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Section
3.4 Co-payments
3.4.1
Introduction
3.4.2 References
3.4.3 Scope
3.4.4 Did you know…?
3.4.5 Definitions
3.4.6 Objectives
3.4.7 Procedures
3.4.7-A. Co-payments for Non-Title XIX/XXI eligible persons determined to have a Serious Mental Illness (SMI)
3.4.7-B. Co-payments for Title XIX/XXI eligible
persons
3.4.1
Introduction
Persons not covered by the Arizona Health Care Cost Containment System (AHCCCS)
must contribute to the cost of behavioral health services, in accordance with state
law (see A.R.S. 36-3409). A co-payment is a fixed amount, which does not exceed the
actual cost of services, that a person pays directly to a provider at the time covered
services are rendered. For individuals who are Non-Title XIX/XXI eligible persons
determined to have a Serious Mental Illness (SMI), the Arizona Department of Health
Services/Division of Behavioral Health Services (ADHS/DBHS) has established a
co-payment to be charged to these members for covered services. Under limited
circumstances, persons who are Title XIX/XXI eligible may be assessed a co-payment
in accordance with
A.A.C. R9-22-711.
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3.4.2
References
The following citations can serve as additional resources for this
content area:
3.4.3
Scope
To whom does this apply?
Non-Title XIX/XXI eligible
persons determined to have a Serious Mental Illness (SMI) and Title XIX/XXI eligible
persons who are referred to, or enrolled with, a behavioral health provider to
receive publicly funded behavioral health services. Co-payment requirements in this
policy are not applicable to services funded by the Substance Abuse Prevention and
Treatment (SAPT), Community Mental Health Services (CMHS) or Project for Assistance
in Transition from Homelessness (PATH) federal block grants.
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3.4.4
Did you know…?
Persons determined to have a
Serious Mental Illness must be informed prior to the provision of services of any
fees associated with the services (R9-21-202(A)(8)), and providers must document such
notification to the person in his/her comprehensive clinical record.
Individuals and families with
income exceeding 100% of the Federal Poverty Level (FPL) and who have medical
expenses that reduce the countable income to 40% of the FPL may be eligible for the
Arizona Health Care Cost Containment System (AHCCCS) Medical Expense Deduction
(MED-Spend Down) Program (see the description of
AHCCCS Health Insurance programs
for additional information). When a provider discovers that a behavioral health
recipient is unable to make his/her co-payment due to medical expenses, providers
must screen those individuals for AHCCCS eligibility. Providers can utilize the
Health-e Arizona web tool to verify potential eligibility and submit behavioral
health recipient’s information for formal eligibility determination and screening
for other public assistance programs simultaneously.
When a person is accessing
public behavioral health services, the person will be required to provide
documentation to verify income and expenses (see section 3.3.7-G, Eligibility
screening and supporting documentation, of
PM Section 3.3, Referral and Intake).
Behavioral health providers must not bill, nor attempt to collect payment
directly or through a collection agency from a person claiming to be AHCCCS
eligible without first receiving verification from AHCCCS that the person was
ineligible for AHCCCS on the date of service, or that services provided were not
Title XIX/XXI covered services.
3.4.5
Definitions
Co-payment
In-network services
Out of network services
Serious Mental Illness
Third Party Liability
Transitional Medical Assistance (TMA)
Title XIX Waiver Group (TWG)
3.4.6 Objectives
Identify when and how providers must assess co-payments,
address the collection of co-payments and address the actions to take for
nonpayment of co-payments.
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3.4.7
Procedures
Co-payments must be assessed and collected consistent with state
law and Arizona Administrative Code requirements.
3.4.7-A.
Co-payments for Non-Title XIX/XXI eligible persons determined to have a Serious Mental Illness (SMI)
Non-Title XIX/XXI eligible
persons determined to have a Serious Mental Illness are eligible to receive a
medication only benefit (see
ADHS/DBHS Guidelines to RBHAs and Providers for Services
to Non Title XIX Members with Serious Mental Illness). Co-payments assessed for
non-Title XIX/XXI persons determined SMI are intended to be payments by the member for
the service package (e.g., psychiatric assessments, medication management, medications),
but co-payments are only collected at the time of the psychiatric assessment and
psychiatric follow up appointments. Co-payments are not assessed for crisis services
or collected at the time crisis services are provided. Co-payments
are:
- A fixed
dollar amount of $31;
- Applied to
in network services; and
- Collected
at the time services are rendered.
Collecting Co-payments
Providers will be responsible for collecting co-payments. Providers
will:
- Assess the fixed dollar amount
per service received, regardless of the number of units encountered;
- Collect the $3 co-payment at
the time of the psychiatric assessment or the psychiatric follow up appointment; and
-
Ensure that no co-payments are imposed for
American Indians or persons within other specific eligibility groups, as identified in
R9-22-711(B)
Providers may take reasonable steps to collect on delinquent accounts. Behavioral
health recipients who are having difficulties making co-payments must be screened for
AHCCCS eligibility.
Any co-payments collected are retained by
the provider and reported
to ADHS/DBHS in the encounter.
Other Payment Sources
If a person has third party liability coverage, T/RBHAs or their providers must follow the requirements set forth in
Section 3.5, Third Party Liability and Coordination of Benefits. Non-Title XIX/XXI persons determined to have SMI will pay the ADHS/DBHS co-payment or the costs required by a third party insurer, whichever amount is less, as described in PM Section 3.5, Third Party Liability and Coordination of Benefits.
Non-payment
of Co-payments
Behavioral
health providers may not refuse to provide or terminate services
when behavioral health recipients are unable to pay co-payments.
The following methods may be utilized to encourage a collaborative approach to resolve non-payment issues:
- Engage in informal discussions and avoid confrontational situations;
- Re-screen the person for AHCCCS eligibility;
and
- Present other payment options, such as payment plans or payment deferrals, and
discuss additional payment options as requested by the person.
The collection of co-payments is an administrative process, and as such, co-payments must not be collected in conjunction with a person’s behavioral health treatment. All efforts to resolve non-payment issues, as they occur, must be clearly documented in the person’s comprehensive clinical record.
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3.4.7-B.
Co-payments for Title XIX/XXI eligible persons
Under certain conditions, a behavioral health provider may collect
a co-payment from a Title XIX/XXI eligible person.
Who is exempt from co-payments?
- Children under the age of 19.
- Persons determined to have a
Serious Mental Illness (SMI).
-
Individuals up through age 20 eligible for the Children's
Rehabilitative Services program;
- People
who are in nursing homes, residential facilities such as an
Assisted Living Home or who receive Home and Community Based
Services such as attendant care or a visiting nurse; and
- Persons
receiving hospice care.
Hospitalizations, emergency services and services paid on a
fee-for-service basis are exempt form co-payments for all
members.
Optional/nominal
co-payments for Title XIX/XXI eligible persons
- Behavioral
health recipients in some AHCCCS programs will have co-payments
for the following Title XIX/XXI covered behavioral health
services:
-
$2.30 per prescription drug; and
- $3.40
per doctor or other outpatient visit.
Behavioral
health providers must ensure that persons subject to nominal
co-payments
are not denied services because of their inability to pay a
co-payment.
Mandatory co-payments for Title XIX/XXI eligible persons
Behavioral health recipients in the Transitional Medical Assistance (TMA) and Title XIX Waiver Group (TWG) programs are subject to mandatory co-payments. Behavioral health providers may deny a service to a TMA or TWG member if the member does not pay the required co-payment.
Co-payments must be collected for TMA program members for the following Title XIX/XXI covered behavioral health services:
- $2.30 per prescription drug; and
- $4.00 per doctor or other outpatient visit.
Co-payments must be collected for TWG program members for the following Title XIX/XXI covered behavioral health services:
- $4.00 per generic prescription and brand name prescription when there is no generic available;
- $10.00 per brand name prescription when there is a generic available;
- $30.00 per visit for nonemergency use of the emergency room; and
- $5.00 per doctor office visit
Other considerations
for Title XIX and Title XXI eligible persons
T/RBHAs or their providers must follow the requirements set forth
in Section
3.5, Third Party Liability and Coordination of Benefits,
and collect third party payments for behavioral health services that are rendered to Medicaid
(Title XIX)/Medicare (Title XVIII) dually eligible persons, as
applicable.
This co-payment covers the costs associated with the Service Package
for Non-Title XIX/XXI Persons determined to have SMI, including
medications, laboratory services, psychiatric assessments and
psychiatric follow up visits.
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3.4
Co-payments
Last Revised: 12/22/2010
Effective Date: 02/01/2011 |
