charges.
14960.1 Co-Payment Requirement
Effective January 10, 2005, 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.
14960.2 Exclusions from Co-payment Requirement
The following individuals and services are excluded from the co-payment requirement:
a. individuals under age 21
b. pregnant women, including the postpartum period
c. individuals eligible under the long term care nursing
facility group or the acute care hospital group
d. emergency services
e. family planning services and supplies
f. hospice services
14960.3 Inability to Pay
The pharmacy provider may not refuse to dispense the prescription(s) subject to the co-payment requirement because of the individual's inability to pay the co-payment amount. When a recipient indicates that he or she is unable to meet the co-payment requirement, the pharmacy provider must dispense the prescription(s) as written. Medicaid reimbursement for the prescription(s) will be the Medicaid fee minus the applicable co-payment amount.
The recipient remains liable for the co-payment amount and is responsible for paying the pharmacy when financially able. The pharmacy provider is permitted to pursue reimbursement of the co-payment amount from the recipient.
