RULES AND REGULATIONS
DEPARTMENT OF PUBLIC WELFARE
[ 55 PA. CODE CH. 1101 ]
Amendments to Copayment Regulations
[42 Pa.B. 2010]
[Saturday, April 14, 2012]The Department of Public Welfare (Department) amends Chapter 1101 (relating to general provisions) to read as set forth in Annex A under the authority of sections 201(2), 403(b) and 403.1 of the Public Welfare Code (code) (62 P. S. §§ 201(2), 403(b) and 403.1), as amended by the act of June 30, 2011 (P. L. 89, No. 22) (Act 22).
Omission of Proposed Rulemaking
On July 1, 2011, the General Assembly enacted Act 22, which amended the code. Act 22 added several new provisions to the code, including section 403.1. Section 403.1(a)(1) and (3) of the code authorizes the Department to promulgate final omitted regulations under section 204(1)(iv) of the act of July 31, 1968 (P. L. 769, No. 240) (45 P. S. § 1204(1)(iv)), known as the Commonwealth Documents Law (CDL), to establish rules, regulations, procedures and standards for the nature and extent of assistance and to modify existing benefits. Section 204(1) of the CDL authorizes an agency to omit or modify notice of proposed rulemaking when a regulation relates to Commonwealth grants or benefits. The Medical Assistance (MA) Program is a Commonwealth grant program through which eligible recipients receive coverage of certain health care benefits. In addition, to ensure that the Department's expenditures for State Fiscal Year (FY) 2011-2012 do not exceed the aggregate amount appropriated by the General Assembly, section 403.1(d) of the code expressly exempts these regulations from the Regulatory Review Act (71 P. S. §§ 745.1—745.12), section 205 of the CDL (45 P. S. § 1205) and section 204(b) of the Commonwealth Attorneys Act (71 P. S. § 732-204(b)).
The Department is amending § 1101.63(b) (relating to payment in full) in accordance with section 403.1(a)(1) and (3) of the code because this final-omitted rulemaking pertains to the nature and extent of assistance and benefits for the MA Program. Further, consistent with section 403.1(c) of the code, this final-omitted rulemaking is necessary to ensure that expenditures for State FY 2011-2012 for assistance programs administered by the Department do not exceed the aggregate amount appropriated for the program by the General Appropriations Act of 2011.
Purpose
The purpose of this final-omitted rulemaking is to amend § 1101.63 to: 1) eliminate recipient copayment reimbursements; 2) update the sliding-scale MA copayment amount and provide that the Department may, by publication of a notice in the Pennsylvania Bulletin, adjust these copayments amounts; and 3) make technical amendments to Chapter 1101 to codify certain Federally mandated copayment exclusions and to clarify existing MA copayment policies.
Background
The Department administers the MA Program under Title XIX of the Social Security Act (act) (42 U.S.C.A. §§ 1396—1396w-5) for low-income individuals, pregnant women, infants and children, and individuals who are aged, blind or disabled. In addition, the Department administers an MA program for General Assistance (GA) MA recipients, principally single adults, which is funded solely by State funds and is not mandated by the Federal government. Both MA programs provide a continuum of physical and behavioral health services, including long-term care, inpatient hospital, pharmacy, outpatient services such as physician, podiatric, medical and psychiatric clinics, chiropractic services and dental services, and medical supplies and durable medical equipment to approximately 2.1 million eligible MA recipients.
In an effort to address the current budget constraints, the Department has taken steps to implement a series of initiatives aimed at reducing costs while still providing needed care to MA recipients, including limiting pharmacy benefits for recipients 21 years of age and older to six prescriptions for drugs per calendar month and by limiting certain dental benefits for recipients 21 years of age and older. Despite these and other cost saving efforts, the Department was compelled to identify additional ways to achieve the necessary cost savings. After reviewing various options, the Department determined that modifying the recipient copayment obligations will produce savings with the least impact on services and care provided to MA recipients.
The Department implemented nominal copayment requirements for certain nonexempt MA recipients in September 1983. At that time, the Department also implemented a reimbursement process for MA recipients other than GA recipients for copayments paid in excess of $90 in a 6-month period. In January 1993, the copayment reimbursement process was expanded to apply to GA recipients who pay copayments in excess of $180 in a 6-month period. Although this copayment reimbursement was intended to limit the potential adverse fiscal impact of the copayment requirement, it prevents the Department from maximizing the potential cost savings available to the MA Program through application of MA recipient copayments. As a result, the Department will eliminate the copayment reimbursement provision in § 1101.63(b)(7) with this final-omitted rulemaking.
Until 2006, Federal Medicaid regulations permitted nominal sliding scale copayments ranging from $0.50 to $3 depending on the amount the Commonwealth pays for the service. The Department's MA sliding scale copayments for MA recipients, other than GA recipients, have remained fixed at these amounts for many years. For State-funded GA recipients, the Department applies twice the nominal copayments applicable to other MA recipients. The Deficit Reduction Act of 2005 (DRA) (Pub. L. No. 109-171) and implementing regulations increased the maximum Medicaid nominal sliding copayment amounts each year, beginning in 2006, by the annual percentage increase in the medical care component of the Consumer Price Index for All Urban Consumers (CPI-U) for the period September to September ending in the preceding calendar year and rounded to the next higher 5 cent increment. See section 1916(a)(3) and (b)(3) of the Social Security Act (42 U.S.C.A. § 1396o(a)(3) and (b)(3)) and 42 CFR 447.54 (relating to maximum allowable and nominal charges). The Department has not increased the copayment amount as permitted by Federal law. In an effort to meet current budgetary objectives, the Department is updating the MA sliding scale copayment amounts for MA recipients, other than GA recipients, to reflect the current CPI-U adjustments and may, through publication of a notice in the Pennsylvania Bulletin, update the sliding scale copayment amounts on a recurring basis to account for future CPI-U adjustments, as permitted by the DRA. The Department may also update the sliding scale copayment amounts for GA MA recipients, which will continue to be twice the amounts applied to MA recipients other than GA recipients, consistent with current MA copayment policy for these populations.
Technical Amendments
The Department is making several technical corrections to § 1101.63(b). These technical corrections do not represent changes to the Department's current MA copayment policies. The technical corrections reflect and clarify copayment exclusions that have been in effect under the MA Program, based upon Federal Medicaid requirements and MA copayment policies, but have not yet been incorporated into Chapter 1101. These technical corrections are as follows:
• Exclude from MA copayments services provided to individuals who are eligible under the Breast and Cervical Cancer Prevention and Treatment (BCCPT) Program and individuals, regardless of age, who qualify for benefits under Title IV-B Foster Care and Title IV-E Foster Care and Adoption Assistance, as mandated under the DRA. The Department adopted this mandate effective March 31, 2006, and notified providers by way of MA Bulletin 99-06-12, ''Change to copayment requirements for recipients eligible under the Breast and Cervical Cancer Prevention and Treatment Program and Titles IV-B & IV-E Foster Care and Adoption Assistance,'' issued December 10, 2006.
• Exclude tobacco cessation counseling services from MA copayments. In September, 2006, the Department excluded these services to remove perceived barriers to accessing this MA covered service that helps recipients quit smoking.
• Exclude from MA copayments services for recipients residing in personal care homes (PCH) and domiciliary care homes (DCH). In October 2007, the Department amended the Medicaid State Plan to exclude PCH and DCH residents from MA copayments, as most of these individuals receive Supplemental Security Income (SSI) and contribute all but a minimal amount of the SSI income to the costs of the PCH or DCH care.
• Exclude from MA copayments services for recipients in hospice care. This is a Federal Medicaid requirement that has been in effect under the MA Program for many years, but is not currently identified in MA copayment regulations.
• Clarify that the exclusion of pregnant women from copayment requirements extends throughout the woman's postpartum period, consistent with 42 CFR 447.53(b)(2) (relating to applicability; specification; multiple charges). The inadvertent omission of the postpartum period language in the Department's current MA copayment regulation has led to some confusion for MA enrolled providers regarding the full scope of this exclusion.
• Specify that intermediate care facilities (ICF/MR) or other related conditions (ICF/ORC) are facilities that meet the criteria for the copayment exclusion for institutionalized individuals. Institutionalized recipients are excluded from copayment requirements under 42 CFR 447.53(b)(3) if the institutionalized individuals are, as a condition of receiving services in the institution, required to spend all but a minimal amount of their income for medical services. Within the Commonwealth's MA Program, ICF/MRs and ICF/ORCs are facilities that meet the criteria for this copayment exclusion. The Department's current MA copayment regulation does not explicitly identify ICF/MRs and ICF/ORCs, which has resulted in confusion for MA providers regarding applicability of the exclusion to residents of these facilities.
Additionally, the Department is renumbering the copayment regulations.
Therefore, with this final-omitted rulemaking, the Department is amending § 1101.63(b)(2) to codify and clarify the scope and applicability of these copayment exclusions. The technical amendments do not impose new or additional copayment exclusions and reflect the manner in which these copayment exclusions are currently applied in the MA Program.
Public Process
The Department published an advance public notice at 42 Pa.B 1001 (February 18, 2012) announcing its intent to amend the copayment provisions under Chapter 1101. The Department invited interested persons to comment. In addition, the Department discussed these copayment amendments with the Medical Assistance Advisory Committee on February 23, 2012.
The Department also posted the draft regulation on the Department's web site on February 24, 2012, with a 15-day comment period. The Department again invited interested persons to submit written comments regarding the regulation to the Department. The Department received 16 topically-related comments from 85 commentators. The Department also discussed the Act 22 regulations and responded to questions at the House Health Committee hearing on March 8, 2012.
The Department considered the comments in response to the draft regulation.
Discussion of Comments
The following is a summary of the major comments received within the public comment period and the Department's response to those comments.
Comment: Several commentators stated that the Department did not allow sufficient time for review and comment of the regulations.
Response: The Department engaged in a transparent public process through which the Department solicited and received numerous comments and input from stakeholders and other interested parties.
As previously mentioned, the Department published advance public notice at 42 Pa.B. 1001 announcing its intent to amend the copayment provisions under Chapter 1101. The Department invited interested persons to comment. The Department also posted the draft regulation on the Department's web site on February 24, 2012. The Department again invited interested persons to submit written comments, on or before March 9, 2012, regarding the regulation to the Department. As a final-omitted regulation under Act 22, the Department was not required to have a public comment process. However, to encourage transparency and public input the Department provided an opportunity for comment by publishing the notice and posting the draft regulation on the Department's web site. This public comment process provided sufficient opportunity for interested parties to submit comments, as supported by the number of comments that were submitted.
Comment: Several commentators stated that the Department exceeded its authority under Act 22 by issuing a final-omitted rulemaking that changes copayments in future years. Further, the Department may not give itself the authority to adjust copayments by publishing a notice in the Pennsylvania Bulletin. Under State law, the Department may only adjust copayments by adopting regulations through a full rulemaking process.
Response: Act 22 authorizes the Department to promulgate final-omitted regulations that revise payment rates. To ensure that the Department's expenditures for State FY 2011-2012 do not exceed the amount appropriated by the General Assembly, these regulations are exempt from the Regulatory Review Act, section 205 of the CDL and section 204(b) of the Commonwealth Attorneys Act. There is nothing in Act 22 that precludes the promulgation of final-omitted regulations that will have an impact in both State FY 2011-2012 and in future years.
The Department is not required to undertake the full rulemaking process to adjust copayments. Federal law provides for annual increases in the maximum Medicaid nominal sliding copayment amounts each year based upon the annual percentage increase in the medical care component of the CPI-U for the period September to September ending in the preceding calendar year and rounded to the next higher 5 cent increment. See section 1916(a)(3) and (b)(3) of the Social Security Act and 42 CFR 447.54. The Department's regulation simply authorizes this inflation adjustment to be made to the Department's existing copayments if and only to the extent permitted by Federal law. Regulatory authority for routine adjustments to be made by notice in the Pennsylvania Bulletin is neither novel nor unusual. For example, see the following: § 501.7 (authorizing the Department to make adjustments to the standard utility allowance amounts, the telephone allowances and the homeless shelter allowances for recipients by publishing a notice in the Pennsylvania Bulletin); § 1187.2 (authorizing the Department to define certain types of Durable Medical Equipment by publishing a notice in the Pennsylvania Bulletin); § 1151.54(i) (authorizing the Department to publish a notice in Pennsylvania Bulletin to list qualifying inpatient psychiatric facilities and their annual disproportionate share payment percentages); § 1150.61 (authorizing the Department to publish a notice when fees are changed and when procedures or items are added to or deleted from the MA Program Fee Schedule); § 1128.52 (for renal dialysis services, authorizing the Department to publish notice for rate increases and decreases and changes in methodology used in establishing maximum fees).
Comment: Several commentators suggested that eliminating the copayment reimbursement provision would impose a severe financial hardship on MA consumers.
Response: The Department acknowledges that the elimination of the copayment reimbursement provision may be viewed by some as a financial burden but is compelled to implement cost saving initiatives. The Department determined that eliminating the copayment reimbursement provision is preferable to other options, such as reducing or eliminating services.
Comment: Several commentators expressed concern that an increase in the sliding scale copayment amount will put added strain on MA consumer's limited income and reduce their ability to become self-sufficient.
Response: As noted in the previous response, the Department is compelled to implement cost savings initiatives. After analyzing the options, the Department concluded that increasing the sliding scale copayment amounts as authorized under the DRA is preferable to other options, such as reducing or eliminating services.
Comment: Several commentators stated that it is unfair for GA recipients to be required to pay double the copayment of MA recipients.
Response: The Department has considered the fiscal impact on GA recipients. However, GA copayments have always been double that of MA recipients. This change is simply in keeping with that standard.
Comment: Several commentators suggested providers should be able to deny services to individuals who cannot or refuse to pay their copayments.
Response: The Department acknowledges concerns that some recipients will be unable to pay the copayments at time of service. Section 1916(e) of the Social Security Act and 42 CFR 447.53(e), which pertain to the Department's nominal MA copayments for Medicaid recipients, prohibit denial of service due to a MA recipient's inability to pay the copayment. The DRA includes state options regarding enforcement of alternative cost-sharing. The Department may consider alternative cost sharing options provided for in the DRA in the future.
Comment: Many commentators, including several county MA transportation providers, objected to the impos-ition of a $2 per one-way trip copayment for non-emergency medical transportation (NEMT) paratransit services.
Response: The Department included the NEMT paratransit copayment in the public notice description of the intended regulatory change and the draft regulation. After careful consideration of public comments on this subject, the Department is removing the NEMT paratransit copayment from this final-omitted rulemaking.
Comment: Many comments expressed concern over the application of copayments for children with disabilities whose family income exceeds 200% of the Federal Poverty Income Guidelines.
Response: This final-omitted rulemaking does not impose MA copayments for children with disabilities.
Requirements
The final-omitted rulemaking amends § 1101.63(b)(2) as follows:
• Subsection (b)(5)(vi) is amended by updating the slid- ing scale copayment amounts for MA recipients other than GA recipients to coincide with the current CPI-U medical component adjustment.
• Subsection (b)(5)(vi) is amended by adding clause (E) to state that the Department may update the sliding scale copayment amount on a recurring basis to account for future CPI-U adjustments by publication of a notice in the Pennsylvania Bulletin.
• Subsection (b)(6)(iv) is amended by updating the slid- ing scale copayment amounts for GA recipients to twice the amounts established for MA recipients other than GA recipients.
• Subsection (b)(6)(iv) is amended by adding clause (E) to state that the Department may update the sliding scale copayment amount on a recurring basis to account for future CPI-U adjustments by publication of a notice in the Pennsylvania Bulletin.
• Subsection (b)(7) regarding recipient copayment reimbursement is deleted and the remaining paragraphs are renumbered accordingly.
• Subsection (b)(2)(ii) is amended to add language to clarify that the copayment exclusion for services furnished to pregnant women extends throughout the postpartum period.
• Subsection (b)(2)(iii) is amended to add language to clarify that the copayment exclusion for services furnished to institutionalized individuals includes individuals residing in ICF/MRs or ICF/ORCs.
• Subsection (b)(2)(iv) is added to exclude from MA copayment requirements services furnished to individuals residing in PCHs or DCHs.
• Subsection (b)(2)(v) is added to specify that services furnished to women eligible under the BCCPT Program are excluded from MA copayment requirements.
• Subsection (b)(2)(vi) is added to specify that services furnished to individuals for whom assistance is made available under Titles IV-B and IV-E of the Social Security Act, without regard to the individual's ages, are excluded from MA copayment requirements.
• Subsection (b)(2)(xii) is added to specify that services provided to individuals receiving hospice care are excluded from MA copayment requirements.
• Subsection (b)(2)(xxi) is added to specify that tobacco cessation counseling services are excluded from MA copayment requirements.
• Numbering under subsection (b)(2) is changed as a result of these additions.
Affected Individuals and Organizations
MA recipients who are not otherwise excluded from copayment requirements will be affected by the final-omitted rulemaking, which increases the nominal sliding scale MA copayment amounts and eliminates excess copayment reimbursement to recipients.
MA enrolled providers will benefit from the enhanced clarity of the copayment regulation afforded through the technical amendments.
Accomplishments and Benefits
This final-omitted rulemaking imposes limited additional copayment liability on MA and GA MA recipients who are not otherwise excluded from copayment requirements, which will enable the Department to preserve vital benefits to the greatest number of MA recipients while reducing costs in accordance with the goals in section 403.1 of the code. The technical amendments will codify copayment exclusions as well as enhance clarity of the regulation.
Fiscal Impact
The final-omitted rulemaking ensures that the Department's expenditures do not exceed the aggregate amount appropriated by the General Assembly for FY 2011-2012.
Paperwork Requirements
There are no additional reports, paperwork or new forms needed to comply with the final-omitted rulemaking.
Regulatory Review Act
Under section 403.1 of the code, this final-omitted rulemaking is not subject to review under the Regulatory Review Act.
Findings
The Department finds that:
(1) Notice of proposed rulemaking is omitted in accordance with section 204(1)(iv) of the CDL, 1 Pa. Code § 7.4(1)(iv) and section 403.1(d) of the code because the final-omitted rulemaking relates to Commonwealth grants and benefits.
(2) The adoption of this final-omitted rulemaking in the manner provided by this order is necessary and appropriate for the administration and enforcement of the code.
Order
The Department, acting under the code, orders that:
(a) The regulations of the Department, 55 Pa. Code Chapter 1101, are amended by amending § 1101.63 to read as set forth in Annex A.
(b) The Secretary of the Department shall submit this order and Annex A to the Office of General Counsel for approval as to legality and form as required by law.
(c) The Secretary of the Department shall certify and deposit this order and Annex A with the Legislative Reference Bureau as required by law.
(d) This order shall take effect on May 15, 2012.
GARY D. ALEXANDER,
SecretaryFiscal Note: 14-529. No fiscal impact; (8) recommends adoption.
Annex A
TITLE 55. PUBLIC WELFARE
PART III. MEDICAL ASSISTANCE MANUAL
CHAPTER 1101. GENERAL PROVISIONS
FEES AND PAYMENTS § 1101.63. Payment in full.
(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.
[Pa.B. Doc. No. 12-645. Filed for public inspection April 13, 2012, 9:00 a.m.]
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