Beginning January 1, 2014, some services will be assigned copay amounts for Medicaid Members. The following copays will apply to claims with a date of service on or after January 1, 2014:
Service TIER 1 Up to 50.00% FPL TIER 2 50.01-100.00% FPL TIER 3 100.01% FPL and above
Inpatient Hospital (Acute Care 11x) --- $0 $35 $75
Office Visit (Physicians and Nurse Practitioners) (99201-99205, 99212-99215 only for office visits for new and established patients based on level of care) --- $0 $2 $4
Non-Preferred Drugs ---- $2 $4 $8
Non-Emergency use of Emergency Department - Hospital only (Lowest level (99281) of Emergency Room visits in hospitals. The definition of this visit is an emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A problem focused history; A problem focused examination; and straightforward medical decision making.) ---------- $8 $8 $8
Any outpatient surgical services rendered in a physician’s office, ASC or Outpatient Hospital excluding emergency rooms. --- $0 $2 $4
Maximum Out of Pocket (OOP):
Each calendar year quarter, Members will have a maximum out of pocket (OOP) payment. The OOP is the most the Member will ever be required to pay in any given quarter regardless of the number of healthcare services received. The following table shows the OOP for each tier level.
Tier Level Out of Pocket Maximum
1 (Up to 50.00% FPL) $8
2 (50.01-100.00% FPL) $71
3 (100.01% FPL and above) $143
January 1 – March 31, 2014
April 1 – June 30, 2014
July 1 – September 30, 2014
October 1 – December 31, 2014
The following populations and services are exempt from copays:
Pregnant Women including pregnancy-related services up to 60 days post-partum;
Children under age 21;
Native American and Alaska natives;
Intermediate Care Facility or MR services;
Preventive services for children under age 18;
Individuals in Nursing Homes,
Receiving Hospice services,
Medicaid Waiver services, or covered through the Breast and Cervical Cancer Treatment Program;
Family Planning services and Emergency services.
Additional exemptions for Pharmacy include diabetic testing supplies syringes and needles, BMS approved Home Infusion supplies and 3-day emergency supplies.
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