Louisiana Administrative Code
Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE
Part XXIX - Pharmacy
Chapter 1 - General Provisions
Section XXIX-111 - Copayment

Universal Citation: LA Admin Code XXIX-111

Current through Register Vol. 50, No. 9, September 20, 2024

A. Payment Schedule

1. A copayment requirement in the Pharmacy Program is based on the following payment schedule.
a. For dates of service April 1, 2019 through December 31, 2019, recipients with a household income of less than or equal to $800 per month will not be subject to copay.

Calculated

State Payment

Copayment

$10.00 or less

$0.50

$10.01 to $25.00

$1.00

$25.01 to $50.00

$2.00

$50.01 or more

$3.00

2. The pharmacy provider shall collect a copayment from the Medicaid beneficiary for each drug dispensed and covered by Medicaid. The following pharmacy services are exempt from the copayment requirements:
a. services furnished to pregnant women;

b. emergency services;

c. family planning services;

d. preventive medications as designated by the U.S. Preventive Services Task Force's A and B recommendations; and

e. services provided during a federal public health emergency (PHE).

3. The following population groups are exempt from copayment requirements:
a. individuals under the age of 21;

b. individuals residing in a long-term care facility;

c. individuals receiving hospice care;

d. Native Americans and Alaskan Eskimos;

e. women whose basis for Medicaid eligibility is breast or cervical cancer; and

f. home and community-based services waiver recipients.

B. In accordance with federal regulations, the following provisions apply.

1. The provider may not deny services to any eligible individual on account of the individuals inability to pay the copayment amount. However, this service statement does not apply to an individual who is able to pay, nor does an individuals inability to pay eliminate his or her liability for the copayment.

2. Providers shall not waive the recipient copayment liability.

3. Departmental monitoring and auditing will be conducted to determine provider compliance.

4. Violators of this Section maybe subject to a penalty, including but not limited to, termination from the Medicaid Program.

5. The state will ensure Medicaid premiums and cost sharing incurred by all individuals in the Medicaid household do not exceed an aggregate limit of 5 percent of the familys income applied on a monthly basis.

AUTHORITY NOTE: Promulgated in accordance with R.S. 36:254 and Title XIX of the Social Security Act.

Disclaimer: These regulations may not be the most recent version. Louisiana may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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