Ohio Admin. Code 5160-26-12 - Managed care: member co-payments
(A)
This rule does
not apply to MyCare Ohio plans as defined in rule
5160-58-01
of the Administrative Code or the Ohio resilience through integrated systems
and excellence (OhioRISE) plan as defined in rule 5160-59-01 of the
Administrative Code.
(C)
Upon
implementation of the SPBM, the SPBM may only elect to implement a member
co-payment program pursuant to section
5162.20
of the Revised Code for prescription drugs as provided for in this rule if
directed to by ODM.
(1) Exclude the populations and services set
forth in paragraph (C
E ) of this rule;
(2) Not deny services to members as specified
in paragraph (D
F ) of this rule;
(3) Not impose co-payment amounts in excess
of the maximum amounts specified in
42
C.F.R. 447.54 (October 1,
2019
2021 );
(4)
Specify in provider subcontracts
contracts governed by rule
5160-26-05
of the Administrative Code the circumstances under which member co-payment
amounts can be requested. For MCOs
If the MCO or SPBM
that elect to implements a co-payment program, no provider can waive a
member's obligation to pay the provider a co-payment except as described in
paragraph (G
I ) of this rule;
(5) Ensure that the member is not billed for
any difference between the MCO's
MCO or SPBM's payment and the provider's charge
or request that the member share in the cost through co-payment or other
similar charge, other than medicaid co-payments as defined in this
rule;
(6) Ensure that member
co-payment amounts are requested by providers in accordance with this rule;
and
(7) Ensure that no provider or
drug manufacturer, including the manufacturer's representative, employee,
independent contractor, or agent shall pay any co-payment on behalf of the
member.
(1) Children. Members who are under the age
of twenty-one are excluded from medicaid co-payment obligations.
(2) Pregnant women. With the exception of
routine eye examinations and the dispensation of eyeglasses during a member's
pregnancy or post-partum period, all services provided to pregnant women during
their pregnancy and the postpartum period are excluded from a medicaid
co-payment obligation. The postpartum period is the period that begins on the
last day of pregnancy and extends through the end of the month in which the
sixty-day period following termination of pregnancy ends.
(3) Institutionalized members. Services or
medications provided to members who reside in a nursing facility (NF) or
intermediate care facility for individuals with intellectual disabilities
(ICF/IID) are excluded from medicaid co-payment obligations.
(4) Emergency. An MCO shall not impose a
co-payment obligation for emergency services provided in a hospital, clinic,
office, or other facility that is equipped to furnish the required care, 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 placing the
patient's health in serious jeopardy; serious impairment to bodily functions;
or serious dysfunction of any bodily part or organ.
(5) Family planning (pregnancy prevention or
contraceptive management). An
The MCO or SPBM
shall not impose a medicaid co-payment obligation on any service identified by
ODM as a pregnancy prevention/contraceptive management service in accordance
with rules
5160-21-02
and
5160-1-09 of the
Administrative Code and provided to an individual of child-bearing
age.
(6) Hospice. Members receiving
services for hospice care are excluded from medicaid co-payment
obligation.
(7) Medicare cross-over
claims. Medicare cross-over claims defined in accordance with rule
5160-1-05
of the Administrative Code will not be subject to medicaid co-payment
obligations.
(8) Medications
administered to a member during a medical encounter provided in a hospital,
clinic, office or other facility, when the medication is part of the evaluation
and treatment of the condition, are not subject to a member
co-payment.
(1) For dental services, the member
co-payment amount may not exceed the amount set forth in Chapter 5160-5 of the
Administrative Code. Services provided to a member on the same date of service
by the same provider are subject to only one co-payment.
(2) For non-emergency emergency department
services, the member co-payment amount must not exceed the amount set forth in
Chapter 5160-2 of the Administrative Code. For purposes of this rule, the
hospital provider shall determine if services rendered are non-emergency
emergency department services and will report, through claim submission, the
applicable co-payment to the MCO in accordance with medicaid hospital billing
instructions.
(3) For vision
services, the member co-payment amounts must not exceed the amounts set forth
in Chapter 5160-6 of the Administrative Code.
(4) For pharmacy services, the member
co-payment amounts must not exceed the amounts set forth in Chapter 5160-9 of
the Administrative Code.
Notes
Promulgated Under: 119.03
Statutory Authority: 5167.02
Rule Amplifies: 5162.20, 5164.02, 5167.03, 5167.10, 5167.12
Prior Effective Dates: 01/01/2006, 06/01/2006, 01/01/2007, 07/01/2009, 02/01/2010, 10/01/2011, 02/01/2015, 08/01/2016, 07/19/2020
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