§ 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.
Authority The provisions of this § 1101.63 amended under sections 201(2), 403(b), 403.1, 443.1, 443.3, 443.6, 448 and 454 of the Public Welfare Code (62 P. S. § § 201(2), 403(b), 403.1, 443.1, 443.3, 443.6, 448 and 454).
Source The provisions of this § 1101.63 amended August 10, 1984, effective September 1, 1984, 14 Pa.B. 2926; amended January 22, 1988, effective January 23, 1988, 18 Pa.B. 336; amended April 12, 1991, effective May 1, 1991, 21 Pa.B. 1557; amended December 11, 1993, effective January 1, 1993, 22 Pa.B. 5995; amended August 26, 2005, effective August 29, 2005, 35 Pa.B. 4811; amended April 13, 2012, effective May 15, 2012, 42 Pa.B. 2010. Immediately preceding text appears at serial page (312929) to (312932) and (337473).
(Editor’s Note: The amendment made to this section at 21 Pa.B. 1557 (April 13, 1991) was promulgated under section 6(b) of the Regulatory Review Act (71 P. S. § 745.6(b)).)
Notes of Decisions The Board of Claims may decide whether the Department’s action in refusing to reimburse for depreciation and interest expenses constituted a breach of the provided agreement. The Department’s jurisdiction over provider appeal is not mandatory and exclusive. Department of Public Welfare v. Divine Providence Hospital, 516 A.2d 82 (Pa. Cmwlth. 1986); appeal dismissed 544 A.2d 1323 (Pa. 1988).
Cross References This section cited in 55 Pa. Code § 1101.31 (relating to scope); 55 Pa. Code § 1101.63a (relating to full reimbursement for covered services rendered—statement of policy); 55 Pa. Code § 1121.55 (relating to method of payment); 55 Pa. Code § 1127.51 (relating to general payment policy); and 55 Pa. Code § 1128.51 (relating to general payment policy).
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