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PA Bulletin, Doc. No. 12-1551



Amendment to the Commonwealth's Medicaid State Plan for Children with Disabilities

[42 Pa.B. 5303]
[Saturday, August 11, 2012]

 The Department of Public Welfare (Department) is announcing its intent to amend the Commonwealth's Medicaid State Plan to apply copayments to services provided to certain Medical Assistance (MA) eligible children with disabilities.


 On July 1, 2011, the General Assembly enacted the act of June 30, 2011 (P. L. 89, No. 22) (Act 22), which amended the Public Welfare Code (code) (62 P. S. §§ 101—1503). Section 7 of Act 22 amended section 454(a) of the code (62 P. S. § 454(a)) by requiring the Department to establish, by publication of a notice in the Pennsylvania Bulletin, copayments for MA services provided to children with disabilities whose household income is above 200% of the Federal poverty income guidelines based on family size.

 The Department intends to amend the State Plan consistent with section 454 of the code and applicable Federal law to apply these copayments as follows:

 • Except for those services and items identified as follows, 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 Limit 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 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 for persons under 21 years of age provided through the Early and Periodic Screening, Diagnosis and Treatment Program (EPSDT)
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
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 Amount MA Service Copayment Amount
Diagnostic Radiology $1.00 Inpatient Hospital Services $20.00 per day
(up to $140.00 per stay)
Nuclear Medicine $1.00
Medical Diagnostic Test $1.00
Radiation Therapy $1.00
Prescription and Prescription Drug Refills $1.00 Generic
$3.00 Brand
Psychotherapy Services
$0.50 per unit

 • For all other services, copayments will be on a sliding scale based on the MA fee for the service, as follows:

Sliding Scale Copayments
MA Fee for the Service Copayment
MA Fee for the Service Copayment
$2.00—$10.00 $.65 $200.01—$300.00 $40.00
$10.01—$25.00 $2.00 $300.01—$400.00 $60.00
$25.01—$50.00 $5.00 $400.01—$500.00 $80.00
$50.01—$100.00 $10.00 $500.01 or greater $100.00
$100.01—$200.00 $20.00

 • Copayments will be collected by the MA provider. In accordance with Federal regulations in 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, nor may they waive or reduce the copayment, because of an individual's inability to pay the copayment amount.

 • 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 claim 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 that the copayment maximum has been reached and should not collect further copayments.

 • The Department will send a written notice to recipients subject to these copayments informing them of the copayments and their maximum copayment liability. The Department will issue a bulletin to providers to inform them of the copayment. In addition, the Department will post copayment information on its web site.

 The Department intends to make these changes effective for dates of service on and after October 1, 2012, for the newly eligible beneficiaries and November 1, 2012, for current beneficiaries.

Fiscal Impact

 The estimated cost savings for Fiscal Year (FY) 2012-2013 is $9.405 million ($4.300 million in State funds). The annualized cost savings for FY 2013-2014 is $12.540 million ($5.813 million in State funds).

Public Comment

 Interested persons are invited to submit written comments regarding this notice to the Department of Public Welfare, Office of Medical Assistance Programs, c/o Deputy Secretary's Office, Attention: Regulations Coordinator, Room 515, Health and Welfare Building, Harrisburg, PA 17120. Comments received within 30 days will be reviewed and considered in the development of the State Plan amendment and the final public notice. Persons with a disability who require an auxiliary aid or service may submit comments using the Pennsylvania AT&T Relay Service (800) 654-5984 (TDD users) or (800) 654-5988 (voice users).


Fiscal Note: 14-NOT-781. 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. 12-1551. Filed for public inspection August 10, 2012, 9:00 a.m.]

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