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) Dental services related to trauma or the treatment of a disease/medical condition;
   2. (B) Optical services related to trauma or the treatment of a disease/medical condition, and one (1) eye exam every two (2) years;
   3. (C) Podiatry services provided through the podiatry program;
   4. (D) Inpatient hospital services;
   5. (E) Hospital outpatient clinic/emergency room services; and
   6. (F) All physician-related services.
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), (excepting dentures), (B), (C), and (F), based on the following schedule:

Medicaid Payment Recipient for Each Item of Copayment Service Amount $10 or less $0.50 $10.01–$25 $1.00 $25.01–$50 $2.00 $50.01 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 three dollars ($3) for each date of service on which the recipient receives, either one (1) or both, outpatient clinic or emergency room services.

4. (7) The following is a list of exemptions to the Medicaid copayment requirement:

   1. (A) Services provided to recipients under nineteen (19) years of age;
   2. (B) Services provided to recipients residing within a skilled nursing facility, an intermediate care facility, a residential care facility, an adult boarding home or a psychiatric hospital;
   3. (C) Services provided 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, after the sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that the absence of immediate medical attention could reasonably be expected to result in:

      1. 1. Placing the patient’s health in serious

jeopardy;

1. 2. Serious impairment to bodily func-

tions; or

1. 3. Serious dysfunction of any bodily

organ or part;

1. (F) Certain therapy services (physical therapy, chemotherapy, radiation therapy, psychotherapy and chronic renal dialysis) except when provided as an inpatient hospital service;
2. (G) Family planning services;
3. (H) Services provided to pregnant women;
4. (I) Services provided to foster care recipients;
5. (J) Services identified as medically necessary through an Early Periodic Screening, Diagnosis and Treatment (EPSDT) screen;
6. (K) Services provided through MC+ Managed Care Contracts;
7. (L) Personal care services;
8. (M) Mental health services;
9. (N) Services provided to the blind;
10. (O) Hospice services; and
11. (P) Medicaid waiver services.

1. (8) Providers are responsible for collecting the copayment or coinsurance amounts from individuals. The medical assistance program shall not increase its reimbursement to a provider to offset an uncollected copayment from a recipient. A provider shall collect a copayment from a recipient at the time each service is provided or at a later date. 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.
2. (9) 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 or prevent a provider from attempting to collect a copayment.
3. (10) 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.
4. (11) 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.
5. (12) Providers must maintain records of copayment or coinsurance amounts for five
6. (5) years and must make those records available to the Department of Social Services upon request.
7. (13) If it is the routine business practice of a provider to discontinue future services to an individual with uncollected debt, the provider may include uncollected copayments under this practice.
8. (14) A provider shall give a Medicaid recipient a reasonable opportunity to pay an uncollected copayment.
9. (15) A provider shall give a Medicaid recipient with uncollected debt advanced notice and a reasonable opportunity to arrange care with a different provider before services can be discontinued.
10. (16) If a provider is not willing to provide services to a recipient with uncollected copayments and the requirements of this regulation have been met, the provider may discontinue future services to an individual with uncollected copayments. In accordance with 42 Code of Federal Regulations (CFR) 431.51, a recipient may obtain services from any qualified provider who is willing to provide services to that particular recipient and accept their ability/inability to pay the required copayments.

AUTHORITY: sections 208.152, RSMo Supp. 2004 and as enacted by the 93rd General Assembly and 208.201, RSMo 2000.* 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. Emergency amendment filed Aug. 11, 2005, effective Sept. 1, 2005, expired Feb. 27, 2006. Amended: Filed May 16, 2005, effective Nov. 30, 2005. *Original authority: 208.152, RSMo 1967, amended 1969, 1971, 1972, 1973, 1975, 1977, 1978, 1981, 1986, 1988, 1990, 1992, 1993, 2004 and 208.201, RSMo 1987.