2642 Healthy Pennsylvania cost sharing changes

Healthy Pennsylvania Cost Sharing Changes

[44 Pa.B. 7973]
[Saturday, December 20, 2014]

 As part of the Department of Human Service's (Department) Healthy Pennsylvania plan, the Department is announcing its intent to allow providers to require non-exempt beneficiaries with household income above 100% of the Federal Poverty Limit (FPL) to pay cost sharing as a condition for receiving items or services.

Discussion

 Effective January 1, 2015, a provider, including a pharmacy or hospital, may require a Medicaid beneficiary to pay cost sharing as a condition for receiving an item or service if the Medicaid beneficiary has household income above 100% of the FPL, as specified by Federal Medicaid regulation in 42 CFR 447.52(e)(1) (relating to cost sharing). A provider may only deny services to Medicaid beneficiaries if it is the customary practice for all patients the provider serves to be denied services in these situations. A provider may not deny services to Medicaid beneficiaries with household income of 100% of the FPL or below. However, this does not change the beneficiaries' liability for the copayment and does not prevent a provider from attempting to collect the cost sharing amount due.

 In accordance with 42 CFR 447.56(f) (relating to limitations on premiums and cost sharing), Medicaid premiums and cost sharing incurred by all individuals in the Medicaid household may not exceed an aggregate limit of 5% of household income applied on a quarterly basis. The Department's claims processing system, also known as PROMISe^TM, will determine when the quarterly aggregate limit has been reached and no further cost sharing will be assessed until the next quarter.

Fiscal Impact

 The Department anticipates no financial impact.

Public Comment

 Interested persons are invited to submit written comments regarding this notice to the Department of Human Services, Office of Medical Assistance Programs, c/o Regulations Coordinator, Room 515, Health and Welfare Building, Harrisburg, PA 17120. Comments received within 30 days will be reviewed and considered for any subsequent revision of the notice.

 Persons with a disability who require an auxiliary aid or service may submit comments using the Pennsylvania AT&T Relay Service at [phone] (TDD users) or [phone] (voice users).

BEVERLY D. MACKERETH, 
Secretary

 Fiscal Note: 14-NOT-926. No fiscal impact. (8) recommends adoption.

[Pa.B. Doc. No. 14-2642. Filed for public inspection December 19, 2014, 9:00 a.m.]