37.85.204 MEMBER REQUIREMENTS, COST SHARING
(1) Except as provided in this rule each member must pay cost share to the provider of service as described below.
(2) The cost share applied to a service or item is not to exceed the Medicaid allowed amount.
(3) A member with income at or below 100% of the federal poverty level (FPL) is responsible for the following copayments:
(a) inpatient hospital - $75 per discharge;
(b) pharmacy-preferred brand drugs - $4 per prescription;
(c) pharmacy-nonpreferred brand drugs - $8 per prescription;
(d) outpatient hospital services - $4 per visit;
(e) podiatry services - $4 per visit;
(f) physical therapy services - $4 per visit;
(g) speech therapy services - $4 per visit;
(h) audiology services - $4 per visit;
(i) hearing aid services - $4 per visit;
(j) occupational therapy services - $4 per visit;
(k) home health services - $4 per visit;
(l) ambulatory surgical center services - $4 per visit;
(m) public health center services - $4 per visit;
(n) dental treatment services - $4 per visit;
(o) denturist services - $4 per visit;
(p) durable medical equipment - $4 per visit;
(q) optometric and optician services - $4 per visit;
(r) professional services - $4 per visit;
(s) federally qualified health center services - $4 per visit;
(t) rural health clinic services - $4 per visit;
(u) dialysis clinic services - $4 per visit;
(v) independent diagnostic testing facility services - $4 per visit;
(w) home infusion therapy services - $4 per therapy;
(x) mental health clinic services - $4 per visit; and
(y) chemical dependency services - $4 per visit
(4) A member with income above 100 percent of the FPL, except as noted in (a) and (b) is responsible for cost share of 10% of the provider reimbursed amount. A member is responsible for cost share for outpatient pharmacy services as follows:
(a) preferred brand drugs - $4 per prescription;
(b) nonpreferred brand drugs - $8 per prescription.
(5) Members with the following statuses are exempt from cost sharing:
(a) persons under 21 years of age;
(b) pregnant women;
(c) American Indians/Alaska Natives who are eligible for, currently receiving, or have ever received an item or service furnished by:
(i) an Indian Health Service (IHS) provider;
(ii) a Tribal 638 provider;
(iii) an IHS Tribal or Urban Indian Health provider; or
(iv) through referral under contract health services.
(d) persons who are terminally ill receiving hospice services;
(e) persons who are receiving services under the Medicaid breast and cervical cancer treatment category;
(f) institutionalized persons who are inpatients in a skilled nursing facility, intermediate care facility, or other medical institution if the person is required to spend for the cost of care all but their personal needs allowance, as defined in ARM 37.82.1320.
(6) Cost sharing may not be charged to members for the following services:
(a) emergency services;
(b) family planning services;
(c) hospice services;
(d) home and community based waiver services;
(e) transportation services;
(f) eyeglasses purchased by the Medicaid program under a volume purchasing arrangement;
(g) early and periodic screening, diagnostic and treatment (EPSDT) services;
(h) provider preventable health care acquired conditions as provided for in 42 CFR 447.26(b);
(i) generic drugs;
(j) preventive services as approved by CMS through the Health and Economic Livelihood Partnership (HELP) Medicaid 1115 waiver;
(k) services for Medicare crossover claims where Medicaid is the secondary payer under ARM 37.85.406(18). If a service is not covered by Medicare but is covered by Medicaid, cost sharing will be applied; and
(l) services for third party liability (TPL) claims where Medicaid is the secondary payor under ARM 37.85.407. If a service is not covered by the TPL but is covered by Medicaid, cost sharing will be applied.
(7) Cost share may not be charged to the member until the claim has been processed through the claims adjudication process and the provider has been notified of payment and amount owing.
(8) The total of Medicaid premiums and cost sharing incurred by a Medicaid household may not exceed an aggregate limit of five percent of the family's income applied quarterly. There may not be further cost sharing applied to the household members in a quarter once a household has met the quarterly aggregate cap.
(9) Providers may directly charge members only for the following services if the member signs an Advanced Beneficiary Notice for the specific service prior to the service being provided:
(a) noncovered services;
(b) experimental services;
(c) unproven services;
(d) services performed in an inappropriate setting;
(e) services that are not medically necessary;
(f) investigational services; or
(g) dental treatment expenses that exceed the annual dental treatment cap.
History: 53-2-201, 53-6-113, MCA; IMP, 53-6-101, 53-6-113, 53-6-141, MCA; NEW, 1983 MAR p. 1197, Eff. 8/26/83; AMD, 1986 MAR p. 677, Eff. 4/25/86; AMD, 1987 MAR p. 895, Eff. 7/1/87; AMD, 1987 MAR p. 1688, Eff. 10/1/87; AMD, 1988 MAR p. 758, Eff. 4/15/88; AMD, 1989 MAR p. 272, Eff. 3/1/89; AMD, 1989 MAR p. 859, Eff. 6/30/89; AMD, 1989 MAR p. 842, Eff. 7/1/89; AMD, 1994 MAR p. 686, Eff. 4/1/94; AMD, 1995 MAR p. 1159, Eff. 7/1/95; AMD, 1997 MAR p. 548, Eff. 3/25/97; AMD, 1997 MAR p. 1208, Eff. 7/8/97; AMD, 1999 MAR p. 1301, Eff. 7/1/99; TRANS, from SRS, 2000 MAR p. 479; AMD, 2002 MAR p. 797, Eff. 3/15/02; EMERG, AMD, 2002 MAR p. 3156, Eff. 11/15/02; AMD, 2016 MAR p. 829, Eff. 5/7/16; AMD, 2017 MAR p. 100, Eff. 1/7/17; AMD, 2017 MAR p. 2326, Eff. 1/1/18.