PURPOSE: This rule establishes the regulatory basis for the Medicaid requirement of eligible recipient copayment when receiving covered pharmacy services.

1. (1) All Medicaid-eligible recipients shall be responsible for a copayment upon receipt of each original or refilled prescription of a Medicaid-covered drug unless the service is exempted under provisions of section (2). Copayment responsibility and amounts collectible shall be as follows:

Medicaid Maximum Recipient Allowable Amount for Copayment Each Item of Service Amount $10.00 or less $0.50 $10.01—$25.00 $1.00 $25.01 or more $2.00 The Medicaid maximum allowable amount for each item of service is the lesser of the providers billed charge or the price(s) in the drug pricing file 13 CSR 70-20.070(3).

1. (2) Services exempted from the copayment requirement for drugs are—

   1. (A) Services to recipients under nineteen

2. (19) years of age;

   1. (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;
   2. (C) Those drugs specifically identified as relating to family planning services (oral contraceptives);
   3. (D) Those drugs which are prescribed and identified as relating to an Early Periodic Screening, Diagnosis and Treatment (EPSDT) program screening or referral service; and
   4. (E) Those drugs prescribed for foster care children.

3. (3) Those drugs which are exempt from the requirement of copayment as related to an EPSDT screening or referral service must be confirmed as such to the dispenser through one (1) of the following methods:

   1. (A) The prescribing physician (MD, DO, dentist, podiatrist) identifies on the prescription that it relates to EPSDT examination and treatment; or
   2. (B) The prescribing physician verbally states that the prescription relates to EPSDT examination and treatment in cases of telephone prescribing. This verbal assertion must be included in the dispensing provider’s reduction into writing of the prescription.
4. (4) Providers of service may not deny or reduce services otherwise eligible for Medicaid benefits on the basis of the recipient’s inability to pay the due copayment amount when charged.
5. (5) A recipient’s inability to pay a required copayment amount, as due and charged when a service is delivered, shall in no way extinguish the recipient liability to pay the due amount.
6. (6) Providers of service must collect co payment as specified in accordance with section 208.152, RSMo. 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 copayment amount required of the recipient and collected or collectible as charged by the provider.
7. (7) Providers must maintain records of copayment amounts for five (5) years and must make these records available to the Department of Social Services upon request.
8. (8) The computation and application of the required copayment as it applies to all nonexempted Medicaid-covered drug prescriptions shall be performed by the provider dispensing the covered Medicaid drug. No alterations or changes are to be made to claims by providers which reflect the collection or application of the required copayment amount.

AUTHORITY: sections 208.152, 208.153 and 208.201, RSMo 1994.* This rule was previously filed as 13 CSR 40-81.055. Original rule filed April 14, 1982, effective July 11, 1982. Amended: Filed Oct. 13, 1983, effective Jan. 13, 1984. Amended: FIled May 15, 2000, effective Nov. 30. 2000.

*Original authority: 208.152 RSMo 1967, amended 1969, 1971, 1972, 1973, 1975, 1977, 1978, 1981, 1986, 1988, 1990, 1992, 1993; 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991; and 208.201, RSMo 1987.