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Co-Payment Changes for Medicaid Services

May 23, 2013

TO:  All Providers

RE:  Co-Payment Changes for Medicaid Services

Effective for dates of service July 1, 2013, and thereafter, copayments for Medicaid covered services will be based on the federally approved maximum amounts shown below (including Medicare crossovers):

Services with Co-payments

Co-payment Amounts

Based on Medicaid’s Allowed Amount for the Services

Office Visits (including visits to physicians, optometrists, nurse practitioners)

$1.30 to $3.90 per office visit code

$50.01 or more - $3.90

$25.01 - $50.00 - $2.60

$10.01 - $25.00 - $1.30

Federally Qualified Health Centers (FQHC)

$3.90 per encounter

 

Rural Health Clinic (RHC)

$3.90 per encounter

 

Inpatient Hospital

$50.00 per admission

 

Outpatient Hospital

$3.90 per visit

 

Ambulatory Surgical Centers

$3.90 per visit

 

Durable Medical Equipment

$1.30 to $3.90 per item

$50.01 or more - $3.90

$25.01 - $50.00 - $2.60

$10.01 - $25.00 - $1.30

Medical Supplies and Appliances

$0.65 to $3.90 per item

$50.01 or more - $3.90

$25.01 - $50.00 - $2.60

$10.01 - $25.00 - $1.30

$10.00 or less - $0.65

Prescription Drugs

$0.65 to $3.90 per prescription

$50.01 or more - $3.90

$25.01 - $50.00 - $2.60

$10.01 - $25.00 - $1.30

$10.00 or less - $0.65

 

Co-payment does not apply to services provided to/for:

·         Pregnant women

·         Nursing facility residents

·         Recipients less than 18 years of age

·         Native American Indians with an active user letter from Indian Health Services (IHS)

·         Emergencies

·         Family Planning

 

The provider may not deny services to any eligible Medicaid recipient because of the recipient’s inability to pay the cost-sharing (co-payment) amount imposed.