1. (a) Except as prohibited by 42 USC § 1396o-1(b)(3)(B), newly eligible individuals who have an income greater than 100 percent of the FPL and are PAP participants shall be subject to the following co-payments:

   1. (1) A co-payment in the amount of $8.00 for each non-preferred drug prescription and refill dispensed;
   2. (2) A co-payment in the amount of $4.00 for each preferred drug prescription and refill dispensed;
   3. (3) A co-payment in the amount of $5.00 for each primary care provider visit to treat illness or injury;
   4. (4) A co-payment in the amount of $125.00 for each inpatient mental health admission, inpatient substance use disorder treatment admission or hospital admission, excluding maternity admissions;
   5. (5) A co-payment in the amount of $50.00 for high-cost imaging such as CT/PET scans, and MRIs;
   6. (6) A co-payment in the amount of $5.00 for each mental health outpatient visit;
   7. (7) A copayment in the amount of $5.00 for each substance use disorder outpatient visit;
   8. (8) A co-payment in the amount of $8.00 for each physical therapy visit;
   9. (9) A co-payment in the amount of $8.00 for each occupational therapy visit;
   10. (10) A co-payment in the amount of $8.00 for each speech therapy visit;
   11. (11) A co-payment in the amount of $5.00 for each chiropractor visit;
   12. (12) A co-payment in the amount of $8.00 for each specialty physician visit;
   13. (13) A co-payment in the amount of $5.00 for each visit to other medical professionals such as an advanced practice registered nurse or a physician’s assistant; and
   14. (14) A co-payment in the amount of $5.00 for each laboratory outpatient visit.
2. (b) Co-payment obligations shall be suspended for the remainder of the calendar year quarter when the total co-payments made out of pocket by the newly eligible individual reach 5 percent of the individual’s household income for that quarter. Co-payment obligations shall resume at the beginning of the next quarter. “Quarter” means one of 4 calendar periods ending March 31, June 30, September 30, and December 31.

Source. #10656, eff 8-15-14; ss by #11012, INTERIM, eff 1-1-16, EXPIRES: 6-29-16 (from He-W 512.05); ss by #11119, eff 6-29-16; ss by #12438, eff 1-1-18