Issue Text of Regulation and Citation Regulation Change Concerns Co-payments for Low Income Patients (Visits and Drugs) 12.03(6)(b) (b) Co-payments and Deductibles. 1. Co-payments and deductibles for Low Income Patients including patients enrolled in MassHealth, Healthy Start, CMSP, or CenterCare are not Eligible. 2. Co-payments and deductibles for Low Income Patients covered by other insurance programs are Eligible to the extent that such charges are related to Permissible not covered by the patient's insurance program. 3. Community Health Center Co-Payments. (a) Visits. Community Health Centers shall charge Low Income Patients a three ($3) dollar co-payment for each visit. This copayment amount shall be assessed in addition to any percentage of the Community Health Center bill that may be charged to a Low Income Patient pursuant to 12.03(6)(c)(3). (b) Prescribed Drugs. 1. Community Health Centers may establish a patient co-pay policy for patients eligible to receive Uncompensated Care Pool assistance. Revenue from this policy shall be limited to covering the aggregate remaining reasonable costs attributable to 15% of the Actual Acquistion Cost plus unreimbursed dispensing costs exceeding the $7.50 dispensing fee. These copayments may not be applied to the deductible of a Low Income Patient determined pursuant to 114.6 CMR 12.03(3)(b) 2. If a patient is determined a Low Income Patient pursuant to 12.03(3)(b), a Community Health Center may charge an amount, in addition to any co-pay amount assessed, equaled to the product of their sliding scale contribution percentage determined pursuant to 114.6 CMR 12.03(6)(c)(3) and 85% of the Actual Acquisition Cost + the $7.50 dispensing fee. = Sliding Scale Percentage * (85% of Actual Acquisition Cost + $7.50). This deductible contribution may be applied to a Low Income Patient s Partial Payment Deductible. 4. Hospital Co-Payments. (a) Hospitals shall charge Low Income Patients a co-payment of five ($5) dollars for each visit or inpatient stay. (b) Hospitals shall charge Low Income Patients a co-payment of five ($5) dollars for each brand name drug dispensed and three ($3) dollars for each Requires co-pays for services provided to Low Income Patients - $3 per community health center visit. See 12.03(6)(b)(3)(a). - $5 per hospital visit or inpatient admission. See 12.03(6)(b)(4)(a). - Hospitals only: $5 for brand name drugs; $3 for generic drugs. See 12.03(6)(b)(4)(b). - CHCs only: may establish a patient co-pay policy for drugs. There is a complicated formula for the amount that can be set by each CHC. See 12.03(b)(3)(b). According to a recent report from the Center on Budget and Policy Priorities, The Effect of Increased Cost-Sharing in Medicaid: A Summary of Research Findings, research has illustrated the dangers that accompany increases in co-payments for low income patients. The CBPP found that higher co-payments tend to cause low-income people to decrease their use of essential as well as other health care, and can trigger the subsequent use of more expensive forms of care such as emergency room care or hospitalization. The new co-payment requirement may result in a decline in hospital and health center visits and a reduction in prescriptions filled by low income patients. As the report points out: reductions in medical care or use of medicines can, in turn, have adverse consequences, including poorer health and greater subsequent use of high-cost services such as emergency rooms. Although these copayment amounts may seem nominal, a recent study published in the July/August 2005 edition of Health Affairs, entitled The Impact of Increased Cost Sharing on Medicaid Enrollees, suggests that even slight increases in copayments can result in reduced access to and use of care. In this way, the amendment requiring low income patients to pay co-payments on visits and prescriptions may have devastating consequences for these individuals. Furthermore, high cost-sharing arrangements have a disproportionate effect on people with serious and/or chronic illnesses or disabilities. Patients with these conditions must visit the hospital more often for treatment, and mandatory co-payments require them to pay for each hospital admission and each medication they receive. Many patients cannot afford these co-pays; once again, this can undermine patients ability to get regular and preventative This resource is being made available to you by Community Partners. www.compartners.org - 8/18/2005-1
generic drug dispensed through outpatient pharmacies. care and necessary medications and can lead to costly ER and hospital use. Low Income Patient Determination Restrictions 12.03(3)(c)(1) and (2) (c) Exclusions. An individual may not be determined to be a Low Income Patient if he or she: 1. has been terminated from MassHealth due to failure to pay a MassHealth premium or deductible; or 2. is eligible for Premium Assistance for Employer Sponsored Insurance, but fails to enroll or apply for ESI. An individual may not be determined a Low Income Patient if he or she (a) was terminated from MassHealth for failure to pay premiums or deductibles or (b) is eligible for premium assistance for employer sponsored insurance but fails to enroll or apply for employer sponsored insurance. See 12.03(3)(c)(1) and (2). In 2003, MassHealth began imposing new premiums on many families with incomes as low as 114% of the poverty level ($10,900 for an individual). These premiums have resulted in many people losing their coverage for failure to make a monthly payment on time. Hospitals can bill these patients despite their inability to pay. Retroactive Eligibility Period 12.03(5)(a) (5) Eligibility Period. (a) For individuals determined to be Low Income Patients, providers may submit claims for Permissible for the period beginning sixty (60) days prior to (1) the date that MassHealth eligibility begins as determined by the Office of Medicaid, or (2) if the Provider is processing the application pursuant to 114.6 CMR 12.03(4)(b), the date the Provider determines that the applicant is a Low Income Patient. Retroactive eligibility period for services provided to Low income patients is 60 days prior to the date of eligibility requirement (change from 6 months). See 12.03(5)(a). The new regulations allow hospitals to bill a Pool-eligible patient if the patient applies more than 60 days after a service is provided. Patients who do not discover that they are Pool-eligible until 60 days after they have received services may be liable for substantial charges. Pooleligible patients, therefore, are vulnerable to incurring significant hospital charges which could result in medical debt. Time Limit on Submission of Claims 12.03(6)(e) (e) Time Limitation on Submission of Claims. Providers must submit claims for Eligible no later than ninety (90) days after the provision of said services. Requires that claims for eligible services be submitted within 90 days of the date of service (previously no explicit time limitation). See 12.03(6)(e). Elimination of Eligible 12.03(6)(a)(2)(a) (6) Claims for Eligible. (a) Claims for Eligible to Low Income Patients determined pursuant to 114.6 CMR 12.03(3)(a) (Income up to 200% FPL) 2. MassHealth enrolled/low Income Patient. a. A Provider may not submit claims for services provided to individuals enrolled in MassHealth Standard, Basic, Essential, CommonHealth, Family Assistance Direct Coverage, Family Assistance Premium Assistance, Eliminates payments for services except medically necessary dental services provided to individuals enrolled in MassHealth. See 12.03(6)(a)(2)(a). This resource is being made available to you by Community Partners. www.compartners.org - 8/18/2005-2
Buy In, and any other full MassHealth benefit category as determined by the Division except that a Provider may submit claims for medically necessary dental services. Eligible Payments Limited to Covered by MassHealth Standard 12.03(6)(a)(2)(b) (6) Claims for Eligible. (a) Claims for Eligible to Low Income Patients determined pursuant to 114.6 CMR 12.03(3)(a) (Income up to 200% FPL) 2. MassHealth enrolled/low Income Patient. b. A Provider may submit claims for Eligible not covered by Center Care, Healthy Start, EAEDC, CMSP, and MassHealth Limited only for those services that would be covered by MassHealth Standard, except that a Provider may submit claims for medically necessary dental services. Limits payments for services to individuals enrolled in EAEDC, CMSP, MassHealth Limited, Healthy Start and the Center Program (only for those services that would be covered by MassHealth Standard) and medically necessary dental services. See 12.03(6)(a)(2)(b). Prescription Drugs Must Be on MassHealth Approved Drug List 12.03(2)(c)(3) and (4) Limits hospital outpatient claims (c) Pharmacy. for prescription drugs to drugs on 3. Hospital Outpatient Claims. Hospitals may submit claims only for the MassHealth approved drug prescribed drugs listed on the MassHealth approved drug list. Hospitals may list; no exception policy if drug is not submit claims for drugs listed on the MassHealth excluded drug list or for more expensive than one on the drugs that require Prior Approval by MassHealth, unless the drug is clinically list. See 12.03(2)(c)(3). Limits equivalent and is less expensive than the drug on the MassHealth drug list. CHC claims for drugs to drugs on 4. Community Health Center 340B Pharmacy Claims. Community Health the MassHealth approved list or Centers may submit claims only for prescribed drugs that are either listed on those that have been approved by the MassHealth approved drug list or have been approved by the provider s the provider s internal Pharmacy internal Pharmacy and Therapeutics committee. and Therapeutics committee. See 12.03(2)(c)(4). The exceptions policy available to MassHealth patients, which allows a doctor to prescribe a drug not on the approved list, will not be available to patients using hospital pharmacies. Payments for ER Bad Debt 12.04(2)(a) 12.04: Emergency Bad Debt (2) Allowable Claims. Limits payments for ER Bad Debt to services provided in the first 24 hours, unless the hospital obtains a This resource is being made available to you by Community Partners. www.compartners.org - 8/18/2005-3
Limited to (a) Hospital may submit a claim for Emergency Bad Debt charges resulting from the emergency visit, including any ancillary services, incurred during the first twenty-four (24) hours. The hospital may submit a Provided in claim for services provided after the 24 hour period only if an application is First 24 Hours submitted and the patient is determined to be a Low Income Patient. completed application and the individual is determined to be a Low Income Patient. See 12.04(2)(a). Billing for Rendered Prior to Free Care Eligibility Determination 12.08(3)(b) and (c) (b) Low Income Patients determined pursuant to 114.6 CMR 12.03(3)(a) are exempt from Collection Action for any services rendered by a provider receiving payments from the Uncompensated Care Pool for services received during the period for which they have been determined Low Income Patients, except for co-payments and deductibles that are not Eligible under 114.6 CMR 12.03(7)(b). Providers may continue to bill Low Income Patients for services rendered prior to their determination as Low Income Patients. (c) Low Income Patients determined pursuant to 114.6 CMR 12.03(3)(b) are exempt from Collection Action for the portion of his or her Provider bill that exceeds the Deductible, except Collection Actions for co-payments and deductibles that are not Eligible under 114.6 CMR 12.03(7)(b). Providers may continue to bill Low Income Patients for services rendered prior to their determination as Low Income Patients. [emphasis added] Allows providers to bill Low Income Patients for services rendered prior to their eligibility period. See 12.08(3)(b) and (c). Lien Prohibitions Applicable to Low Income Patients Only 12.08(1)(b) (b) A Provider or agent thereof shall not seek legal execution against the personal residence or motor vehicle of a Low Income Patient determined pursuant to 114.6 CMR 12.03(3)(a) or 114.6 CMR 12.03(3)(b) without the express approval of the Provider s Board of Trustees. All approvals by the Board must be made on an individual case basis. Limits scope of home and auto lien prohibitions to Low Income Patients. See 12.08(1)(b). The existing regulation protects consumers by requiring careful deliberation prior to the execution of a lien against a patient s car or home as a consequence of that individual s failure to pay a bill. Last summer, DHCFP proposed new Pool regulations that included the elimination of this protection. In response to a large outcry from consumers, DHCFP subsequently reversed their decision and reinstated the protection that requires an This resource is being made available to you by Community Partners. www.compartners.org - 8/18/2005-4
individual vote of a hospital or community health center Board of Trustees prior to the execution of a lien against the home or car of a patient. Once again, DHCFP is trying to chip away at this crucial protection by eliminating the prohibition on the execution of a lien for patients who do not qualify as Low Income Patients, as defined in the regulations. The execution of liens against the homes and cars of patients is a form of collection action that may increase the incidence of bankruptcy and medical debt in the Commonwealth. This resource is being made available to you by Community Partners. www.compartners.org - 8/18/2005-5