Department of Health and Social Services
Division of Social Services
EMERGENCY REGULATION
Client Cost Sharing for Pharmaceutical Services:
Cumulative Maximum
Nature of the Proceedings:
This Emergency Regulation is being promulgated to amend the Title XIX Medicaid State Plan and the Division of Social Services Manual (DSSM) to establish a cumulative maximum on pharmacy co-payments effective July 1, 2005. Delaware Health and Social Services (“Department”) must take this action on an emergency basis to ensure access to quality healthcare. The Department has determined that a threat to the public welfare exists if it is not implemented without prior notice or hearing.
Nature of Proposed Amendment:
Statutory Basis:
Amending the Following Title XIX Medicaid State Plan Pages:
Amending the Following Sections of the Division of Social Services Manual:
Summary of Amendment Provisions:
On June 1, 2005, DSS published a Notice of Intent to amend its client cost-sharing regulations for pharmacy services. The purpose of this action is to give public notice of the agency’s intent to submit an amendment to the Title XIX Medicaid State Plan to the Centers for Medicare and Medicaid Services (CMS) to establish a cumulative maximum on pharmacy co-payments, effective July 1, 2005.
To encourage and facilitate client access to pharmaceutical care services, an emergency regulation is needed for the immediate implementation of a cumulative maximum. This action is necessary to minimize adverse impacts to clients.
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:
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).
Findings of Fact:
The Department finds that this change should be made in the best interest of the general public of the State of Delaware. The Department will receive, consider, and respond to petitions by any interested person for the reconsideration or revision thereof.
THEREFORE, IT IS ORDERED, that the proposed amendment to the Title XIX Medicaid State Plan and the Division of Social Services Manual (DSSM) to establish a cumulative maximum on pharmacy co-payments be adopted on an emergency basis without prior notice or hearing, and shall become effective July 1, 2005.
Vincent P. Meconi, Secretary, DHSS
Title XIX Medicaid State Plan, Establish a Cumulative Maximum on Pharmacy Co-payments
DSS EMERGENCY ORDER #05-36a
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
through 447.58 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.
Not applicable. There is no
maximum.
DSS EMERGENCY ORDER #05-36b
ATTACHMENT 4.18-A
Page 3
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
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.
DSS EMERGENCY ORDER #05-36c
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.
