Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1101 - GENERAL PROVISIONS › FEES AND PAYMENTS › Section 1101.63 - Payment in full

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
Supplementary payment for a compensable service.
A provider
				  shall accept as payment in full, the amounts paid by the Department plus a
				  copayment required to be paid by a recipient under subsection (b). A provider
				  who seeks or accepts supplementary payment of another kind from the Department,
				  the recipient or another person for a compensable service or item is required
				  to return the supplementary payment. A provider may bill a MA recipient for a
				  noncompensable service or item if the recipient is told before the service is
				  rendered that the program does not cover it.
(b)
Copayments for MA
				  services.
(1) Recipients receiving
				  services under the MA Program are responsible to pay the provider the
				  applicable copayment amounts set forth in this subsection.
(2) The following services are excluded from
				  the copayment requirement for all categories of recipients:
(i) Services furnished to individuals under
				  18 years of age.
(ii) Services and
				  items furnished to pregnant women, which include services during the postpartum
				  period.
(iii) Services furnished to
				  an individual who is a patient in a long term care facility, an intermediate
				  care facility for the mentally retarded or other related conditions, as defined
				  in 42 CFR
				  435.1009 (relating to definitions relating to
				  institutional status) or other medical institution if the individual is
				  required as a condition of receiving services in the institution, to spend all
				  but a minimal amount of his income for medical care costs.
(iv) Services provided to individuals
				  residing in personal care homes and domiciliary care homes.
(v) Services provided to individuals eligible
				  for benefits under the Breast and Cervical Cancer Prevention and Treatment
				  Program.
(vi) Services provided to
				  individuals eligible for benefits under Title IV-B Foster Care and Title IV-E
				  Foster Care and Adoption Assistance.
(vii) Services provided in an emergency
				  situation as defined in §
												1101.21 (relating to
				  definitions).
(viii) Laboratory
				  services.
(ix) The professional
				  component of diagnostic radiology, nuclear medicine, radiation therapy and
				  medical diagnostic services, when the professional component is billed
				  separately from the technical component.
(x) Family planning services and
				  supplies.
(xi) Home health agency
				  services.
(xii) Services provided
				  to individuals receiving hospice care.
(xiii) Psychiatric partial hospitalization
				  program services.
(xiv) Services
				  furnished by a funeral director.
(xv) Renal dialysis services.
(xvi) Blood and blood products.
(xvii) Oxygen.
(xviii) Ostomy supplies.
(xix) Rental of durable medical
				  equipment.
(xx) Targeted case
				  management services.
(xxi) Tobacco
				  cessation counseling services.
(xxii) Outpatient services when the MA fee is
				  under $2.
(xxiii) Medical
				  examinations when requested by the Department.
(xxiv) Screenings provided under the EPSDT
				  Program.
(xxv) More than one of a
				  series of a specific allergy test provided in a 24-hour period.
(3) The following services are
				  excluded from the copayment requirement for categories of recipients except GA
				  recipients age 21 to 65:
(i) Drugs, including
				  immunizations, dispensed by a physician.
(ii) Specific drugs identified by the
				  Department in the following categories:
(A)
				  Antihypertensive agents.
(B)
				  Antidiabetic agents.
(C)
				  Anticonvulsants.
(D) Cardiovascular
				  preparations.
(E) Antipsychotic
				  agents, except those that are also schedule C-IV antianxiety agents.
(F) Antineoplastic agents.
(G) Antiglaucoma drugs.
(H) Antiparkinson drugs.
(I) Drugs whose only approved indication is
				  the treatment of acquired immunodeficiency syndrome (AIDS).
(4) Except for the
				  exclusions specified in paragraphs (2) and (3), each MA service furnished by a
				  provider to an eligible recipient is subject to copayment
				  requirements.
(5) The amount of the
				  copayment, which is to be paid to providers by categories of recipients, except
				  GA recipients, and which is deducted from the Commonwealth's MA fee to
				  providers for each service, is as follows:
(i)
				  For pharmacy services, drugs and over-the-counter medications:
(A) For recipients other than State Blind
				  Pension recipients, $1 per prescription and $1 per refill for generic
				  drugs.
(B) For recipients other
				  than State Blind Pension recipients, $3 per prescription and $3 per refill for
				  brand name drugs.
(C) For State
				  Blind Pension recipients, $1 per prescription and $1 per refill for brand name
				  drugs and generic drugs.
(ii) For inpatient hospital services,
				  provided in a general hospital, rehabilitation hospital or private psychiatric
				  hospital, the copayment is $3 per covered day of inpatient care, to an amount
				  not to exceed $21 per admission.
(iii) For nonemergency services provided in a
				  hospital emergency room, the copayment on the hospital support component is
				  double the amount shown in subparagraph (vi), if an approved waiver exists from
				  the United States Department of Health and Human Services. If an approved
				  waiver does not exist, the copayment will follow the schedule shown in
				  subparagraph (vi).
(iv) When the
				  total component or only the technical component of the following services are
				  billed, the copayment is $1:
(A) Diagnostic
				  radiology.
(B) Nuclear
				  medicine.
(C) Radiation
				  therapy.
(D) Medical diagnostic
				  services.
(v) For
				  outpatient psychotherapy services, the copayment is 50¢ per unit of
				  service.
(vi) For all other
				  services, the amount of the copayment is based on the MA fee for the service,
				  using the following schedule:
(A) If the MA
				  fee is $2 through $10, the copayment is 65¢.
(B) If the MA fee is $10.01 through $25, the
				  copayment is $1.30.
(C) If the MA
				  fee is $25.01 through $50, the copayment is $2.55.
(D) If the MA fee is $50.01 or more, the
				  copayment is $3.80.
(E) The
				  Department may, by publication of a notice in the
Pennsylvania
				  Bulletin
, adjust these copayment amounts based on the percentage
				  increase in the medical care component of the Consumer Price Index for All
				  Urban Consumers for the period of September to September ending in the
				  preceding calendar year and then rounded to the next higher 5-cent
				  increment.
(6)
				  The amount of the copayment, which is to be paid to providers by GA recipients
				  age 21 to 65, and which is deducted from the Commonwealth's MA fee to providers
				  for each service, is as follows:
(i) For
				  prescription drugs:
(A) $1 per prescription
				  and $1 per refill for generic drugs.
(B) $3 per prescription and $3 per refill for
				  brand name drugs.
(ii)
				  For inpatient hospital services, provided in a general hospital, rehabilitation
				  hospital or private psychiatric hospital, the copayment is $6 per covered day
				  of inpatient care, not to exceed $42 per admission.
(iii) When the total component or only the
				  technical component of the following services are billed, the copayment is $2:
(A) Diagnostic radiology.
(B) Nuclear medicine.
(C) Radiation therapy.
(D) Medical diagnostic
				  services.
(iv) For all
				  other services, the amount of the copayment is based on the MA fee for the
				  service, using the following schedule:
(A) If
				  the MA fee is $2 through $10, the copayment is $1.30.
(B) If the MA fee is $10.01 through $25, the
				  copayment is $2.60.
(C) If the MA
				  fee is $25.01 through $50, the copayment is $5.10.
(D) If the MA fee is $50.01 or more, the
				  copayment is $7.60.
(E) The
				  Department may, by publication of a notice in the
Pennsylvania
				  Bulletin
, adjust these copayment amounts based on the percentage
				  increase in the medical care component of the Consumer Price Index for All
				  Urban Consumers for the period of September to September ending in the
				  preceding calendar year and then rounded to the next higher 5-cent
				  increment.
(7)
				  A provider participating in the program may not deny covered care or services
				  to an eligible MA recipient because of the recipient's inability to pay the
				  copayment amount. This paragraph does not change the fact that the recipient is
				  liable for the copayment, and it does not prevent the provider from attempting
				  to collect the copayment amount. If a recipient believes that a provider has
				  charged the recipient incorrectly, the recipient shall continue to pay
				  copayments charged by that provider until the Department determines whether the
				  copayment charges are correct.
(8)
				  A provider may not waive the copayment requirement or compensate the recipient
				  for the copayment amount.
(9) If a
				  recipient is covered by a third-party resource and the provider is eligible for
				  an additional payment from MA, the copayment required of the recipient may not
				  exceed the amount of the MA payment for the item or
				  service.