(a) Every participating health plan shall require copayments for benefits provided to subscribers, except as provided under federal law to subscribers who are American Indians or Alaska Natives receiving services at an Indian Health Service Facility, subject to the following:
(1) In any benefit year that the applicant has incurred $250 in health benefit copayments for services received by subscribers who live in one household and for whom the applicant applied to the program, the applicant shall be deemed to have met the copayment maximum.
(2) No deductibles shall be charged to subscribers for health benefits.
(3) The following specific copayments shall apply except that subscribers with household income at or below 150% of the Federal Poverty Level shall pay a $5 copayment when a copayment is required.
(A) Inpatient Facility Services provided in a licensed hospital, skilled nursing facility, hospice, or mental health facility: No copayment.
(B) Inpatient Professional Services provided in a licensed hospital, skilled nursing facility, hospice, or mental health facility: No copayment.
(C) Facility Services on an Outpatient Basis for Subscribers: No copayment, except for a $15 copayment per visit for Emergency Health Care Services. The emergency health care services copayment is waived if the subscriber is hospitalized.
(D) Outpatient Professional Services: $10 copayment per office or home visit. No copayment for surgery or anesthesia; radiation, chemotherapy, or dialysis treatments.
(E) Outpatient Mental Health: $10 copayment per visit.
(F) Home Health Care: No copayment except for $10 per visit for physical, occupational, and speech therapy visits performed in the home.
(G) Alcohol and Drug Abuse Services: No copayment for inpatient services. $10 per visit for outpatient services.
(H) Hospice: No copayment for any services provided under this benefit.
(I) Transplants: No copayment for any services provided under this benefit.
(J) Physical, Occupational, and Speech Therapy: No copayment for therapy performed on an inpatient basis. $10 copayment per visit for therapy performed in the home or other outpatient setting.
(K) Biofeedback, Acupuncture, and Chiropractic Visits, when offered at the participating health plan's option: $10 copayment per visit. For subscriber parents, copayment of $10 for each biofeedback visit for mental health.
(L) Diagnostic Laboratory Services, diagnostic and therapeutic radiological services, and other diagnostic services; durable medical equipment, prosthetics and orthotics; blood and blood products; medical transportation services: No copayment.
(M) Prescription Drugs:
1. No copayment for prescription drugs provided in an inpatient setting, or for drugs administered in the doctor's office or in an outpatient facility setting during the subscriber's stay at the facility. For subscriber children, no copayment for FDA approved contraceptive drugs.
2. For subscribers with household income at or below 150% of the Federal Poverty Level: a $5 copayment per prescription for up to 30 day supply for brand name or generic drugs, including tobacco use cessation drugs. $5 copayment per 90 day supply of maintenance drugs purchased either through a participating health plan's participating pharmacies or through its mail order program.
3. For subscribers with household income greater than 150% of the Federal Poverty Level:
a. $10 copayment per prescription for up to 30 day supply for generic drugs, including tobacco use cessation drugs. $10 copayment per 90 day supply of generic maintenance drugs purchased either through a participating health plan's participating pharmacies or through its mail order program.
b. $15 copayment per prescription for up to 30 day supply for brand name drugs, including tobacco use cessation drugs. $10 copayment if no generic equivalent is available for the drug prescribed or if the use of a brand name drug is medically necessary.
c. $15 copayment per 90 day supply of brand name maintenance drugs purchased either through a participating health plan's participating pharmacies or through its mail order program. $10 copayment per 90 day supply of brand name maintenance drugs purchased either through a participating health plan's participating pharmacies or through its mail order program if no generic equivalent is available for the drug prescribed or if the use of a brand name drug is medically necessary.
4. Maintenance drugs are drugs that are prescribed for 60 days or longer and are usually prescribed for chronic conditions such as arthritis, heart disease, diabetes or hypertension.
5. For subscriber parents, $5 copayment for 90 day supply of FDA approved oral and injectable contraceptives and contraceptive devices. No refund if the medication is removed. (Represents the copayment for oral contraceptives at $5 copayment for each 90-day supply for the approximate number of months the medication will be effective).
(4) Preventive services
(A) Periodic Health Exams; No copayment for subscriber children; $5 copayment per exam for subscriber parents.
(B) A variety of voluntary family planning services; including contraceptive services: No copayment for subscriber children. For subscriber parents $5 copayment per office visit and $5 copayment per device.
(C) Maternity Services: No copayment.
(D) Vision Services: No copayment for subscriber children. For subscriber parents, $5 copayment per visit.
Eye refraction to determine the need for corrective lenses -- No copayment for subscriber children. For subscriber parents, optional with $5 copayment per exam and limited to one visit per year.
(E) Hearing Services and Hearing Aids: No copayment.
(F) Immunizations; No copayment for subscriber children. $5 copayment per visit for subscriber parent.
(G) Sexually Transmitted Disease Testing: No copayment for subscriber children. $5 copayment for subscriber parents.
(H) Cytology Examinations on a reasonable periodic basis: No copayment for subscriber children. For subscriber parents, $5 copayment per exam.
(I) Health Education Services: No copayment for subscriber children.
For subscriber parents, up to $5 copayment for diabetes outpatient self-management training, education, and medical nutrition therapy services. Charge may vary for other education services.
(J) Well Baby Care, Health Examinations and Other Office Visits for subscribers 24 months of age and under: No copayment.
(K) Gynecological Examinations and Cancer Screening: No copayment.
(5) No copayments shall apply if the applicant has submitted acceptable documentation as described in Subsection 2699.6600(c)(1)(GG) that the applicant or the subscriber is American Indian or Alaska Native.
(6) Reconstructive Surgery: No copayment
Credits
Note: Authority cited: Sections 12693.21, 12693.22 and 12693.755, Insurance Code. Reference: Sections 12693.21, 12693.22, 12693.615 and 12693.755, Insurance Code.
History
1. New section filed 2-20-98 as an emergency; operative 2-20-98 (Register 98, No. 8). A Certificate of Compliance must be transmitted to OAL by 6-22-98 or emergency language will be repealed by operation of law on the following day.
2. Certificate of Compliance as to 2-20-98 order transmitted to OAL 6-5-98 and filed 7-15-98 (Register 98, No. 29).
3. New subsection (a)(6) filed 3-21-2000 as an emergency; operative 3-21-2000 (Register 2000, No. 12). A Certificate of Compliance must be transmitted to OAL by 7-19-2000 or emergency language will be repealed by operation of law on the following day.
4. Certificate of Compliance as to 3-21-2000 order transmitted to OAL 6-23-2000 and filed 7-17-2000 (Register 2000, No. 29).
5. Amendment of section and Note filed 4-29-2002 as an emergency; operative 4-29-2002 (Register 2002, No. 18). Pursuant to Chapter 946, Statutes of 2000, section 2, a Certificate of Compliance must be transmitted to OAL by 10-28-2002 or emergency language will be repealed by operation of law on the following day.
6. Certificate of Compliance as to 4-29-2002 order transmitted to OAL 10-28-2002 and filed 12-12-2002 (Register 2002, No. 50).
7. Amendment of subsection (a)(6) filed 7-31-2003 as an emergency; operative 7-31-2003 (Register 2003, No. 31). A Certificate of Compliance must be transmitted to OAL by 1-27-2004 or emergency language will be repealed by operation of law on the following day.
8. Certificate of Compliance as to 7-31-2003 order transmitted to OAL 11-17-2003 and filed 12-30-2003 (Register 2004, No. 1).
9. Amendment of subsection (a)(6) filed 7-1-2004 as an emergency; operative 7-1-2004 (Register 2004, No. 27). Pursuant to Section 80, A.B. 1762 (Chapter 230, Stats. 2003) a Certificate of Compliance must be transmitted to OAL by 12-28-2004 or emergency language will be repealed by operation of law on the following day.
10. Certificate of Compliance as to 7-1-2004 order transmitted to OAL 11-24-2004 and filed 1-7-2005 (Register 2005, No. 1).
12. Amendment of section and Note filed 10-29-2009; operative 11-1-2009 pursuant to Government Code section 11346.1(d) (Register 2009, No. 44). A Certificate of Compliance must be transmitted to OAL by 4-30-2010 or emergency action will be repealed by operation of law on the following day. This regulatory action is deemed to meet the emergency standard and is exempt from OAL review pursuant to Insurance Code section 12693.22.
13. Certificate of Compliance as to 10-29-2009 order transmitted to OAL 4-27-2010 and filed 6-9-2010 (Register 2010, No. 24).
This database is current through 5/10/24 Register 2024, No. 19.
