No. 29977 (Amendment): R414-200-4. Cost Sharing

DAR File No.: 29977
Filed: 05/29/2007, 08:44
Received by: NL

RULE ANALYSIS

Purpose of the rule or reason for the change:

This amendment is necessary to implement a copayment change for prescription drugs in the Non-Traditional Medicaid (NTM) program.

Summary of the rule or change:

The copayment for prescription drugs is changed from $2 to $3 per prescription.

State statutory or constitutional authorization for this rule:

Sections 26-18-3 and 26-1-5

Anticipated cost or savings to:

the state budget:

There is a savings of $115,090 to the General Fund and $270,342 in federal funds.

local governments:

There is no budget impact because local governments do not fund pharmacy services for NTM clients.

other persons:

There is no cost or savings for pharmacists because they receive $1 less in Medicaid reimbursement, which offsets the $1 copayment increase from the client.

Compliance costs for affected persons:

There is a $1 copayment increase from $2 to $3 per prescription for a single NTM client. However, the total pocket expense for an NTM client is limited to $500 per calendar year.

Comments by the department head on the fiscal impact the rule may have on businesses:

Impact on business is neutral. Pharmacies collect an additional $1 in a copayment from the Medicaid recipient and their reimbursement is reduced by the same amount. There may be some administrative burden on pharmacies which will be gauged during the public comment period. David N. Sundwall, MD, Executive Director

The full text of this rule may be inspected, during regular business hours, at the Division of Administrative Rules, or at:

Health
Health Care Financing, Coverage and Reimbursement Policy
CANNON HEALTH BLDG
288 N 1460 W
SALT LAKE CITY UT 84116-3231

Direct questions regarding this rule to:

Craig Devashrayee at the above address, by phone at 801-538-6641, by FAX at 801-538-6099, or by Internet E-mail at [e-mail]

Interested persons may present their views on this rule by submitting written comments to the address above no later than 5:00 p.m. on:

07/16/2007

This rule may become effective on:

07/23/2007

Authorized by:

David N. Sundwall, Executive Director

RULE TEXT

R414. Health, Health Care Financing, Coverage and Reimbursement Policy.

R414-200. Non-Traditional Medicaid Health Plan Services.

R414-200-4. Cost Sharing.

(1) An enrollee is responsible to pay to the:

(a) hospital a $220 co-insurance payment for each inpatient hospital admission;

(b) hospital a $6 copayment for each non-emergency use of hospital emergency services;

(c) provider a $3 copayment for outpatient office visits for physician, physician-related, mental health, and physical therapy services; except, no copayment is due for preventive services, immunizations and health education; and

(d) pharmacy a $[2]3 copayment per prescription for prescription drugs.

(2) The out-of-pocket maximum payment for copayments or co-insurance is limited to $500 per enrollee per calendar year.

 

KEY: Medicaid, non-traditional, cost sharing

Date of Enactment or Last Substantive Amendment: [October 11, 2006]2007

Notice of Continuation: May 24, 2007

Authorizing, and Implemented or Interpreted Law: 26-18