Pennsylvania Code
Title 55 - HUMAN SERVICES
Part III - MEDICAL ASSISTANCE MANUAL
Chapter 1101 - GENERAL PROVISIONS
FEES AND PAYMENTS
Section 1101.63 - Payment in full
Universal Citation: 55 PA Code ยง 1101.63
Current through Register Vol. 54, No. 44, November 2, 2024
(a) Supplementary payment for a compensable service. A provider shall accept as payment in full, the amounts paid by the Department plus a copayment required to be paid by a recipient under subsection (b). A provider who seeks or accepts supplementary payment of another kind from the Department, the recipient or another person for a compensable service or item is required to return the supplementary payment. A provider may bill a MA recipient for a noncompensable service or item if the recipient is told before the service is rendered that the program does not cover it.
(b) Copayments for MA services.
(1) Recipients receiving
services under the MA Program are responsible to pay the provider the
applicable copayment amounts set forth in this subsection.
(2) The following services are excluded from
the copayment requirement for all categories of recipients:
(i) Services furnished to individuals under
18 years of age.
(ii) Services and
items furnished to pregnant women, which include services during the postpartum
period.
(iii) Services furnished to
an individual who is a patient in a long term care facility, an intermediate
care facility for the mentally retarded or other related conditions, as defined
in 42 CFR
435.1009 (relating to definitions relating to
institutional status) or other medical institution if the individual is
required as a condition of receiving services in the institution, to spend all
but a minimal amount of his income for medical care costs.
(iv) Services provided to individuals
residing in personal care homes and domiciliary care homes.
(v) Services provided to individuals eligible
for benefits under the Breast and Cervical Cancer Prevention and Treatment
Program.
(vi) Services provided to
individuals eligible for benefits under Title IV-B Foster Care and Title IV-E
Foster Care and Adoption Assistance.
(vii) Services provided in an emergency
situation as defined in §
1101.21 (relating to
definitions).
(viii) Laboratory
services.
(ix) The professional
component of diagnostic radiology, nuclear medicine, radiation therapy and
medical diagnostic services, when the professional component is billed
separately from the technical component.
(x) Family planning services and
supplies.
(xi) Home health agency
services.
(xii) Services provided
to individuals receiving hospice care.
(xiii) Psychiatric partial hospitalization
program services.
(xiv) Services
furnished by a funeral director.
(xv) Renal dialysis services.
(xvi) Blood and blood products.
(xvii) Oxygen.
(xviii) Ostomy supplies.
(xix) Rental of durable medical
equipment.
(xx) Targeted case
management services.
(xxi) Tobacco
cessation counseling services.
(xxii) Outpatient services when the MA fee is
under $2.
(xxiii) Medical
examinations when requested by the Department.
(xxiv) Screenings provided under the EPSDT
Program.
(xxv) More than one of a
series of a specific allergy test provided in a 24-hour period.
(3) The following services are
excluded from the copayment requirement for categories of recipients except GA
recipients age 21 to 65:
(i) Drugs, including
immunizations, dispensed by a physician.
(ii) Specific drugs identified by the
Department in the following categories:
(A)
Antihypertensive agents.
(B)
Antidiabetic agents.
(C)
Anticonvulsants.
(D) Cardiovascular
preparations.
(E) Antipsychotic
agents, except those that are also schedule C-IV antianxiety agents.
(F) Antineoplastic agents.
(G) Antiglaucoma drugs.
(H) Antiparkinson drugs.
(I) Drugs whose only approved indication is
the treatment of acquired immunodeficiency syndrome (AIDS).
(4) Except for the
exclusions specified in paragraphs (2) and (3), each MA service furnished by a
provider to an eligible recipient is subject to copayment
requirements.
(5) The amount of the
copayment, which is to be paid to providers by categories of recipients, except
GA recipients, and which is deducted from the Commonwealth's MA fee to
providers for each service, is as follows:
(i)
For pharmacy services, drugs and over-the-counter medications:
(A) For recipients other than State Blind
Pension recipients, $1 per prescription and $1 per refill for generic
drugs.
(B) For recipients other
than State Blind Pension recipients, $3 per prescription and $3 per refill for
brand name drugs.
(C) For State
Blind Pension recipients, $1 per prescription and $1 per refill for brand name
drugs and generic drugs.
(ii) For inpatient hospital services,
provided in a general hospital, rehabilitation hospital or private psychiatric
hospital, the copayment is $3 per covered day of inpatient care, to an amount
not to exceed $21 per admission.
(iii) For nonemergency services provided in a
hospital emergency room, the copayment on the hospital support component is
double the amount shown in subparagraph (vi), if an approved waiver exists from
the United States Department of Health and Human Services. If an approved
waiver does not exist, the copayment will follow the schedule shown in
subparagraph (vi).
(iv) When the
total component or only the technical component of the following services are
billed, the copayment is $1:
(A) Diagnostic
radiology.
(B) Nuclear
medicine.
(C) Radiation
therapy.
(D) Medical diagnostic
services.
(v) For
outpatient psychotherapy services, the copayment is 50¢ per unit of
service.
(vi) For all other
services, the amount of the copayment is based on the MA fee for the service,
using the following schedule:
(A) If the MA
fee is $2 through $10, the copayment is 65¢.
(B) If the MA fee is $10.01 through $25, the
copayment is $1.30.
(C) If the MA
fee is $25.01 through $50, the copayment is $2.55.
(D) If the MA fee is $50.01 or more, the
copayment is $3.80.
(E) The
Department may, by publication of a notice in the Pennsylvania
Bulletin, adjust these copayment amounts based on the percentage
increase in the medical care component of the Consumer Price Index for All
Urban Consumers for the period of September to September ending in the
preceding calendar year and then rounded to the next higher 5-cent
increment.
(6)
The amount of the copayment, which is to be paid to providers by GA recipients
age 21 to 65, and which is deducted from the Commonwealth's MA fee to providers
for each service, is as follows:
(i) For
prescription drugs:
(A) $1 per prescription
and $1 per refill for generic drugs.
(B) $3 per prescription and $3 per refill for
brand name drugs.
(ii)
For inpatient hospital services, provided in a general hospital, rehabilitation
hospital or private psychiatric hospital, the copayment is $6 per covered day
of inpatient care, not to exceed $42 per admission.
(iii) When the total component or only the
technical component of the following services are billed, the copayment is $2:
(A) Diagnostic radiology.
(B) Nuclear medicine.
(C) Radiation therapy.
(D) Medical diagnostic
services.
(iv) For all
other services, the amount of the copayment is based on the MA fee for the
service, using the following schedule:
(A) If
the MA fee is $2 through $10, the copayment is $1.30.
(B) If the MA fee is $10.01 through $25, the
copayment is $2.60.
(C) If the MA
fee is $25.01 through $50, the copayment is $5.10.
(D) If the MA fee is $50.01 or more, the
copayment is $7.60.
(E) The
Department may, by publication of a notice in the Pennsylvania
Bulletin, adjust these copayment amounts based on the percentage
increase in the medical care component of the Consumer Price Index for All
Urban Consumers for the period of September to September ending in the
preceding calendar year and then rounded to the next higher 5-cent
increment.
(7)
A provider participating in the program may not deny covered care or services
to an eligible MA recipient because of the recipient's inability to pay the
copayment amount. This paragraph does not change the fact that the recipient is
liable for the copayment, and it does not prevent the provider from attempting
to collect the copayment amount. If a recipient believes that a provider has
charged the recipient incorrectly, the recipient shall continue to pay
copayments charged by that provider until the Department determines whether the
copayment charges are correct.
(8)
A provider may not waive the copayment requirement or compensate the recipient
for the copayment amount.
(9) If a
recipient is covered by a third-party resource and the provider is eligible for
an additional payment from MA, the copayment required of the recipient may not
exceed the amount of the MA payment for the item or
service.
(c) MA deductible.
(1) A $150 deductible
per fiscal year shall be applied to adult GA recipients for the following MA
compensable services:
(i) Ambulatory surgical
center services.
(ii) Inpatient
hospital services.
(iii) Outpatient
hospital services.
(2)
Laboratory and X-ray services are excluded from the deductible
requirement.
The provisions of this §1101.63 amended under sections 201(2), 403(b), 403.1, 443.1, 443.3, 443.6, 448 and 454 of the Public Welfare Code (62 P. S. §§ 201(2), 403(b), 403.1, 443.1, 443.3, 443.6, 448 and 454).
This section cited in 55 Pa. Code § 1101.31 (relating to scope); 55 Pa. Code § 1101.63a (relating to full reimbursement for covered services rendered-statement of policy); 55 Pa. Code § 1121.55 (relating to method of payment); 55 Pa. Code § 1127.51 (relating to general payment policy); and 55 Pa. Code § 1128.51 (relating to general payment policy).
Disclaimer: These regulations may not be the most recent version. Pennsylvania 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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