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Ohio Laws and Rules
(A) Beginning January 1, 2004 consumers eligible for the medicaid program (except for consumers who are members of a medicaid managed health care program) as defined in paragraph (C) of this rule, and consumers eligible for the disability medical assistance program as defined in rule 5101:3-23-01 of the Administrative Code, will pay a three dollar co-payment for prescription medications not found in appendix A of rule 5101:3-9-12 of the Administrative Code. This co-payment is required on prescription medications not found in appendix A of rule 5101:3-9-12 of the Administrative Code which are prior authorized on or after January 1, 2004. Prescriptions for medications prior authorized prior to January 1, 2004 which have unfilled periods extending beyond the January 1, 2004 effective date are not subject to co-payment.
(B) Beginning January 1, 2006, consumers eligible for the medicaid program (except for consumers who are members of a medicaid managed health care program) as defined in paragraph (C) of this rule, and consumers eligible for the disability medical assistance program as defined in rule 5101:3-23-01 of the Administrative Code, will pay a two dollar co-payment for selected trade name drugs as indicated in appendix A of rule 5101:3-9-12 of the Administrative Code.
(C) Consumers subject to co-payment for medications are identified as adults eligible under the medicaid and disability medical assistance programs, age twenty-one and over. Co-payment requirements as contained in this rule are also subject to the provisions of rules 5101:3-1-09 and 5101:3-1-60 of the Administrative Code.
(D) Exclusions to the co-payment requirement for prescription medications as described in paragraphs (A) and (B) of this rule are described in rule 5101:3-1-09 of the Administrative Code and as follows:
(1) Children. Prescriptions for medications given to eligible consumers under twenty-one years of age, are excluded from co-payment. The department identifies those eligible consumers who are under age twenty-one through the department’s recipient master file (RMF) and excludes them from co-payment at the time the medication is dispensed. In the event that there is a dispute concerning the consumer’s age, and the RMF and the client registry information system-enhanced (CRIS-E) are found to be in error, the consumer may be refunded any paid co-payment in accordance with rule 5101:3-1-60.2 of the Administrative Code.
(2) Pregnant women. Prescriptions for medications given to eligible pregnant women are excluded from co-payment during the woman’s pregnancy and the post-partum period. The post-partum period is the immediate post-partum period which begins on the last day of pregnancy and extends through the end of the month in which the sixty day period following termination of pregnancy ends. Pregnant women may declare their pregnancy or their sixty day post-partum period at the time their prescription medication is dispensed and they will not be charged a co-payment for their medication.
(3) Institutionalized individuals. Prescriptions for medication given to any eligible consumer who is a resident in a long term care facility are excluded from co-payment. The department identifies residents of long term care facilities (those living in nursing facilities (NFs) and intermediate care facilities for the mentally retarded (ICFs-MR)) through the department’s RMF and excludes them from co-payment at the time the medication is dispensed.
(4) Hospice care. Prescriptions for medication given to any eligible consumer who is receiving hospice care are excluded from co-payment. The department identifies consumers who are receiving hospice care in accordance with paragraph (C) of rule 5101:3-56-03 of the Administrative Code.
(5) Family planning. Prescriptions for medication given to an eligible consumer of child-bearing age for the purposes of family planning are excluded from co-payment. The department identifies medications that qualify as family planning services in appendix A of rule 5101:3-9-12 of the Administrative Code and the department’s pharmacy point-of-sale vendor will exempt these medications from co-payment.
(6) Emergency services. Medications administered to an eligible consumer during emergency care provided in a hospital, clinic, office, or other facility that is equipped to furnish the required care, after the sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that the absence of immediate medical attention could reasonably be expected to result in placing the patient’s health in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of any bodily part or organ, are not subject to co-payment.
(7) Medications administered to an eligible consumer during a medical encounter provided in a hospital, clinic, office, or other facility, when the medication is a part of the evaluation and treatment of the condition, are not subject to co-payment.
(E) Prescriptions for medication given to an eligible consumer during a medical encounter provided in the emergency department or other hospital setting, clinic, office, or other facility as a result of the evaluation and treatment of the condition, to be filled at a pharmacy located at the facility or at an outside location, are subject to co-payment under the conditions described in paragraphs (A), (B), and (C) of this rule.
(F) No provider of pharmacy services may deny services, to a consumer who is eligible for the services, on account of the consumer’s inability to pay the co-payment. Consumers who are unable to pay their co-payment may declare their inability to pay and obtain their medication without paying their cost sharing amount; they remain, however, liable for the co-payment. The provider may bill the consumer for the co-payment or may request payment for a prior uncollected co-payment, however, the consumer may not be denied subsequent services based on their failure to pay an outstanding co-payment except as described in paragraph (B)(5) of rule 5101:3-1-09 of the Administrative Code.
(G) In accordance with rule 5101:3-1-08 of the Administrative Code, providers are expected to take reasonable measures to ascertain any third-party resource available to the consumer and to file a claim with that third party. The department shall reimburse the difference between the third party payment and the medicaid calculated allowable minus the three dollar co-payment as defined in paragraph (A) of this rule.
For Appendix — see Agency
Effective: 01/01/2006
R.C. 119.032 review dates: 08/19/2005 and 01/01/2011
Promulgated Under: 119.03
Statutory Authority: 5111.02, 5111.0112
Rule Amplifies: 5111.01, 5111.02, 5111.0112
Prior Effective Dates: 1/1/04