§3173-C. Copayments

1.  Authorization required.  The department may not require any MaineCare member to make any payment toward the cost of a MaineCare service unless that payment is specifically authorized by this section, except that any copayment or premium expressly approved by the federal Secretary of the Department of Health and Human Services as part of a waiver must be implemented.

[PL 2003, c. 20, Pt. K, §5 (AMD).]

2.  Prescription drug services.  Except as provided in this subsection and subsections 3 and 4, a pharmacy shall charge a MaineCare member $3.00 for each drug prescription that is an approved MaineCare service. The department shall adopt and follow procedures to ensure compliance with the requirements of 42 United States Code, Section 1396o-1. A pharmacy that has followed the procedures adopted by the department to ensure compliance with the requirements of 42 United States Code, Section 1396o-1 may refuse to dispense the drug if the copayment is not paid. Copayments must be capped at $30 per month per member. If a member is prescribed a drug in a quantity specifically intended by the provider or pharmacist, for the recipient's health and welfare, to last less than one month, only one payment for that drug for that month is required.

[PL 2011, c. 458, §1 (AMD); PL 2011, c. 458, §4 (AFF).]

3.  Exemptions.  No copayment may be imposed with respect to the following services:

A. Family planning services;   [PL 1983, c. 240 (NEW).]

B. Services furnished to individuals under 21 years of age;   [PL 1983, c. 240 (NEW).]

C. Services furnished to any individual who is an inpatient in a hospital, nursing facility or other institution, if that individual is required, as a condition of receiving services in that institution, to spend for costs of care all but a minimal amount of income required for personal needs;   [PL 1991, c. 780, Pt. R, §3 (AMD).]

D. Services furnished to pregnant women, and services furnished during the post-partum phase of maternity care to the extent permitted by federal law;   [PL 1983, c. 240 (NEW).]

E. Emergency services, as defined by the department;   [PL 1983, c. 240 (NEW).]

F. Services furnished to an individual by a Health Maintenance Organization, as defined in the United States Social Security Act, Section 1903(m), in which he is enrolled; and   [PL 1983, c. 240 (NEW).]

G. Any other service or services required to be exempt under the provisions of the United States Social Security Act, Title XIX and successors to it.   [PL 1983, c. 240 (NEW).]

[PL 1991, c. 780, Pt. R, §3 (AMD).]

4.  Persons in state custody.  Any copayment imposed on a Medicaid recipient in the custody of the State is to be collected from the state agency having custody of the recipient.

[PL 1983, c. 240 (NEW).]

5.  Limitation.

[PL 1993, c. 6, Pt. C, §7 (RP).]

6.  Designated copayment.

[PL 1991, c. 780, Pt. R, §4 (RP); PL 1991, c. 780, Pt. R, §10 (AFF).]

7.  Copayments.  Notwithstanding any other provision of law, the following copayments per service per day are imposed and reimbursements are reduced, or both, to the following levels:

A. Outpatient hospital services, $3;   [PL 1993, c. 6, Pt. C, §8 (NEW).]

B. Home health services, $3;   [PL 1993, c. 6, Pt. C, §8 (NEW).]

C. Durable medical equipment services, $3;   [PL 1993, c. 6, Pt. C, §8 (NEW).]

D. Private duty nursing and personal care services, $5 per month;   [PL 1993, c. 6, Pt. C, §8 (NEW).]

E. Ambulance services, $3;   [PL 1993, c. 6, Pt. C, §8 (NEW).]

F. Physical therapy services, $2;   [PL 1993, c. 6, Pt. C, §8 (NEW).]

G. Occupational therapy services, $2;   [PL 1993, c. 6, Pt. C, §8 (NEW).]

H. Speech therapy services, $2;   [PL 1993, c. 6, Pt. C, §8 (NEW).]

I. Podiatry services, $2;   [PL 1993, c. 6, Pt. C, §8 (NEW).]

J. Psychologist services, $2;   [PL 1993, c. 410, Pt. I, §8 (AMD).]

K. Chiropractic services, $2;   [PL 1993, c. 410, Pt. I, §8 (AMD).]

L. Laboratory and x-ray services, $1;   [PL 1993, c. 410, Pt. I, §9 (NEW).]

M. Optical services, $2;   [PL 1993, c. 410, Pt. I, §9 (NEW).]

N. Optometric services, $3;   [PL 1993, c. 410, Pt. I, §9 (NEW).]

O. Mental health clinic services, $2;   [PL 1993, c. 410, Pt. I, §9 (NEW).]

P. Substance use disorder services, $2;   [PL 2017, c. 407, Pt. A, §76 (AMD).]

Q. Hospital inpatient services, $3 per patient day;   [PL 2003, c. 20, Pt. K, §7 (AMD).]

R. Federally qualified health center services, $3 per patient day, effective July 1, 2004; and   [PL 2003, c. 451, Pt. H, §1 (AMD); PL 2003, c. 451, Pt. H, §3 (AFF).]

S. Rural health center services, $3 per patient day.   [PL 2003, c. 20, Pt. K, §8 (NEW).]

The department may adopt rules to adjust the copayments set forth in this subsection. The rules may adjust amounts to ensure that copayments are deemed nominal in amount and may include monthly limits or exclusions per service category. The need to maintain provider participation in the Medicaid program to the extent required by 42 United States Code, Section 1396a(a)(30)(A) or any successor provision of law must be considered in any reduction in reimbursement to providers or imposition of copayments.

[PL 2017, c. 407, Pt. A, §76 (AMD).]

8.  Notification.  The department shall notify each MaineCare member who is subject to the copayment requirement in subsection 2 of the copayment requirements, any exemptions and limitations prior to coding the member's information for required copayments and shall notify the member again during annual recertification of eligibility.

[PL 2011, c. 458, §2 (NEW); PL 2011, c. 458, §4 (AFF).]

SECTION HISTORY

PL 1981, c. 703, §A24 (NEW). PL 1983, c. 240 (RPR). PL 1991, c. 528, §§P10,11 (AMD). PL 1991, c. 528, §RRR (AFF). PL 1991, c. 591, §§P10,11 (AMD). PL 1991, c. 622, §M11 (AMD). PL 1991, c. 780, §§R3,4 (AMD). PL 1991, c. 780, §R10 (AFF). PL 1993, c. 6, §§C5-8 (AMD). PL 1993, c. 410, §§I8,9 (AMD). PL 2003, c. 20, §§K5-8 (AMD). PL 2003, c. 451, §H1 (AMD). PL 2003, c. 451, §H3 (AFF). PL 2007, c. 240, Pt. GGG, §1 (AMD). PL 2009, c. 415, Pt. A, §12 (AMD). PL 2011, c. 458, §§1, 2 (AMD). PL 2011, c. 458, §4 (AFF). PL 2017, c. 407, Pt. A, §76 (AMD).