Appendix D: Copayment Guidelines

The MA program has rules for copayment exclusions and copayment amounts for covered services. Some MA covered services are excluded from copayment, some services have a fixed copayment amount, and other services have a copayment based on a sliding scale.

Excluded Services

The following services are excluded from copayment for all categories of recipients:

NOTE:  An emergency is when immediate medical care is needed to prevent death or serious harm to a individual’s health. If the medical provider does not agree that the situation is an emergency, the individual will have to pay the copayment for the services.

NOTE:  A copayment is needed for durable medical equipment that is bought

NOTE:  Examples are exams needed to decide on eligibility, whether someone can be employed, how mentally able a individual is, how well a individual can see, and whether a individual needs skilled nursing or intermediate care facility service.

The following services are excluded from copayment for all recipients except adult General Assistance MA recipients:

Fixed Copayments

The following copayments must be paid to the provider by the recipient, except for adult General Assistance MA recipients:

> $1 for each prescription and $1 for each refill for generic drugs

> $3 for each prescription and $3 for each refill for brand name drugs

The following copayments must be paid to the provider by General Assistance MA recipients:

Sliding Scale Copayments:

For all other MA covered services, the amount of the copayment is based on the MA fee for the service.

Copayment Example

An adult SSI recipient (J/00) visits a doctor and must have both arms x-rayed. The doctor bills DHS for three services provided; one office visit, at an MA fee of $26.50, and two x-rays, at $15.00 each. The recipient has to make the following copayments:

 

Updated May 15, 2012, Replacing February 14, 2012