5101:3-25-12 Children's buy-in program: member cost-sharing obligations.

(A) ODJFS will implement a cost-sharing program for the CBI program. Member cost-sharing amounts for the CBI program are listed in the appendix to this rule and are subject to change by ODJFS.

(B) MCPs must:

(1) Specify in provider subcontracts per paragraph (D) of rule 5101:3-25-05 of the Administrative Code under what circumstances member cost-sharing amounts can be requested;

(2) Assure that the member is not billed for any difference between the MCP’s payment and the provider’s charge or request that the member share in the cost through cost-sharing or other similar charge, other than the member cost-sharing amounts set forth in this rule;

(3) Assure that member cost-sharing amounts are requested by providers in accordance with this rule; and

(4) Assure that no provider or drug manufacturer, including the manufacturer’s representative, employee, independent contractor, or agent, shall pay any cost-sharing amounts on behalf of the member.

(C) A provider may refuse to provide a service to an individual if the cost-sharing amounts permitted by this rule are not paid.

Appendix 1 Children’s Buy-In Program Summary of Cost Sharing Requirements

Cost Sharing Description Cost Sharing Detail

Deductible 1,2 $1,600

Deductible and Coinsurance Maximum 2 $2,600

Lifetime Benefit Maximum Unlimited

Inpatient Hospital 20% Coinsurance

Outpatient Hospital 20% Coinsurance

Emergency Room $75 Co-pay and 20% Coinsurance (Co-pay waived if admitted)

Urgent Care $25 Co-pay

Physical / Occupational / Speech Therapy 20 Visit Limit Per Therapy. $15 Co-pay Outpatient / 20% Coinsurance Inpatient

Office Visits / Consults $15 Co-pay

Pharmacy (Generic / Preferred Brand / Non-Preferred Brand) $10/$22/$44

Mental Health/Substance Abuse $15 Co-pay Outpatient / 20% Coinsurance Inpatient

Ancillary Services (DME, Supplies, Home Health, Ambulance, Miscellaneous Services) 20% Coinsurance

All Other Covered Benefits Not Specifically Listed 20% Coinsurance

Notes:

1. Deductible applies to all services except Office Visits/Consults and Pharmacy.

2. Co-payments do not accrue to the deductible amount or the deductible and coinsurance maximum amount. Co-payments are still required after the deductible and coinsurance maximum amount is satisfied.

Replaces: 5101:3-25-12

Effective: 06/30/2008

R.C. 119.032 review dates: 06/30/2013

Promulgated Under: 119.03

Statutory Authority: 5101.5215

Rule Amplifies: 5101.5211, 5101.5212, 5101.5213, 5101.5214, 5101.5215, 5101.5216

Prior Effective Dates: 4/1/08