NOTICES
DEPARTMENT OF
PUBLIC WELFARE
Alternative Cost Sharing for Families of Children with Disabilities with Incomes over 200% of the Federal Poverty Income Guidelines
[42 Pa.B. 6222]
[Saturday, September 29, 2012]The Department of Public Welfare (Department), as required by section 454(a) of the Public Welfare Code (code) (62 P. S. § 454(a)), is implementing copayments for services provided to Medical Assistance (MA) eligible children with disabilities whose household income is above 200% of the Federal poverty income guidelines based on family size. As specified in section 454(a) of the Code, the Department is establishing these copayments by publication of this notice in the Pennsylvania Bulletin. The copayments will be effective for dates of service on and after October 1, 2012, for newly eligible beneficiaries and November 1, 2012, for current beneficiaries.
Discussion
Medicaid is a means-tested Federal and State-funded program designed to provide health care benefits to individuals with limited income and resources. The Federal government provides a baseline of what eligibility groups must be covered and what services must be provided for states to receive Federal Financial Participation. States may choose to expand eligibility to include additional groups. The Commonwealth has exercised various options to use less restrictive methodologies to determine eligibility for Medicaid. In this Commonwealth, there is a special category of MA for children with disabilities whose family income would otherwise make them ineligible for MA. To receive benefits in this category, a child must meet the level of disability established by the Social Security Administration. No other state has an eligibility category comparable to the Commonwealth's MA for Children with Special Needs category. In 2010, the Commonwealth spent more than $708 million to serve approximately 56,000 children in this category. It is estimated that more than 38,000 of these children had family incomes in excess of 200% of the Federal poverty income guideline.
States across the country, including the Commonwealth, are struggling to maintain their Medicaid programs. Measures must be taken to conserve and use the Commonwealth's increasingly scarce public assistance resources as efficiently and effectively as possible. Toward that end, the Department is exercising alternative cost sharing as provided for in the Deficit Reduction Act of 2005 (DRA) (Pub. L. No. 109-171) and implementing Federal regulations.
The Department published a public notice at 42 Pa.B. 5303 (August 11, 2012) announcing its intent to amend the Pennsylvania Medicaid State Plan to apply copayments to services provided to children with disabilities and invited interested persons to comment. The Department received comments from 70 commentators.
After reviewing and considering the comments, the Department is proceeding with implementation of the copayments, consistent with section 454 of the code and applicable Federal law, as follows:
• Except for the following services and items, MA copayments will be applied to children with disabilities who are under 18 years of age and whose household income is above 200% of the Federal Poverty Income Guidelines based on family size.
• The Department will determine family income based on the family's gross annual income, prorated for monthly periods.
The following services and items will not have copayments:
• Preventive services
• Early Intervention services
• Emergency services
• Laboratory services
• Family planning services and supplies
• Home health agency services
• Rental of durable medical equipment
• Services when the MA fee is less than $2.00
• Medical exams provided through the Early and Periodic Screening, Diagnosis and Treatment Program
• Targeted case management services
• Tobacco cessation counseling services
• School-Based Access Program services
• Home and Community Based Waiver services
• The doctor's fee for x-rays, diagnostic tests, nuclear medicine or radiation therapy
• Psychiatric partial hospitalization program services
• Medical exams requested by the Department
• Renal dialysis services
• Blood and blood products
• Oxygen
• Ostomy supplies
• More than one set of specific allergy tests in a 24-hour period
The following services will have a fixed copayment:
Fixed Copayments
MA Service Copayment
AmountDiagnostic Radiology $1.00 Nuclear Medicine $1.00 Medical Diagnostic Test $1.00 Radiation Therapy $1.00 Prescription and Prescription Drug Refills $1.00 Generic
$3.00 BrandInpatient Hospital Services $20.00 per day (up to $140.00 per stay) Outpatient Psychotherapy Services $0.50 per unit For all other services, copayments will be determined on a sliding scale based on the MA fee for the service, as follows:
Sliding Scale Copayments
MA Fee for the Service Copayment
Amount$2.00—$10.00 $.65 $10.01—$25.00 $2.00 $25.01—$50.00 $5.00 $50.01—$100.00 $10.00 $100.01—$200.00 $20.00 $200.01—$300.00 $40.00 $300.01—$400.00 $60.00 $400.01—$500.00 $80.00 $500.01 or greater $100.00 • Copayments will be collected by the MA provider.
• Consistent with 42 CFR 447.82(a) (relating to restrictions on payments to providers), the copayment amount will be deducted from the Department's payment to the provider.
• MA providers may not deny covered care or services because of an individual's inability to pay the copayment amount.
• MA providers may not waive or reduce the copayment.
• The total aggregate amount of the copayments will not exceed 5% of the family's gross annual income, prorated and applied on a monthly basis.
• The Department will track the copayments that have been incurred by using the information in the claims processing system to identify the copayment amounts that have been deducted from the payments made to providers.
• Providers will be advised through the eligibility verification system of the amount of the monthly copayment liability remaining or that the monthly copayment liability has been reached and therefore, no copayments should be collected until the first of the following month. In addition, providers will be advised that they may bill beneficiaries for copayments after they submit claims and receive remittance advices (RAs) from the Department for those claims. The RAs will identify the MA payments for the services and the beneficiaries' copayment liability. If providers choose to collect copayments at the time of service, providers will be instructed to monitor their RAs and refund any copayment amounts collected that exceed the copayment amounts identified on the RAs.
• The Department will send a written notice to beneficiaries subject to these copayments informing them of their monthly copayment liability and when they will be required to start paying the copayments.
The Department issued a Medical Assistance Bulletin, Copayments for Children with Disabilities, to providers to inform them of the copayments. In addition, the Department posted copayment information on its web site.
Fiscal Impact
The estimated cost savings for Fiscal Year 2012-2013 is $9.405 million ($4.300 million in State funds). The annualized cost savings for Fiscal Year 2013-2014 is $12.540 million ($5.813 million in State funds).
GARY D. ALEXANDER,
SecretaryFiscal Note: 14-NOT-796. This change is expected to result in savings of $4.3 million in State funds in FY 2012-13; (8) recommends adoption.
[Pa.B. Doc. No. 12-1915. Filed for public inspection September 28, 2012, 9:00 a.m.]
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