Provider Notice issued 03/29/13

Cost Sharing Effective April 1, 2013

To:​ Participating Physicians, Chiropractors, Podiatrists, Optometrists, Advance Practice Nurses, Federally Qualified Health Center (FQHC), Encounter Rate Clinic (ERC), Rural Health Clinic (RHC), Hospitals and Pharmacies​
Date:​ March 29, 2013​
Re:​ Cost Sharing Effective April 1, 2013​

The purpose of this notice is to inform providers of changes the department has made regarding cost sharing. Effective with dates of service on or after April 1, 2013, the department will be increasing the $3.65 copayment to $3.90. In addition, some changes have been made to the services that are eligible to receive copayments. The following identify the specific changes:

  • Copayment removed for non-emergent use of the emergency room for children enrolled in All Kids Assist or All Kids Share.

  • Copayment removed for emergency room use for children enrolled in All Kids Share.

  • Inpatient hospitalization copayment for children enrolled in All Kids Share or Premium Level 1 has been changed to per day instead of per admission.

  • Copayments have been removed for any behavioral health service rendered in an Encounter Rate Clinic, Federally Qualified Health Center or Rural Health Clinic.

  • Medicaid adults may be charged a copayment for psychiatric services.

The chart included with this notice identifies the eligibility categories, specific procedure codes subject to cost sharing and the copayment amounts. The chart will replace the copayment information in Appendix 12 of Chapter 100, General Policy and Procedures Handbook.

Note: The following individuals are exempt from copayments: residents of nursing homes, intermediate care facilities for the developmentally disabled and supportive living facilities; pregnant women; children under the age of 19; hospice patients; American Indians or Alaskan Natives; non-institutionalized individuals whose care is subsidized by the Department of Children and Family Services or the Department of Corrections; and individuals enrolled in "Health Benefits for Persons with Breast or Cervical Cancer".

Collection of Co-payments

The department will automatically deduct the co-payment from the provider's reimbursement. When billing the department, providers should bill their usual and customary charge and should not report the co-payment on the claim. Providers will be responsible for collecting co-payments from the participant. Providers may choose not to charge a co-payment, but if co-payments are charged, the co-payment amount cannot exceed the amounts shown on the chart.

Federal regulations stipulate that for certain low income individuals covered under a Title XIX or Title XXI program, a provider cannot deny services due to the person's inability to pay a co-payment. This requirement does not apply to the All Kids Premium Level 2. Providers may apply their office policies relating to the co-payments to participants covered under the All Kids Premium Level 2.

Questions regarding this notice may be directed to the Bureau of Comprehensive Health Services at 1-877-782-5565.

Theresa A. Eagleson, Administrator

Division of Medical Programs