Section 140.402 Copayments for Non-institutional Medical Services

Section 140

Section 140.402  Copayments

for Non-institutional Medical Services

The following implements cost

sharing in compliance with 42 USC 1396o (section 1916 of the Social Security

Act):

a)         Each recipient, with the exception of those classes of

recipients identified in subsection (d), shall be required to pay a copayment

of $2.00 for generic legend drugs and over-the-counter drugs billed to the

Department, and for other services, with the exception of those services

identified in subsection (e), the nominal copayment amount as defined at 42 CFR

447.54.  For dates of service beginning July 1, 2012 through March 31, 2013 the

nominal copayment amount is $3.65.  Beginning with dates of service on April 1,

2013 through August 31, 2019, the nominal copayment amount is $3.90.  Beginning

with dates of service on or after September 1, 2019, recipients will no longer

be required to pay a copayment for medical assistance services.  Specific

copayment amounts are described and updated on the Department's Web site for

the following non-institutional medical services:

1)         Office visits to enrolled practitioners for services

reimbursed under the Illinois Public Aid Code.

2)         Each brand name legend drug billed to the Department.

3)         Each encounter billed to the Department by an Encounter Rate

Clinic (ERC), Federally Qualified Health Center (FQHC) or Rural Health Clinic

(RHC), but excluding behavioral services provided by these facilities.  For

dates of service beginning July 1, 2013 through August 31, 2019, copayments for

behavioral health services provided by these facilities are no longer excluded

and shall be required to be paid by recipients with the exception of those

classes of recipients identified in subsection (d).

b)         In each instance in which a copayment is payable, the

Department will reduce the amount payable to the affected provider by the

respective amount of the required copayment

ts for

behavioral health services provided by these facilities are no longer excluded

and shall be required to be paid by recipients with the exception of those

classes of recipients identified in subsection (d).

b)         In each instance in which a copayment is payable, the

Department will reduce the amount payable to the affected provider by the

respective amount of the required copayment.

c)         No provider of services listed in subsection (a) may deny

service to an individual who is eligible for service on account of the

individual's inability to pay the cost of a copayment.

d)         The following individuals receiving medical assistance are

exempt from the copayment requirement set forth in subsection (a):

1)         Pregnant women, including a postpartum period of 60 days.

2)         Children under 19 years of age.

3)         All non-institutionalized individuals whose care is subsidized

by the Department of Children and Family Services or the Department of

Corrections.

4)         Hospice patients.

5)         Individuals residing in hospitals, nursing facilities, and

intermediate care facilities for the developmentally disabled who, as a

condition of receiving services, are required to pay all of their income,

except an authorized protected amount for personal use, for the cost of their

care.  For the purpose of this subsection (d)(5), the protected amount shall be

no greater than the protected amount authorized for personal use under 89 Ill.

Adm. Code 146.225(c).

6)         Residents of a State-certified, State-licensed, or

State-contracted residential care program where residents, as a condition of

receiving care in that program, are required to pay all of their income, except

an authorized protected amount for personal use, for the cost of their

residential care program. For the purpose of this subsection (d)(6), the

protected amount shall be no greater than the protected amount authorized for

personal use under 89 Ill. Adm. Code 146.225(c)

re program where residents, as a condition of

receiving care in that program, are required to pay all of their income, except

an authorized protected amount for personal use, for the cost of their

residential care program. For the purpose of this subsection (d)(6), the

protected amount shall be no greater than the protected amount authorized for

personal use under 89 Ill. Adm. Code 146.225(c).

7)         Individuals enrolled in the "Health Benefits for Person

with Breast or Cervical Cancer" program under 89 Ill. Adm. Code 120.500.

8)         American Indians or Alaskan Natives.

e)         The

following medical services are exempt from any copayments:

1)         Renal dialysis treatment.

2)         Radiation therapy.

3)         Cancer chemotherapy.

4)         Insulin.

5)         Services for which Medicare is the primary payer.

6)         Emergency services as defined at 42 USC 1396u-2(b)(2) (section

1932(b)(2) of the Social Security Act) and 42 CFR 438.114(a).

7)         Any pharmacy compounded drugs.

8)         Any prescription (legend drug) dispensed or administered by a

hospital, clinic or physician.

9)         Family planning services and supplies described in 42 USC

1396d(a)(4)(C) (section 1905(a)(4)(C) of the Social Security Act), including

contraceptives and other pharmaceuticals for which the State claims or could

claim federal financial participation at the enhanced rate under 42 USC

1396b(a)(5) (section 1903(a)(5) of the Social Security Act) for family planning

services and supplies.

10)         Other therapeutic drug classes as specified by the Department.

11)         Preventive services as described in section 4106(b) of the

Affordable Care Act.