Current through all regulations passed and filed through September 16, 2024
(A) This rule does not apply to MyCare Ohio
plans as defined in rule
5160-58-01 of the Administrative
Code or the Ohio resilience through integrated systems and excellence
(OhioRISE) plan as defined in rule
5160-59-01 of the Administrative
Code.
(B) The managed care
organization (MCO) may elect to implement a member co-payment program pursuant
to section 5162.20 of the Revised Code for
dental services, vision services, or non-emergency emergency department
services or until implementation of the single pharmacy benefit manager (SPBM),
prescription drugs as provided for in this rule. The MCO must receive prior
approval from the Ohio department of medicaid (ODM) before notifying members
that a co-payment program will be implemented.
(C) Upon implementation of the SPBM, the SPBM
may only elect to implement a member co-payment program pursuant to section
5162.20 of the Revised Code for
prescription drugs as provided for in this rule if directed to by
ODM.
(D) If the MCO or SPBM
implements a member co-payment program, the MCO and SPBM must:
(1) Exclude the populations and services set
forth in paragraph (E) of this rule;
(2) Not deny services to members as specified
in paragraph (F) of this rule;
(3)
Not impose co-payment amounts in excess of the maximum amounts specified in
42 C.F.R.
447.54 (October 1, 2021);
(4) Specify in provider contracts governed by
rule 5160-26-05 of the Administrative
Code the circumstances under which member co-payment amounts can be requested.
If the MCO or SPBM implements a co-payment program, no provider can waive a
member's obligation to pay the provider a co-payment except as described in
paragraph (I) of this rule;
(5)
Ensure that the member is not billed for any difference between the MCO or
SPBM's payment and the provider's charge or request that the member share in
the cost through co-payment or other similar charge, other than medicaid
copayments as defined in this rule;
(6) Ensure that member co-payment amounts are
requested by providers in accordance with this rule; and
(7) Ensure that no provider or drug
manufacturer, including the manufacturer's representative, employee,
independent contractor, or agent shall pay any copayment on behalf of the
member.
(E) Exclusions
to the member co-payment program for dental, vision, non-emergency emergency
department services, and prescription medications include the following:
(1) Children. Members who are under the age
of twenty-one are excluded from medicaid co-payment obligations.
(2) Pregnant women. With the exception of
routine eye examinations and the dispensation of eyeglasses during a member's
pregnancy or post-partum period, all services provided to pregnant women during
their pregnancy and the postpartum period are excluded from a medicaid
co-payment obligation. The postpartum period is the period that begins on the
last day of pregnancy and extends through the end of the month in which the
twelve
month period following termination of pregnancy ends.
(3) Institutionalized members. Services or
medications provided to members who reside in a nursing facility (NF) or
intermediate care facility for individuals with intellectual disabilities
(ICF/IID) are excluded from medicaid co-payment obligations.
(4) Emergency. An MCO shall not impose a
co-payment obligation for emergency services provided in a hospital, clinic,
office, or other facility that is equipped to furnish the required care, after
the sudden onset of a medical condition manifesting itself by acute symptoms of
sufficient severity (including severe pain) that the absence of immediate
medical attention could reasonably be expected to result in placing the
patient's health in serious jeopardy; serious impairment to bodily functions;
or serious dysfunction of any bodily part or organ.
(5) Family planning (pregnancy prevention or
contraceptive management). The MCO or SPBM shall not impose a medicaid
co-payment obligation on any service identified by ODM as a pregnancy
prevention/contraceptive management service in accordance with rules
5160-21-02 and
5160-1-09 of the Administrative
Code and provided to an individual of child-bearing age.
(6) Hospice. Members receiving services for
hospice care are excluded from medicaid co-payment obligation.
(7) Medicare cross-over claims. Medicare
cross-over claims defined in accordance with rule
5160-1-05 of the Administrative
Code will not be subject to medicaid co-payment obligations.
(8) Medications administered to a member
during a medical encounter provided in a hospital, clinic, office or other
facility, when the medication is part of the evaluation and treatment of the
condition, are not subject to a member copayment.
(F) No provider may deny services to a member
who is eligible for services due to the member's inability to pay the member
co-payment. Members who are unable to pay their member co-payment may declare
their inability to pay for services or medication and receive their services or
medications without paying their member co-payment amount. This provision does
not relieve the member from the obligation to pay a member co-payment or
prohibit the provider from attempting to collect an unpaid member co-payment.
If it is the routine business practice of the provider to refuse service to any
individual who owes an outstanding debt to the provider, the provider may
consider an unpaid medicaid co-payment as an outstanding debt and may refuse
service to a member who owes the provider an outstanding debt. If the provider
intends to refuse service to a member who owes the provider an outstanding
debt, the provider shall notify the individual of the provider's intent to
refuse services. In such situations, the MCO or SPBM must still ensure that the
member has access to needed services.
(G) The MCO or SPBM may impose member
co-payments as follows:
(1) For dental
services, the member co-payment amount may not exceed the amount set forth in
Chapter 5160-5 of the Administrative Code. Services provided to a member on the
same date of service by the same provider are subject to only one
co-payment.
(2) For non-emergency
emergency department services, the member co-payment amount must not exceed the
amount set forth in Chapter 5160-2 of the Administrative Code. For purposes of
this rule, the hospital provider shall determine if services rendered are
non-emergency emergency department services and will report, through claim
submission, the applicable co-payment to the MCO in accordance with medicaid
hospital billing instructions.
(3)
For vision services, the member co-payment amounts must not exceed the amounts
set forth in Chapter 5160-6 of the Administrative Code.
(4) For pharmacy services, the member
co-payment amounts must not exceed the amounts set forth in Chapter 5160-9 of
the Administrative Code.
(H) Prescriptions for medications are subject
to the applicable member co-payment for medications if they are given to a
member during a medical encounter provided in the emergency department or other
hospital setting, clinic, office, or other facility as a result of the
evaluation and treatment of the condition, regardless of whether they are
filled at a pharmacy located at the facility or at an outside
location.
(I) If the MCO has
implemented a member co-payment program for non-emergency emergency department
services, as described in paragraph (G)(2) of this rule, a hospital may take
action to collect a co-payment by providing, at the time services are rendered
to a managed care member, notice that a co-payment may be owed. If the hospital
provides the notice and chooses not to take further action to pursue collection
of the co-payment, the prohibition against waiving co-payments, as described in
paragraph (D)(4) of this rule, does not apply.
(J) If the MCO or SPBM does not to impose a
co-payment amount for dental services, vision services, non-emergency emergency
department services or prescription drugs, and the MCO or SPBM reimburses
contracting or non-contracting providers for these services using the medicaid
provider reimbursement rate, the MCO or SPBM must not reduce its provider
payments by the applicable co-payment amount set forth in this rule.
