Title 907 | Chapter 001 | Regulation 604
SUPERSEDED
This document is no longer current.
907 KAR 1:604.Recipient cost-sharing.
Section 1.
Definitions.(1)
"Copayment" means a dollar amount representing the portion of the cost of a Medicaid benefit that a recipient is required to pay.(2)
"Department" means the Department for Medicaid Services or its designee.(3)
"Enrollee" means a Medicaid recipient who is enrolled with a managed care organization.(4)
"Managed care organization" or "MCO" means an entity for which the Department for Medicaid Services has contracted to serve as a managed care organization as defined by 42 C.F.R. 438.2.(5)
"Medicaid Works individual" means an individual who:(a)
But for earning in excess of the income limit established under 42 U.S.C. 1396d(q)(2)(B) would be considered to be receiving supplemental security income;(b)
Is at least sixteen (16), but less than sixty-five (65), years of age;(c)
Is engaged in active employment verifiable with:1.
Paycheck stubs;2.
Tax returns;3.
1099 forms; or4.
Proof of quarterly estimated tax;(d)
Meets the income standards established in 907 KAR 20:020; and(e)
Meets the resource standards established in 907 KAR 20:025.(6)
"Recipient" is defined by KRS 205.8451(9).Section 2.
Copayments.Benefit | Copayment Amount |
Emergency room for a nonemergency visit | $1 |
Prescription and over-the-counter drugs | $1 |
Ambulance services provided to individuals in need of nonemergency health transportation services | $1 |
(1)
Except as provided by subsection (4) of this section, the following table shall establish the copayment amounts that a recipient shall pay, unless the recipient is otherwise exempt from cost sharing.(2)
The full amount of the copayment established in the table in subsection (1) of this section shall be deducted from the provider reimbursement, unless the recipient has already met any copayment obligation for the year pursuant to Section 3(1)(b) of this administrative regulation.(3)
The maximum amount of cost-sharing shall not exceed five (5) percent of a family's income for a quarter.(4)
A prescription co-payment shall not apply to:(a)
Certain antipsychotic medications;(b)
Contraceptives for family planning;(c)
Tobacco cessation medications;(d)
All covered diabetes or diabetic supplies;(e)
Pregnant recipients;(f)
Long-term care residents; or(g)
Any recipient exempted pursuant to Sections 3 or 5 of this administrative regulation.Section 3.
Copayment General Provisions and Exemptions.(1)
(a)
Cost-sharing or copayments for the delivery of Medicaid services within the Commonwealth shall not exceed the amounts established in the table in Section 2 of this administrative regulation.(b)
After paying for one (1) copayment each calendar year for any service or product within the table established in Section 2 of this administrative regulation, a recipient shall not be subject to additional copayments or cost-sharing for that service or any other Medicaid covered service or product for the remainder of that calendar year.(2)
A Medicaid beneficiary who is younger than nineteen (19) years of age shall be exempt from the copayment or cost-sharing requirements established pursuant to this administrative regulation.(3)
A copayment shall not be imposed for a service, prescription, item, supply, equipment, or any type of Medicaid benefit provided to a foster care child or a pregnant woman.(4)
The department shall impose no cost sharing for an individual or recipient who is exempt pursuant to 42 C.F.R. 447.56.(5)
A provider shall not deny services to a recipient who cannot pay any required cost sharing.(6)
Any amount of uncollected copayment by a provider from a recipient shall not be considered a debt to the provider.(7)
A provider shall not collect:(a)
A copayment from an enrollee for a service or item if a copayment is not imposed for that service or item; or(b)
Any copayment or cost sharing from an enrollee that is greater than the copayment amounts established in the table in Section 2 of this administrative regulation.(8)
Cumulative cost sharing for copayments for a family with children who receive benefits under Title XXI, 42 U.S.C. 1397aa to 1397jj, shall be limited to five (5) percent of the annual family income.(9)
In response to a declared emergency relating to or rationally related to healthcare or public health, the department may waive or direct the waiving of all required cost-sharing for all Medicaid beneficiaries or any subpopulation of Medicaid beneficiaries not already exempted from this administrative regulation, including a geographic or age-related subpopulation.Section 4.
Premiums for Medicaid Works Individuals.(1)
(a)
A Medicaid Works individual shall pay a monthly premium that is:1.
Based on income used to determine eligibility for the program; and2.
Established in paragraph (b) of this subsection.(b)
The monthly premium shall be:1.
Thirty-five (35) dollars for an individual whose income is greater than 100 percent but no more than 150 percent of the FPL;2.
Forty-five (45) dollars for an individual whose income is greater than 150 percent but no more than 200 percent of the FPL; and3.
Fifty-five (55) dollars for an individual whose income is greater than 200 percent but no more than 250 percent of the FPL.(2)
An individual whose family income is equal to or below 100 percent of the FPL shall not be required to pay a monthly premium.(3)
A Medicaid Works individual shall begin paying a premium with the first full month of benefits after the month of application.(4)
Benefits shall be effective with the date of application if the premium specified in subsection (1) of this section has been paid.(5)
Retroactive eligibility pursuant to 907 KAR 20:010, Section 1(3), shall not apply to a Medicaid Works individual.(6)
If a recipient fails to make two (2) consecutive premium payments, benefits shall be discontinued at the end of the first benefit month for which the premium has not been paid.(7)
A Medicaid Works individual shall be eligible for reenrollment upon payment of the missed premium providing all other technical eligibility, income, and resource standards continue to be met.(8)
If twelve (12) months have elapsed since a missed premium, a Medicaid Works individual shall not be required to pay the missed premium before reenrolling.Section 5.
Provisions for Enrollees. A managed care organization:(1)
Shall not impose a copayment on an enrollee that exceeds a copayment established in this administrative regulation; and(2)
May impose on an enrollee:(a)
A lower copayment than established in this administrative regulation, if possible; or(b)
No copayment.Section 6.
Freedom of Choice.(1)
In accordance with 42 C.F.R. 431.51, a recipient who is not an enrollee may obtain services from any qualified provider who is willing to provide services to that particular recipient.(2)
A managed care organization may restrict an enrollee's choice of providers to the providers in the provider network of the managed care organization in which the enrollee is enrolled except as established in:(a)
42 C.F.R. 438.52; or(b)
42 C.F.R. 438.114(c).Section 7.
Appeal Rights. An appeal of a department decision regarding the Medicaid eligibility of an individual shall be in accordance with 907 KAR 1:560.Section 8.
Federal Approval and Federal Financial Participation. The department's copayment provisions and any coverage of services established in this administrative regulation shall be contingent upon:(1)
Receipt of federal financial participation; and(2)
Centers for Medicare and Medicaid Services' approval.Section 9.
This administrative regulation was found deficient by the Administrative Regulation Review Subcommittee on May 13, 2014.HISTORY: (29 Ky.R. 1458; 2201; 2478; eff. 4-11-2003; 30 Ky.R. 1117; 1533; eff. 2-16-2004; 32 Ky.R. 417; 925; 1111; eff. 1-6-2006; 33 Ky.R. 607; 1386; 1568; eff. 1-5-2007; 34 Ky.R. 1840; 2117; eff. 4-4-2008; TAm eff. 7-16-2013; TAm eff. 8-7-2013; TAm eff. 9-30-2013; 40 Ky.R. 1991; 2524; 2749; eff. 7-7-2014; TAm eff. 10-6-2017; 46 Ky.R. 512, 937; eff. 10-4-2019; 47 Ky.R. 350; 729; eff. 11-19-2020.)
907 KAR 1:604.Recipient cost-sharing.
Section 1.
Definitions.(1)
"Copayment" means a dollar amount representing the portion of the cost of a Medicaid benefit that a recipient is required to pay.(2)
"Department" means the Department for Medicaid Services or its designee.(3)
"Enrollee" means a Medicaid recipient who is enrolled with a managed care organization.(4)
"Managed care organization" or "MCO" means an entity for which the Department for Medicaid Services has contracted to serve as a managed care organization as defined by 42 C.F.R. 438.2.(5)
"Medicaid Works individual" means an individual who:(a)
But for earning in excess of the income limit established under 42 U.S.C. 1396d(q)(2)(B) would be considered to be receiving supplemental security income;(b)
Is at least sixteen (16), but less than sixty-five (65), years of age;(c)
Is engaged in active employment verifiable with:1.
Paycheck stubs;2.
Tax returns;3.
1099 forms; or4.
Proof of quarterly estimated tax;(d)
Meets the income standards established in 907 KAR 20:020; and(e)
Meets the resource standards established in 907 KAR 20:025.(6)
"Recipient" is defined by KRS 205.8451(9).Section 2.
Copayments.Benefit | Copayment Amount |
Emergency room for a nonemergency visit | $1 |
Prescription and over-the-counter drugs | $1 |
Ambulance services provided to individuals in need of nonemergency health transportation services | $1 |
(1)
Except as provided by subsection (4) of this section, the following table shall establish the copayment amounts that a recipient shall pay, unless the recipient is otherwise exempt from cost sharing.(2)
The full amount of the copayment established in the table in subsection (1) of this section shall be deducted from the provider reimbursement, unless the recipient has already met any copayment obligation for the year pursuant to Section 3(1)(b) of this administrative regulation.(3)
The maximum amount of cost-sharing shall not exceed five (5) percent of a family's income for a quarter.(4)
A prescription co-payment shall not apply to:(a)
Certain antipsychotic medications;(b)
Contraceptives for family planning;(c)
Tobacco cessation medications;(d)
All covered diabetes or diabetic supplies;(e)
Pregnant recipients;(f)
Long-term care residents; or(g)
Any recipient exempted pursuant to Sections 3 or 5 of this administrative regulation.Section 3.
Copayment General Provisions and Exemptions.(1)
(a)
Cost-sharing or copayments for the delivery of Medicaid services within the Commonwealth shall not exceed the amounts established in the table in Section 2 of this administrative regulation.(b)
After paying for one (1) copayment each calendar year for any service or product within the table established in Section 2 of this administrative regulation, a recipient shall not be subject to additional copayments or cost-sharing for that service or any other Medicaid covered service or product for the remainder of that calendar year.(2)
A Medicaid beneficiary who is younger than nineteen (19) years of age shall be exempt from the copayment or cost-sharing requirements established pursuant to this administrative regulation.(3)
A copayment shall not be imposed for a service, prescription, item, supply, equipment, or any type of Medicaid benefit provided to a foster care child or a pregnant woman.(4)
The department shall impose no cost sharing for an individual or recipient who is exempt pursuant to 42 C.F.R. 447.56.(5)
A provider shall not deny services to a recipient who cannot pay any required cost sharing.(6)
Any amount of uncollected copayment by a provider from a recipient shall not be considered a debt to the provider.(7)
A provider shall not collect:(a)
A copayment from an enrollee for a service or item if a copayment is not imposed for that service or item; or(b)
Any copayment or cost sharing from an enrollee that is greater than the copayment amounts established in the table in Section 2 of this administrative regulation.(8)
Cumulative cost sharing for copayments for a family with children who receive benefits under Title XXI, 42 U.S.C. 1397aa to 1397jj, shall be limited to five (5) percent of the annual family income.(9)
In response to a declared emergency relating to or rationally related to healthcare or public health, the department may waive or direct the waiving of all required cost-sharing for all Medicaid beneficiaries or any subpopulation of Medicaid beneficiaries not already exempted from this administrative regulation, including a geographic or age-related subpopulation.Section 4.
Premiums for Medicaid Works Individuals.(1)
(a)
A Medicaid Works individual shall pay a monthly premium that is:1.
Based on income used to determine eligibility for the program; and2.
Established in paragraph (b) of this subsection.(b)
The monthly premium shall be:1.
Thirty-five (35) dollars for an individual whose income is greater than 100 percent but no more than 150 percent of the FPL;2.
Forty-five (45) dollars for an individual whose income is greater than 150 percent but no more than 200 percent of the FPL; and3.
Fifty-five (55) dollars for an individual whose income is greater than 200 percent but no more than 250 percent of the FPL.(2)
An individual whose family income is equal to or below 100 percent of the FPL shall not be required to pay a monthly premium.(3)
A Medicaid Works individual shall begin paying a premium with the first full month of benefits after the month of application.(4)
Benefits shall be effective with the date of application if the premium specified in subsection (1) of this section has been paid.(5)
Retroactive eligibility pursuant to 907 KAR 20:010, Section 1(3), shall not apply to a Medicaid Works individual.(6)
If a recipient fails to make two (2) consecutive premium payments, benefits shall be discontinued at the end of the first benefit month for which the premium has not been paid.(7)
A Medicaid Works individual shall be eligible for reenrollment upon payment of the missed premium providing all other technical eligibility, income, and resource standards continue to be met.(8)
If twelve (12) months have elapsed since a missed premium, a Medicaid Works individual shall not be required to pay the missed premium before reenrolling.Section 5.
Provisions for Enrollees. A managed care organization:(1)
Shall not impose a copayment on an enrollee that exceeds a copayment established in this administrative regulation; and(2)
May impose on an enrollee:(a)
A lower copayment than established in this administrative regulation, if possible; or(b)
No copayment.Section 6.
Freedom of Choice.(1)
In accordance with 42 C.F.R. 431.51, a recipient who is not an enrollee may obtain services from any qualified provider who is willing to provide services to that particular recipient.(2)
A managed care organization may restrict an enrollee's choice of providers to the providers in the provider network of the managed care organization in which the enrollee is enrolled except as established in:(a)
42 C.F.R. 438.52; or(b)
42 C.F.R. 438.114(c).Section 7.
Appeal Rights. An appeal of a department decision regarding the Medicaid eligibility of an individual shall be in accordance with 907 KAR 1:560.Section 8.
Federal Approval and Federal Financial Participation. The department's copayment provisions and any coverage of services established in this administrative regulation shall be contingent upon:(1)
Receipt of federal financial participation; and(2)
Centers for Medicare and Medicaid Services' approval.Section 9.
This administrative regulation was found deficient by the Administrative Regulation Review Subcommittee on May 13, 2014.HISTORY: (29 Ky.R. 1458; 2201; 2478; eff. 4-11-2003; 30 Ky.R. 1117; 1533; eff. 2-16-2004; 32 Ky.R. 417; 925; 1111; eff. 1-6-2006; 33 Ky.R. 607; 1386; 1568; eff. 1-5-2007; 34 Ky.R. 1840; 2117; eff. 4-4-2008; TAm eff. 7-16-2013; TAm eff. 8-7-2013; TAm eff. 9-30-2013; 40 Ky.R. 1991; 2524; 2749; eff. 7-7-2014; TAm eff. 10-6-2017; 46 Ky.R. 512, 937; eff. 10-4-2019; 47 Ky.R. 350; 729; eff. 11-19-2020.)