Cost Sharing (Copayment)
The copayment amount for physician office visit (including crossovers, and optometric) is $1.00 per visit. Copayment does not apply to services provided for pregnant women, nursing facility residents, recipients less than 18 years of age, emergencies, and family planning.
The provider may not deny services to any eligible Medicaid recipient because of the recipient’s inability to pay the cost-sharing (copayment) amount imposed.
COINSURANCE/DEDUCTIBLE AND/OR COPAYMENT
Medicaid responsibility for payment of coinsurance/deductible and/or copayment amounts is:
Coinsurance, Copayments, andDeductibles
Medicaid pays the appropriate coinsurance amounts, copayment amounts, and deductibles up to the beneficiary’s financial obligation to pay or the Medicaid allowable amount (less other insurance payments), whichever is less. If the other insurance has negotiated a rate for a service that is lower than the Medicaid allowable amount, that amount must be accepted as payment in full and Medicaid cannot be billed.
Medicaid services not covered by another insurance
If the other insurance does not cover a service that is a Medicaid-covered service ,Medicaid reimburses the provider up to the Medicaid allowable amount if all the Medicaid coverage rules are followed.
MDHHS cannot be billed for copays, coinsurance, deductibles, or any fees for services provided to beneficiaries enrolled in a MHP, or who are receiving services under PIHP/CMHSP/CA capitation.
Beneficiaries are responsible for payment of all copays and deductibles allowed under the MHP/PIHP/CMHSP/CA contract with MDHHS. If the beneficiary with other insurance coverage is enrolled in a MHP or receiving services under a PIHP/CMHSP/CA capitation, the MHP/PIHP/CMHSP/CA assumes the Medicaid payment liabilities.
Beneficiaries cannot be charged for Medicaid-covered services, except for approved copays or deductibles, whether they are enrolled as a FFS beneficiary, MDHHS is paying the HMO premiums to a contracted health plan, or services are provided under PIHP/CMHSP/CA capitation.
