PURPOSE: This rule implements recipient copayment for certain Missouri Medicaid program areas.

1. (1) Recipients eligible to receive Missouri Medicaid services under certain program areas shall be required to pay a small portion of the costs of the services. The services to be affected by the copayment or coinsurance requirements are—

   1. (A) All audiological services and hearing aids provided through the Audiology Program;
   2. (B) All dental services and dentures provided through the Dental Program;
   3. (C) All optometric services, eyeglasses and artificial eyes provided through the Optical Program;
   4. (D) All podiatry services provided through the Podiatry Program;
   5. (E) Inpatient hospital services;
   6. (F) Outpatient hospital clinic/emergency room services; and
   7. (G) Physician services rendered in a hospital outpatient clinic or emergency room.
2. (2) Participating providers of services in the program areas named shall be required to charge copayment or coinsurance, as applicable, on each subject item of service performed or furnished, or on each date of service as applicable.
3. (3) Copayment charged shall be in accordance with 42 CFR 447.54 and, applicable to the services described in subsections (1)(A),
4. (B) (excepting dentures), (C) and (D), based on the following schedule:

Medicaid Payment Recipient for Each Item of Copayment Service Amount $10.99 or less $0.50 $11.00—$25.99 $1.00 $26.00—$50.99 $2.00 $51.00 or more $3.00

1. (4) Under this rule, coinsurance shall apply only to Medicaid-covered full and partial dentures. The coinsurance amount to be charged shall be five percent (5%) of the lesser of the Medicaid maximum allowable amount for the service or the provider’s billed charge.
2. (5) Copayment to be charged for inpatient hospital services shall be ten dollars ($10) per hospitalization, applicable to the first day of the Medicaid-covered hospital stay and to be charged to the recipient prior to discharge.
3. (6) Co-payment to be charged for hospital outpatient clinic or emergency room services shall be two dollars ($2) for each date of service on which the recipient receives, either one (1) or both, outpatient clinic or emergency room services.
4. (7) Co-payment to be charged for physician services provided in a hospital outpatient clinic or emergency room shall be one dollar ($1) for each date of service on which the recipient receives these services.

5. (8) With noted exceptions, the following exemptions to the copayment requirement apply to the services described in subsections (1)(A)–(G):

   1. (A) Services provided on or after December 1, 1984 to recipients under eighteen (18) years of age;
   2. (B) Services to recipients residing within a skilled nursing home, an intermediate care nursing home, a residential care home, an adult boarding home or a psychiatric hospital;
   3. (C) Services to recipients who have both Medicare and Medicaid entitlement if Medicare covers the service and provides payment for it;
   4. (D) Emergency or transfer inpatient hospital admissions;
   5. (E) Emergency services provided in an outpatient clinic or emergency room, such as— heart attack, hemorrhaging, poisoning, concussion, bone fractures or stroke;
   6. (F) Certain therapy services (physical therapy, chemotherapy, radiation therapy, psychotherapy and chronic renal dialysis) except when provided as an inpatient hospital service;
   7. (G) Family planning services;
   8. (H) Services provided to pregnant women which are directly related to the pregnancy or a complication of the pregnancy;
   9. (I) Services provided to foster care recipients; and
   10. (J) Early Periodic Screening, Diagnosis and Treatment services.
6. (9) Providers of services as described in this rule and as subject to a copayment or coinsurance requirement may not deny or reduce services otherwise eligible for Medicaid benefits on the basis of the recipient’s inability to pay the due copayment or coinsurance amount when charged.
7. (10) A recipient’s inability to pay a required coinsurance or copayment amount, as due and charged when a service is delivered, in no way shall extinguish the recipient liability to pay the due amount.
8. (11) Participation privileges in the Medicaid program shall be limited to providers who accept, as payment in full, the amounts paid by the state agency plus any coinsurance or copayment amount required of the recipient.
9. (12) Providers of services in the program areas named must charge copayment or coinsurance as specified at the time the service is provided to retain their participation privileges in the Missouri Medicaid program.
10. (13) Providers must maintain records of copayment or coinsurance amounts for five
11. (5) years and must make those records available to the Department of Social Services upon request.

AUTHORITY: section 207.020, RSMo 1986. This rule was previously filed as 13 CSR 40- 81.054. Emergency rule filed Oct. 21, 1981, effective Nov. 1, 1981, expired Feb. 10, 1982. Original rule filed Oct. 21, 1981, effective Feb. 11, 1982. Emergency amendment filed Jan. 21, 1983, effective Feb. 1, 1983, expired May 11, 1983. Amended: Filed Jan. 21, 1983, effective May 12, 1983. Amended: Filed Aug. 14, 1984, effective Nov. 11, 1984.