(a) Except as provided in subdivision 2, the medical assistance benefit plan shall include the following co-payments for all recipients, effective for services provided on or after October 1, 2003, and before January 1, 2009:
(1) $3 per nonpreventive visit. For purposes of this subdivision, a visit means an episode of service which is required because of a recipient's symptoms, diagnosis, or established illness, and which is delivered in an ambulatory setting by a physician or physician ancillary, chiropractor, podiatrist, nurse midwife, advanced practice nurse, audiologist, optician, or optometrist;
(2) $3 for eyeglasses;
(3) $6 for nonemergency visits to a hospital-based emergency room; and
(4) $3 per brand-name drug prescription and $1 per generic drug prescription, subject to a $12 per month maximum for prescription drug co-payments. No co-payments shall apply to antipsychotic drugs when used for the treatment of mental illness.
(b) Except as provided in subdivision 2, the medical assistance benefit plan shall include the following co-payments for all recipients, effective for services provided on or after January 1, 2009:
(1) $3.50 for nonemergency visits to a hospital-based emergency room;
(2) $3 per brand-name drug prescription and $1 per generic drug prescription, subject to a $7 per month maximum for prescription drug co-payments. No co-payments shall apply to antipsychotic drugs when used for the treatment of mental illness; and
(3) for individuals identified by the commissioner with income at or below 100 percent of the federal poverty guidelines, total monthly co-payments must not exceed five percent of family income. For purposes of this paragraph, family income is the total earned and unearned income of the individual and the individual's spouse, if the spouse is enrolled in medical assistance and also subject to the five percent limit on co-payments.
(c) Recipients of medical assistance are responsible for all co-payments in this subdivision.
Co-payments shall be subject to the following exceptions:
(1) children under the age of 21;
(2) pregnant women for services that relate to the pregnancy or any other medical condition that may complicate the pregnancy;
(3) recipients expected to reside for at least 30 days in a hospital, nursing home, or intermediate care facility for the developmentally disabled;
(4) recipients receiving hospice care;
(5) 100 percent federally funded services provided by an Indian health service;
(6) emergency services;
(7) family planning services;
(8) services that are paid by Medicare, resulting in the medical assistance program paying for the coinsurance and deductible; and
(9) co-payments that exceed one per day per provider for nonpreventive visits, eyeglasses, and nonemergency visits to a hospital-based emergency room.
(a) The medical assistance reimbursement to the provider shall be reduced by the amount of the co-payment, except that reimbursements shall not be reduced:
(1) once a recipient has reached the $12 per month maximum or the $7 per month maximum effective January 1, 2009, for prescription drug co-payments; or
(2) for a recipient identified by the commissioner under 100 percent of the federal poverty guidelines who has met their monthly five percent co-payment limit.
(b) The provider collects the co-payment from the recipient. Providers may not deny services to recipients who are unable to pay the co-payment.
(c) Medical assistance reimbursement to fee-for-service providers and payments to managed care plans shall not be increased as a result of the removal of co-payments effective on or after January 1, 2009.
Official Publication of the State of Minnesota
Revisor of Statutes