Kan. Admin. Regs. § 30-5-71

Current through Register Vol. 43, No. 46, November 14, 2024

Section 30-5-71 - Copayment requirements

(a) Except as set forth in subsection (b) of this regulation, program recipients shall be obligated to the provider for the following copayment charges.

(1) The copayment for inpatient general hospital and freestanding psychiatric facility services shall be $48.00 per admission.

(2) The copayment for outpatient general hospital services shall be $1.00 per non-emergency visit in place of a doctor's office visit.

(3) The copayment for other medical services subject to copayment shall be based upon the following ranges:

average medicaid/medikan payment for services maximum copayment chargeable to recipient

$10.00 or less $.50

$10.01 to $25.00 $1.00

$25.01 to $50.00 $2.00

$50.01 or more $3.00

(4) The copayment for other medical services subject to copayment shall be a standard amount based upon the average medicaid payment for the services, calculated on an annual basis. The average medicaid payment shall be calculated by dividing the cost of the services in aggregate by the total number of claims paid in the previous fiscal year. Any change in copayment shall be published in the Kansas Register on or before December fifteenth to be effective January first of each year.

(5) Other medical services subject to copayment shall include the following:

(A) Ambulatory surgical center services, for each date of service;

(B) audiological services, excluding batteries, for each date of service;

(C) community mental health center services, for each individual psychotherapy visit;

(D) durable medical equipment, prosthetics, and orthotics, for each claim, excluding the rental of durable medical equipment;

(E) home health services, for each skilled nursing visit, excluding the rental of durable medical equipment;

(F) non-emergency ambulance services, for each date of service;

(G) optometric or opthalmologist services, for each date of service;

(H) outpatient general hospital surgery, for each date of service;

(I) prescribed drugs, for each new or refilled prescription;

(J) physician or physician extender services, for each office visit;

(K) podiatric services, for each office visit;

(L) psychological services, for each office visit;

(M) dietician services, for each date of service;

(N) dental services, for each date of service;

(O) federally qualified health center services, for each encounter; and

(P) rural health clinic services, for each encounter.

(b) The provisions of subsection (a) shall not apply to services provided as follows:

(1) To residents in nursing facilities, including swing beds, intermediate care facilities for the mentally retarded, nursing facilities for mental health, and to recipients participating in the home-and community-based services programs;

(2) to inpatients in a state psychiatric hospital who meet both of the following conditions:

(A) Have reached the age of 18 but are not yet 22 years of age; or

(B) are at least 65 years of age;

(3) to recipients under age 18;

(4) to recipients in the custody of the juvenile justice authority or secretary of social and rehabilitation services who are at least 18 years old but under age 21 and who are in out-of-home placements;

(5) to recipients enrolled in a medicaid-funded health maintenance organization;

(6) for family planning purposes;

(7) for medical services relating to an injury incurred on the job during a community work experience project;

(8) for services related to pregnancy; and

(9) for emergency services.

Kan. Admin. Regs. § 30-5-71

Authorized by and implementing K.S.A. 39-708c; effective May 1, 1981; amended May 1, 1982; amended, T-83-38, Nov. 23, 1982; amended May 1, 1983; amended, T-84-36, Jan. 1, 1984; amended May 1, 1984; amended May 1, 1986; amended, T-87-20, Sept. 1, 1986; amended May 1, 1987; amended, T-88-59, Dec. 16, 1987; amended May 1, 1988; amended, T-30-12-28-89, Jan. 1, 1990; amended, T-30-2-28-90, Feb. 28, 1990; amended Aug. 1, 1990; amended Dec. 31, 1992; amended Sept. 27, 1993; amended Dec. 30, 1994; amended, T-30-6-28-95, July 1, 1995; amended Sept. 1, 1995; amended July 1, 1997; amended Sept. 3, 2004.