La. Admin. Code tit. 50 § XXIX-111

Current through Register Vol. 50, No. 11, November 20, 2024

Section XXIX-111 - Copayment

A. Payment Schedule

1. A copayment requirement in the Pharmacy Program is based on the following payment schedule.

a. For dates of service April 1, 2019 through December 31, 2019, recipients with a household income of less than or equal to $800 per month will not be subject to copay.

Calculated State Payment	Copayment
$10.00 or less	$0.50
$10.01 to $25.00	$1.00
$25.01 to $50.00	$2.00
$50.01 or more	$3.00

2. The pharmacy provider shall collect a copayment from the Medicaid beneficiary for each drug dispensed and covered by Medicaid. The following pharmacy services are exempt from the copayment requirements:

a. services furnished to pregnant women;

b. emergency services;

c. family planning services;

d. preventive medications as designated by the U.S. Preventive Services Task Force's A and B recommendations; and

e. services provided during a federal public health emergency (PHE).

3. The following population groups are exempt from copayment requirements:

a. individuals under the age of 21;

b. individuals residing in a long-term care facility;

c. individuals receiving hospice care;

d. Native Americans and Alaskan Eskimos;

e. women whose basis for Medicaid eligibility is breast or cervical cancer; and

f. home and community-based services waiver recipients.

B. In accordance with federal regulations, the following provisions apply.

1. The provider may not deny services to any eligible individual on account of the individuals inability to pay the copayment amount. However, this service statement does not apply to an individual who is able to pay, nor does an individuals inability to pay eliminate his or her liability for the copayment.

2. Providers shall not waive the recipient copayment liability.

3. Departmental monitoring and auditing will be conducted to determine provider compliance.

4. Violators of this Section maybe subject to a penalty, including but not limited to, termination from the Medicaid Program.

5. The state will ensure Medicaid premiums and cost sharing incurred by all individuals in the Medicaid household do not exceed an aggregate limit of 5 percent of the familys income applied on a monthly basis.

La. Admin. Code tit. 50, § XXIX-111

Promulgated by the Department of Health and Hospitals, Office of the Secretary, LR 32:1055 (June 2006), Amended by the Department of Health, Bureau of Health Services Financing, LR 431181 (6/1/2017), Amended by the Department of Health, Bureau of Health Services Financing, LR 431553 (8/1/2017), Amended LR 45, Amended LR 45, Amended by the Department of Health, Bureau of Health Services Financing, LR 46, Amended by the Department of Health, Bureau of Health Services Financing, LR 4634 (1/1/2020), Amended LR 482975 (12/1/2022).

AUTHORITY NOTE: Promulgated in accordance with R.S. 36:254 and Title XIX of the Social Security Act.