department of health and social services
Division of Social Services
PUBLIC NOTICE
proposed
MEDICAID/MEDICAL ASSISTANCE PROGRAMS
Client Cost Sharing for Pharmaceutical Services
In compliance with the State's Administrative Procedures Act (APA - Title 29, Chapter 101 of the Delaware Code) and with 42CFR §447.205, 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 / Medicaid/Medical Assistance Program is proposing 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.
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 and Program Development Unit, Division of Social Services, P.O. Box 906, New Castle, Delaware 19720-0906 by November 30, 2004.
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 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)
DSS PROPOSED REGULATION #04-22a
Page 54
Revision: OMB No.: 0938-
State/Territory: DELAWARE
Citation 4.18 Recipient Cost Sharing and Similar Charges (a) Unless a waiver under
42 CFR 447.51through 447.58 42 CFR 431.55(g) applies deductibles, coinsurance rates, and
copayments 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
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.
Page 55
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State/Territory: DELAWARE
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.
Page 56
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State/Territory: DELAWARE
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
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.
Page 56a
Revision: OMB No.: 0938-
State/Territory: DELAWARE
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.
Not applicable.
There is no
maximum.
Page 56b
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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 PROPOSED REGULATION #04-22b
NEW STATE PLAN PAGE
Revision: ATTACHMENT 4.18-A
Page 1
OMB NO.: 093-0193
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
STATE: DELAWARE
A. The following charges are imposed on the categorically needy for services other than those provided under section 1905
(1) through (5) and (7) of the Act:
|
Service |
Type of Charge |
Amount and Basis for Determination |
||
|
Deductible |
Coinsurance |
Co-payment |
||
|
Pharmacy |
-0- |
-0- |
X |
This co-pay is effective January 10, 2005 and is based on the nominal ranges specified in 42 CFR 447.54(a)(3), based on the State fee for the service. |
NEW STATE PLAN PAGE
Revision: ATTACHMENT 4.18-A
Page 2
OMB NO.: 093-0193
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
STATE: DELAWARE
B. The method used to collect cost sharing charges for categorically needy individuals:
Providers are responsible for collecting the cost sharing charges from individuals.
The agency reimburses providers the full Medicaid rate for services and collects the cost sharing charges from
individuals.
C. The basis for determining whether an individual is unable to pay the charge, and the means by which such an individual
is identified to providers, is described below:
The Pharmacy (Pharmacist) Provider will be advised via the Point-of-Sale System regarding the client's liability for the
drug co-pay and the amount of the co-pay. When a client advises a pharmacy of an inability to pay the applicable co-pay
amount at the time the prescription is filled, the pharmacy cannot refuse to fill the prescription and must dispense the drug
as prescribed.
The client will remain liable for reimbursement of the co-pay amount and will be responsible for paying the pharmacy
when financially able. Medicaid will not pay the co-pay amount to the pharmacy where a client declares an inability to
pay. Provider payment will continue to be that sum which is the Medicaid fee minus the applicable client co-pay amount.
NEW STATE PLAN PAGE
Revision: ATTACHMENT 4.18-A
Page 3
OMB NO.: 093-0193
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
STATE: DELAWARE
D. The procedures for implementing and enforcing the exclusions from cost sharing contained in 42 CFR 447.53 (b) are
described below:
Exclusions from cost sharing requirements are programmed into the Medicaid Management Information System and the
Point-of-Sale (POS) System.
Pharmacy Providers have been informed about applicable service and amount; and, the prohibition of service denial if
client is unable to meet the co-pay amount by the following methods: (1) provider manuals, which are distributed to all
providers; and (2) provider newsletters.
Co-payment requirements are set forth in provider manuals, which are distributed, to all providers. The billing instructions
are updated and transmitted to providers via the Provider Newsletter. These instructions have been incorporated in the
billing instruction section of the provider manuals, which are given to all providers.
E. Cumulative maximums on charges:
State policy does not provide maximums.
Cumulative maximums have been established as described below:
DSS PROPOSED REGULATION #04-22c
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
d. facility group or the acute care hospital group
e. emergency services
f. family planning services and supplies
h. 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.
