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.
The following services are excluded from copayment for all categories of recipients:
Services given to children under 18 years of age
Service and items given to pregnant women (including through the post partum period)
Services given to individuals in a nursing home or other medical institution
Services given to women in the Breast and Cervical Cancer Prevention and Treatment (BCCPT) coverage group
Services given to people of any age under Titles IV-B and IV-E Foster Care and Adoption Assistance
Services given in an emergency situation
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.
Laboratory services
The doctor’s part of diagnostic radiology, nuclear medicine, radiation therapy, and medical diagnostic services, when it is billed separately from the technical procedure
Family planning services and supplies
Home health agency services
Psychiatric partial hospitalization program services
Services performed by a funeral director
Renal dialysis services
Blood and blood products
Oxygen
Ostomy supplies
Rental of durable medical equipment
NOTE: A copayment is needed for durable medical equipment that is bought
Outpatient services when the MA fee is under $2
Medical exams when requested by DHS
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.
Screenings provided under the EPSDT Program
More than one of a specific allergy test given in 24 hours
Targeted case-management services
Tobacco Cessation Counseling Services
The following services are excluded from copayment for all recipients except adult General Assistance MA recipients:
Drugs, including immunizations, given by a physician
Specific drugs in the following categories:
Antihypertensive agents
Antidiabetic agents
Anticonvulsants
Cardiovascular preparations
Antipsychotic agents, except those that are also schedule C-IV antianxiety agents
Antineoplastic agents
Antiglaucoma drugs
Antiparkinson drugs
Drugs whose only approved use is for the treatment of Acquired Immunodeficiency Syndrome (AIDS)
The following copayments must be paid to the provider by the recipient, except for adult General Assistance MA recipients:
For prescription drugs; pharmacy services and over-the-counter medications:
For State Blind Pension recipients, $1 for each prescription and $1 for each refill for brand name drugs and generic drugs
For all other 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
For inpatient services in a general hospital, rehabilitation hospital, or private psychiatric hospital, $3 for each day covered, up to $21 for each admission
When the total amount or only the technical part of any of the following services is billed, the copayment is $1:
Diagnostic radiology
Nuclear medicine
Radiation therapy
Medical diagnostic services
For outpatient psychotherapy services (individual, family, collateral family, or group), 50 cents per unit of service
The following copayments must be paid to the provider by General Assistance MA recipients:
For prescription drugs:
$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
For inpatient services in a general hospital, rehabilitation hospital, or private psychiatric hospital, $6 per covered day of inpatient care, up to $42 for each admission
When the total amount or only the technical part of any of the following services is billed, the copayment is $2:
Diagnostic radiology
Nuclear medicine
Radiation therapy
Medical diagnostic services
For all other MA covered services, the amount of the copayment is based on the MA fee for the service.
For all recipients except for adult General Assistance MA recipients:
If the MA fee is $2.00 through $10.00, the copayment is $.65.
If the MA fee is $10.01 through $25.00, the copayment is $1.30.
If the MA fee is $25.01 through $50.00, the copayment is $2.55.
If the MA fee is $50.01 or more, the copayment is $3.80.
For adult General Assistance MA recipients:
If the MA fee is $2.00 through $10.00, the copayment is $1.30.
If the MA fee is $10.01 through $25.00, the copayment is $2.60.
If the MA fee is $25.01 through $50.00, the copayment is $5.10.
If the MA fee is $50.01 or more, the copayment is $7.60.
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:
Office visit: $2.55 copayment (sliding scale)
1st x-ray: $1 copayment (fixed)
2nd x-ray: $1 copayment (fixed)
Total copayment due from recipient: $4.55
Updated May 15, 2012, Replacing February 14, 2012