13-006 Code Vt. R. 13-174-006-X - MEDICAID COST SHARING

Section 6.100 Medicaid Cost Sharing

(01/01/2020, GCR 19-058)

Section 6.100.1

Cost sharing, including deductibles, co-insurance, or copayments, is charged to Medicaid beneficiaries as set forth in this rule.

Section 6.100.2 Copayment Requirements

(a) Medicaid enrolled beneficiaries are subject to the following copayment requirements, unless they are exempt under section 6.100.3 of this rule.

(1) Outpatient Services: $ 3.00 per day per hospital for outpatient hospital services.

(2) Dental services: $ 3.00 per provider per date of service.

(3) Prescription drugs (original or refill):

(A) $ 1.00 for each prescription with a Medicaid reimbursement rate of less than $ 30.00, or

(B) $ 2.00 for each prescription with a Medicaid reimbursement rate of $ 30.00 or more, but less than $ 50.00, or

(C) $ 3.00 for each prescription with a Medicaid reimbursement rate of $ 50.00 or more.

(b) Copayments are a portion of the Medicaid rate and are deducted from the Medicaid payment for each service that is subject to cost sharing, regardless of whether the provider has collected the payment or waived the cost sharing.

(c) If a beneficiary is unable to pay the copayment, providers shall not deny medical services.

(d) A beneficiary's inability to pay does not eliminate his or her liability for the copayment amount. Providers may bill a beneficiary for unpaid copayments.

(e) The State is not responsible for copayments that a provider may collect in error or that an individual makes on a service that is not paid for by Vermont Medicaid.

Section 6.100.3 Copayment Exemptions

(a) Copayments are never required from Medicaid beneficiaries who are:

(1) Under age 21.

(2) Pregnant, through the duration of their pregnancy and through the end of the calendar month during which the 60 [th] day following the end of pregnancy occurs.

(3) Receiving Medicaid coverage of long-term care services and supports in a long-term care facility.

(4) Otherwise exempt from cost sharing by federal regulation at 42 CFR § 447.56(a)(1).

(b) For beneficiaries also covered by Medicare, the prescription drug copays in 6.100.2(a)(3) do not apply to prescriptions covered by Medicare Part D plans.

(c) The following services are exempt from copayments:

(1) Sexual assault-related services.

(2) Preventive dental services.

(3) Services otherwise exempt from cost sharing by federal regulation at 42 CFR § 447.56(a)(2).

Notes

13-006 Code Vt. R. 13-174-006-X

EFFECTIVE DATE:
June 1, 2018 Secretary of State Rule Log #18-020
AMENDED:
January 1, 2020 Secretary of State Rule Log #19-064

STATUTORY AUTHORITY:

33 V.S.A. § 1901