Provider FAQs: Copayments

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• Who can clients call if they are confused about their copayment requirements?
• Which of my patients are subject to copayments? Are children subject to these copayments?
• Which providers and services are subject to copayments?
• How do you account for OHP copayments in your provider reimbursement system?
• Are OHP copayments charged per procedure, per visit, per day, per provider, etc.?
• Who will collect the OHP copayments? When will they be collected?
• What happens if my patient does not pay the required OHP copayment?
• Can I refuse to serve OHP patients for not paying their copayments?
• Will my patients have appeal rights if I refuse to give them service because they did not pay the OHP copayment? 

Q. Who can clients call if they are confused about their copayment requirements?

A. Clients who need help understanding their copayment requirements can call our Client Services Unit, (1-800) 273-0557. They can also call their caseworker.

Q. Which of my patients are subject to copayments? Are children subject to these copayments?

A. Children under age 19 do not have copayments.

The OHP Standard benefit package does not have copayments.
 
The OHP Plus and OHP with Limited Drug benefit packages do not have copayments for specific outpatient services and prescription drugs for some adults. Automated Voice Response or the Provider Web Portal provide the benefit package and the copayment information for each OHP client.

Some adults are exempt from copayments. Copayments are not charged to adults who are:

• Pregnant
• Getting services under the Home and Community-Based Waiver
• Getting services under the Developmental Disability Waiver
• Inpatients of a hospital or nursing facility
• American Indians or Alaska Natives who are members of federally recognized Indian tribes
• Eligible for benefits through Indian Health Services

In addition, services or drugs covered by a Prepaid Health Plan for an enrolled client are not subject to copayments.

Q. Which providers and services are subject to copayments??

A. This table lists the services generally covered under each OHP benefit package, and any copayments that apply for OHP Plus and OHP with Limited Drug benefit packages. (The OHP Standard benefit package does not have copayments.) Table 120-1230-1 in DMAP's General Rules administrative rulebook also lists the provider types and services subject to OHP Plus copayments.
 
A copayment for an outpatient service will be $3 per visit per day. For prescription drugs, it will be $1 for non-preferred Plan Drug List (PDL) drugs and non-PDL generics costing more than $10; no copayment for preferred PDL generics, non-PDL generics costing less than $10, and preferred PDL brands; and $3 for all other non-PDL brand-name drugs. However, providers do not charge copayments for services and drugs covered by a Prepaid Health Plan for an enrolled client.
 

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Q. How do you account for OHP copayments in your provider reimbursement system?

A. We compute the total OHP copayment due for services you render. (The OHP Standard benefit package does not have copayments.) We pay the total allowable amount, minus the correct copayments and any third-party payments. Our explanation of benefits (EOB) identifies copayment deductions. Please read our provider rules and draft rules. You should also review our rules for submitting claims for payment.

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Q. Are OHP copayments charged per procedure, per visit, per day, per provider, etc.?

A. You may charge up to one copayment per visit per day.

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Q. Who will collect the OHP copayments? When will they be collected?

A. You will collect the copayment. You may collect it at the time of service or during the regular billing cycle.

The OHP Standard benefit package does not have copayments.

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Q. What happens if my patient does not pay the required OHP copayment?

A. If your patient does not pay the copayment, he or she should see your billing clerk. They can discuss the situation and options. You might decide to set a repayment schedule, waive the copayment, or turn the account over to a collection agency.
 
The OHP Standard benefit package does not have copayments.

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Q. Can I refuse to serve OHP patients for not paying their copayments?

A. You cannot deny these Medicaid patients services only because they do not pay a copayment.
 
The OHP Standard benefit package does not have copayments.

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Q. Will my patients have appeal rights if I refuse to give them services because they did not pay the OHP copayment?

A. No. Your patient may, however, ask for a hearing if he or she thinks you made a mistake in the amount charged. Your patient may also ask for a hearing if he or she thinks DHS made a mistake in his or her eligibility.

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