471 Neb. Admin. Code, ch. 3, § 006

Current through June 17, 2024

Section 471-3-006 - COPAYMENTS

006.01COPAYMENT SCHEDULE. The Department has established the following schedule of copayments for Medicaid services:

(A) Chiropractic Office Visits ..............................	... $1 per visit
(B) Dental Services ............................................	... $3 per specified service
(C) Durable Medical Equipment .........................	... $3 per specified service
(D) Drugs (except birth control)
(i) Generic drugs .........................................	... $2 copay
(ii) Brand name drugs ..................................	... $3 copay
(E) Eyeglasses ...................................................	... $2 per frames, lens, or frames with lens
(F) Hearing Aids ................................................	... $3 per hearing aid
(G) Inpatient Hospital .........................................	... $15 per admission
(H) Mental Health/Substance Abuse Visits .........	... $2 per specified service
(i) Occupational Therapy (non-hospital based) .	... $1 per specified service
(J) Optometric Office Visits ................................	... $2 per visit
(K) Outpatient Hospital Services ........................	... $3 per visit
(L) Physical Therapy (non-hospital based) ........	... $1 per specified service
(M) Physicians (M.D.'s and D.O.'s) Office Visits .	... $2 per visit
(i) Excluding Primary Care Physicians Family Practice, General Practice, Pediatricians, Internists, and physician extenders, including physician assistants, nurse practitioners, and nurse midwives, who provide primary care services.
(N) Podiatrists Office Visits .................................	... $1 per visit
(O) Speech Therapy (non-hospital based) ..........	... $2 per specified service

006.02EXCLUDED SERVICES. The following services are excluded from the above copayment requirement by federal regulations:

(A) Emergency services provided to treat an emergency medical condition in a hospital, clinic, office, or other facility equipped to provide the required care. An emergency condition is defined as a medical or behavioral condition, the onset of which is sudden, manifests itself by symptoms of sufficient severity, including but not limited to, severe pain, which a prudent layperson possessing an average knowledge of medicine and health could reasonably expect the absence of immediate medical attention to result in (a) placing the health of the person, or with respect to a pregnant woman, the health of the woman and her unborn child, afflicted with such condition in serious jeopardy or, in the case of a behavioral condition, placing the health of such persons or others in serious jeopardy, (b) serious impairment to such person's bodily functions, (c) serious impairment of any bodily organ or part of such person, or (d) serious disfigurement of such person; and

(B) Family planning services, supplies, and drugs provided to individuals of child-bearing age.

006.03COVERED PERSONS. All Medicaid-eligible adults age 19 or older listed below are subject to the copayment requirement:

(A) Adults eligible under the Aid to Aged, Blind, and Disabled program;

(B) Adults eligible under the Refugee Resettlement Program; and

(C) Individuals who are receiving extended assistance for former Department wards.

006.04CHANGE IN CLIENT'S COPAYMENT STATUS DURING THE MONTH. The client's copayment status may change during the month. If the client's copayment status changes during the month, the provider may submit documentation regarding copayments made or collected erroneously and the Department will make the appropriate adjustments to the claim. The provider will refund the client when a copayment is erroneously collected. Providers can contact the Nebraska Medicaid Eligibility System or use the standard electronic Health Care Eligibility Benefit Inquiry and Response transaction to verify the client's copayment status.

006.05EXEMPTED PERSONS. The following individuals are exempted from the copayment requirement:

(A) Individuals age 18 or younger;

(B) Pregnant women through the immediate postpartum period, beginning on the last day of pregnancy and extending 60 days. The post-partum period ends on the last day of the month in which day 60 occurs;

(C) Any individual who is an inpatient in a hospital, long term care facility, or other medical institution if the individual is required, as a condition of receiving services in the institution, to spend all but a minimal amount of his or her income required for personal needs for medical care costs;

(D) Indians who receive items and services furnished directly by an Indian Health Care Provider or through referral from an Indian Health Care Provider under contract health services.

(E) Individuals who are receiving waiver services, provided under a 1915(c) waiver, such as the Community-Based Waiver for Adults; the Home and Community-Based Waiver for Children; the Home and Community-Based Waiver for Aged Persons or Adults or Children with Disabilities or the Early Intervention Waiver;

(F) Individuals with excess income, both before and after the obligation is met;

(G) Individuals who receive assistance under the State Disability Program.

(H) Individuals eligible for IV-E assistance;

(I) Individuals in hospice care;

(J) Individuals eligible in the Breast and Cervical Cancer category;

(K) Family planning services and supplies;

(L) Individuals approved for emergency services only; and

(M) Individuals enrolled in managed care, though the managed care organization may assess copays as long as they offer at least the same exemptions listed in this section.

006.06CLIENT RIGHTS AND RESPONSIBILITIES. Clients subject to copayments are required to pay the provider the applicable copayment amounts. If a client believes a provider has charged the client incorrectly, the client must continue to pay the copayments charged by the provider until the Department determines whether the copayment amounts are correct. The client has the right to appeal.

006.07COLLECTION OF COPAYMENT. The provider will collect the copayment from the client when the service is provided. The provider cannot refuse to provide services to the client if the client is unable to pay the copayment amount at the time of the service. This does not alleviate the client's liability for the copayment amount nor does it prevent the provider from attempting to collect the copayment amount.

006.07(A)UNCOLLECTED COPAYMENTS. If it is the routine business practice of the provider to refuse service to any individual with uncollected debt, the provider may include uncollected copayments under this practice. Providers must give sufficient notice to the client before services can be denied.

006.07(B)PROVIDER BILLING FOR SERVICES SUBJECT TO COPAYMENT. Providers will bill their usual and customary charge regardless of whether the copayment has been collected. The provider will not enter the copayment as a prior payment or amount paid amount on the claim.

006.07(C) PROVIDER WAIVER OF COPAYMENT. A provider cannot establish a policy to automatically waive copayments or deductibles established by the Department. A provider cannot advertise or promote waiver of the collection of all or any portion of the required copayments or deductibles.

006.07(D)USUAL AND CUSTOMARY CHARGE. The provider cannot collect a copayment amount which exceeds the provider's usual and customary charge or the Nebraska Medicaid payment. Copayment collected from the client must be the lowest of the established copayment amount, the provider's usual and customary charge, or the Nebraska Medicaid payment.

006.08THIRD PARTY LIABILITY. For Medicaid clients enrolled in commercial Health Maintenance Organization or Preferred Provider Organization plans, the Nebraska Medicaid copayment may apply.

006.09MEDICARE. For Medicare and Medicaid dually eligible clients, the Nebraska Medicaid copayment applies. Nebraska Medicaid pays Medicare co-insurance and deductible amounts on Medicare-approved services less any Medicaid copayment.

471 Neb. Admin. Code, ch. 3, § 006

Reserved by 9/10/2017

Amended effective 6/6/2022