A. Unless a waiver under 42 CFR 431.55(g) applies, deductibles, coinsurance rates, and copayments do not exceed the maximum allowable charges under 42 CFR 447.54.

A. DMAS does not charge cost-sharing (deductibles, co-insurance, or co-payments) to individuals covered under Medicaid.

B. With respect to individuals covered as categorically needy or as qualified Medicare beneficiaries (as defined in § 1905(p)(1) of the Act) under the plan:

1. No enrollment fee, premium, or similar charge is imposed under the plan.

2. No deductible, coinsurance, copayment, or similar charge is imposed under the plan for the following:

a. Services to individuals under age 21. Reasonable categories of individuals who are age 18 or older, but under age 21, to whom charges apply are listed below, if applicable.

b. Services to pregnant women related to the pregnancy or any other medical condition that may complicate the pregnancy.

c. Charges apply for services to pregnant women unrelated to the pregnancy.

d. Services furnished to any individual who is an inpatient in a hospital, long-term care facility, or other medical institution, if the individual is required, as a condition of receiving medical services in the institution, to spend for medical care costs all but a minimal amount of his or her income required for personal needs.

e. Emergency services if the services meet the requirements in 42 CFR 447.53(b)(4).

f. Family planning services and supplies furnished to individuals of childbearing age.

g. Services furnished by a health maintenance organization in which the individual is enrolled.

h. Services furnished to an individual receiving hospice care, as defined in § 1905(o) of the Act.

3. Unless a waiver under 42 CFR 431.55(g) applies, nominal deductible, coinsurance, copayment, or similar charges are imposed for services that are not excluded from such charges under item B 2 above:

a. For any service, no more than one type of charge is imposed.

b. Charges apply to services furnished to persons 21 or older.

c. For the categorically needy and qualified Medicare beneficiaries, 12VAC30-20-150 specifies the:

(1) Service(s) for which a charge is applied;

(2) Nature of the charge imposed on each service;

(3) Amount(s) of and basis for determining the charge(s);

(4) Method used to collect the charge(s);

(5) Basis for determining whether an individual is unable to pay the charge and the means by which such an individual is identified to providers; and

(6) Procedures for implementing and enforcing the exclusions from cost sharing contained in 42 CFR 447.53(b).

No cumulative maximum applies to deductible, coinsurance, or copayment charges imposed on a specified time period.

C. Individuals are covered as medically needy under the plan.

1. No enrollment fee, premium, or similar charge is imposed.

2. No deductible, coinsurance, copayment, or similar charge is imposed under the plan for:

a. Services to individuals under 21; reasonable categories of individuals who are age 18, but under age 21, to whom charges apply are listed below, if applicable.

b. Services to pregnant women related to the pregnancy or any other medical condition that may complicate the pregnancy.

c. Charges apply for services to pregnant women unrelated to the pregnancy.

d. Services furnished to any individual who is an inpatient in a hospital, long-term care facility, or other medical institution, if the individual is required, as a condition of receiving services in the institution, to spend for medical care costs all but a minimal amount of his income required for personal needs.

e. Emergency services if the services meet the requirements in 42 CFR 447.53(b)(4).

f. Family planning services and supplies furnished to individuals of childbearing age.

g. Services furnished to an individual receiving hospice care, as defined in § 1905(o) of the Act.

h. Services provided by a health maintenance organization (HMO) to enrolled individuals.

Unless a waiver under 42 CFR 431.55(g) applies, nominal deductible, coinsurance, copayment, or similar charges are imposed on services that are not excluded from such charges under item B 2 above.

(1) For any service, no more than one type of charge is imposed.

(2) Charges apply to services furnished to persons 21 or older.

Reasonable categories of individuals who are 18 years of age, but under 21, to whom charges apply are listed below, if applicable.

(3) For the medically needy, and other optional groups, 12VAC30-20-160 specifies the:

(a) Service(s) for which charge(s) is applied;

(b) Nature of the charge imposed on each service;

(c) Amount(s) of and basis for determining the charge(s);

(d) Method used to collect the charge(s);

(e) Basis for determining whether an individual is unable to pay the charge(s) and the means by which such an individual is identified to providers;

(f) Procedures for implementing and enforcing the exclusions from cost sharing contained in 42 CFR 447.53(b); and

(g) No cumulative maximum applies to deductible, coinsurance, or copayment charges imposed on a family during a specified time period.

A. The following charges are imposed on the categorically needy and Qualified Medicare Beneficiaries for services other than those provided under 42 CFR 447.53.

*NOTE: The applicability of copays to emergency services is discussed further in this section.

B. The method used to collect cost sharing charges for categorically needy individuals requires that providers be responsible for collecting the cost sharing charges from individuals.

C. The basis for determining whether an individual is unable to pay the charge, and the means by which such an individual is identified to providers, is described in this subsection:

Providers will, based on information available to them, make a determination of the recipient's ability to pay the copayment. In the absence of knowledge or indications to the contrary, providers may accept the recipient's assertion that he or she is unable to pay the required copayment.

Recipients have been notified that inability to meet a copayment at a particular time does not relieve them of that responsibility.

D. The procedures for implementing and enforcing the exclusions from cost sharing contained in 42 CFR 447.53(b) are described in this subsection:

The application and exclusion of cost sharing is administered through the program's Medicaid Management Information System. Documentation of the certified computer system delineates, for each type of provider invoice used, protected eligible groups, protected services and applicable eligible groups and services.

Providers have been informed about: copay exclusions; applicable services and amounts; prohibition of service denial if recipient is unable to meet cost-sharing changes.

E. State policy does not provide for cumulative maximums on charges.

F. Emergency Services. No recipient copayment shall be collected for the following services:

1. Services provided in a hospital, clinic, office, or other facility that is equipped to furnish the required care, after the sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that the absence of immediate medical attention could reasonably be expected to result in:

a. Placing the patient's health in serious jeopardy;

b. Serious impairment to bodily functions; or

c. Serious dysfunction of any bodily organ or part; and

2. All services delivered in emergency rooms.

A. The following charges are imposed on the medically needy and Qualified Medicare Beneficiaries for services other than those provided under 42 CFR 447.53.

*NOTE: The applicability of copays to emergency services is discussed further in this section.

B. The method used to collect cost sharing charges for medically needy individuals requires that providers be responsible for collecting the cost sharing charges from individuals.

C. The basis for determining whether an individual is unable to pay the charge, and the means by which such an individual is identified to providers, is described in this subsection:

Providers will, based on information available to them, make a determination of the recipient's ability to pay the copayment. In the absence of knowledge or indications to the contrary, providers may accept the recipient's assertion that he or she is unable to pay the required copayment.

Recipients have been notified that inability to meet a copayment at a particular time does not relieve them of that responsibility.

D. The procedures for implementing and enforcing the exclusions from cost sharing contained in 42 CFR 447.53(b) are described in this subsection:

The application and exclusion of cost sharing is administered through the program's Medicaid Management Information System. Documentation of the certified computer system delineates, for each type of provider invoice used, protected eligible groups, protected services and applicable eligible groups and services.

Providers have been informed about: copay exclusions; applicable services and amounts; and prohibition of service denial if recipient is unable to meet cost-sharing changes.

E. State policy does not provide for cumulative maximums.

F. Emergency Services. No recipient copayment shall be collected for the following services:

1. Services provided in a hospital, clinic, office, or other facility that is equipped to furnish the required care, after the sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that the absence of immediate medical attention could reasonably be expected to result in:

a. Placing the patient's health in serious jeopardy;

b. Serious impairment to bodily functions; or

c. Serious dysfunction of any bodily organ or part; and

2. All services delivered in emergency rooms.

A. Copayments shall apply to all enrollees in an MCHIP.

A. Copayments shall not apply to FAMIS enrollees in a MCHIP or fee-for-service.

B. These cost-sharing provisions shall be implemented with the following restrictions:

1. Total cost sharing for each 12-month eligibility period shall be limited to (i) for families with incomes equal to or less than 150% of federal poverty level (FPL), the lesser of (a) $180 and (b) 2.5% of the family's income for the year (or 12-month eligibility period); and (ii) for families with incomes greater than 150% of FPL, the lesser of $350 and 5.0% of the family's income for the year (or 12-month eligibility period).

2. DMAS or its designee shall ensure that the annual aggregate cost sharing for all FAMIS enrollees in a family does not exceed the aforementioned caps.

3. Families will be required to submit documentation to DMAS or its designee showing that their maximum copayment amounts are met for the year.

4. Once the cap is met, DMAS or its designee will issue a new eligibility card excluding such families from paying additional copays for the 12-month enrollment period.

C. Exceptions to the above cost-sharing provisions:

1. Copayments shall not be required for well child, well baby, and pregnancy-related services. This shall include:

a. All healthy newborn inpatient physician visits, including routine screening (inpatient or outpatient);

b. Routine physical examinations, laboratory tests, immunizations, and related office visits;

c. Routine preventive and diagnostic dental services (i.e., oral examinations, prophylaxis and topical fluoride applications, sealants, and x-rays);

d. Services to pregnant females related to the pregnancy; and

e. Other preventive services as defined by the department.

2. Enrollees are not held liable for any additional costs, beyond the standard copayment amount, for emergency services furnished outside of the individual's managed care network. Only one copayment charge will be imposed for a single office visit.

3. B. No cost sharing will be charged to American Indians and Alaska Natives.

A. Pregnant women enrolled in FAMIS MOMS will be subject to copayments for medical services in the same manner and amount as pregnant women covered by the Medicaid program as defined in 12VAC30-10-570 B and C.

B. These cost-sharing provisions shall be implemented with the following restrictions:

1. Total cost sharing for a pregnant woman shall be limited to (i) for families with incomes equal to or less than 150% of federal poverty level (FPL), the lesser of (a) $180 and (b) 2.5% of the family's income for the year; and (ii) for families with incomes greater than 150% of FPL, the lesser of $350 and 5.0% of the family's income for the year for the duration of the pregnant woman's enrollment in FAMIS MOMS.

2. If a family includes a pregnant woman enrolled in FAMIS MOMS and a child enrolled in FAMIS, DMAS or its designee shall ensure that the annual aggregate cost sharing for all Title XXI enrollees in a family does not exceed the cost sharing caps as defined in 12VAC30-141-160 B.

3. Families will be required to submit documentation to DMAS or its designee showing that their maximum copayment amounts are met for the year.

4. Once the cap is met, DMAS or its designee will issue a new eligibility card or written documentation excluding such families from paying additional copays.

C. Exceptions to the above cost-sharing provisions. No cost sharing will be charged to American Indians and Alaska Natives.