A: Copayments only apply to adults (age 19 and over) who receive OHP Plus (BMH) or OHP with Limited Drug (BMM/BMD) benefits. Some adults are exempt from copayments. Copayments are not charged to adults who are:

• On the OHP Standard benefit package
• Youths in foster care through age 20
• Pregnant
• Receive services under a home- and community-based waiver: These services include most in-home services or services in an adult foster home or other home or facility paid by Seniors and People with Disabilities
• Inpatients in a hospital, nursing facility, or Intermediate Care Facility for the Mentally Retarded (ICF/MR)
• American Indian/Alaska Native clients who are members of a federally recognized Indian tribe or receive services through a tribal clinic.

A: No. Children under age 19 do not have copayments.

A: Clients with both Medicare and Medicaid coverage have copayments for the applicable Medicaid services. Providers cannot charge the client for their TPL copayments, coinsurance or deductibles if they are billing DMAP for what TPL did not pay.

 

Providers should only collect the DMAP copayment when the amount TPL paid for the service, plus the DMAP copayment amount, is less than the amount DMAP would normally pay for the service. This means the amount collected may be less than DMAP's normal copayment, depending on how much TPL paid. See examples in question 4.

A: DMAP charges a $3 copayment for certain types of outpatient services, and a $1 or $3 copayment for certain prescription drugs. The copayment amount depends on the type of prescription filled:

• $1 for non-preferred Preferred 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;
• $3 for all other non-PDL brand-name drugs.

When a client has other health coverage resources (third-party liability, or TPL, which includes Medicare), the copayment amount depends on how much TPL has paid for the service and the amount DMAP would normally pay for the service. For example, with a service requiring a $3 DMAP copayment:

• If DMAP would pay less than $3 after TPL pays, then a less-than-$3 copayment applies. If DMAP would only pay $1 after TPL pays, then DMAP would take $1 (not $3) from what it pays to the provider. The provider may collect a $1 copayment from the client.
• If DMAP would pay nothing after TPL pays, then no copayment applies. DMAP takes no copayment amount from the provider. The provider may not collect any copayment for the client.
• If DMAP would pay $3 or more after TPL pays, then the $3 copayment applies.

A: Table 120-1230-1 in DMAP's General Rules administrative rulebook lists the provider types and services subject to OHP Plus copayments. These include:

• Some prescription drugs
• Office visits
• Home visits
• Hospital emergency room services when there is not an emergency
• Outpatient hospital services
• Outpatient surgery
• Outpatient treatment for chemical dependency
• Outpatient treatment for mental health
• Occupational therapy
• Physical therapy
• Speech therapy
• Restorative dental work
• Vision exams

A: Copayments are not charged for:

• Emergency services
• X-ray and lab services
• Durable medical equipment and supplies
• Routine immunizations
• Drugs ordered through our home-delivery pharmacy program 
• Family planning services and supplies
• Diagnostic and preventive dental services – These include oral examinations to identify changes in your health or dental status. They also include routine cleanings, x-rays, lab work and tests needed to make a diagnosis or treatment decision.
• For clients enrolled in a managed care plan, the services and drugs covered by that plan (until Jan. 1, 2011. On and after Jan. 1, copayments will also apply to managed care plan services, though most plans have chosen not to charge copayments).
• For clients with Medicare and other health coverage resources (third-party liability, or TPL), any services and drugs paid by the TPL where the TPL's payment is as much or more than what DMAP would normally pay for the service/drug.

A: Providers, The Provider Web Portal eligibility verification request and Automated Voice Response (AVR) Recipient Eligibility response provide copayment amounts for OHP Plus (BMM, BMD, BMH, BMP) services. Copayment amounts ($1 or $3) will only display for clients responsible for copayment. If a client is exempt from copayment, the copayment will read $0.00 for all services.
 
Clients can look at the "Copays?" field on page 2 of their coverage letter to see if they are responsible for copayments (when one applies). If they do, this field will contain a "Yes." If they do not, the field will contain a "No."

A: Providers The Provider Web Portal eligibility verification request and Automated Voice Response (AVR) Recipient Eligibility inquiry provide copayment amounts for OHP Plus (BMM, BMD, BMH, BMP) services. If a service requires copayment, the service will list the amount to pay ($1, or $3). Services that do not require copayment will list $0. Table 120-1230-1 in General Rules also lists the services that require copayment and the amounts that apply.
 
Clients can refer to their OHP Client Handbook for general descriptions of services requiring copayment.

A: Providers may charge the applicable copayment per visit per day. Pharmacies may charge for each fill.

A: The health care provider or pharmacy collects the copayment. They may collect it at the time of service or during the regular billing cycle.

A: The client will still be able to receive the health care service or drug; however, the provider can choose whether to collect it at a later time.
 
Clients who do not pay the copayment should see the provider's billing clerk to discuss the situation and options. Only the provider can waive the copayment. However, the provider may also turn the debt over to a collection agency.

A: No. Providers cannot refuse service solely because a client does not pay a copayment. This does not relieve the client of the responsibility to pay and it does not stop the provider from attempting to collect the copayments. The copayment is a legal debt, and is due and payable to the provider.

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

A: We compute the total OHP copayment due for services billed. 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.

A: Clients may ask for a hearing if they think a provider made a mistake in the amount charged. Clients may also ask for a hearing if they think DHS made a mistake in their eligibility that has caused them to be subject to copayment requirements when they should not be subject.