Print Friendly HOUSE BILL NO. 321 – Medical assistance, pharmacy copay
HOUSE BILL NO. 321
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H0321.....................................................by WAYS AND MEANS
MEDICAL ASSISTANCE - Adds to and amends existing law to provide that
certain medical assistance recipients, their spouses or parents pay
copayments for prescription and over-the-counter drugs; to provide services
for which no copayments shall be charged; to provide the maximum amount of
a copayment; to provide for the inability to make a required copayment; to
provide for waivers; to provide for rules; and to revise the medicaid
pharmacy reimbursement rates.
03/11 House intro - 1st rdg - to printing
03/14 Rpt prt - to Health/Wel
]]]] LEGISLATURE OF THE STATE OF IDAHO ]]]]
Fifty-eighth Legislature First Regular Session - 2005
IN THE HOUSE OF REPRESENTATIVES
HOUSE BILL NO. 321
BY WAYS AND MEANS COMMITTEE
1 AN ACT
2 RELATING TO STATE MEDICAL ASSISTANCE; AMENDING CHAPTER 2, TITLE 56, IDAHO
3 CODE, BY THE ADDITION OF A NEW SECTION 56-209q, IDAHO CODE, TO PROVIDE
4 THAT CERTAIN MEDICAL ASSISTANCE RECIPIENTS, THEIR SPOUSES, OR PARENTS PAY
5 COPAYMENTS FOR PRESCRIPTION AND OVER-THE-COUNTER DRUGS, TO PROVIDE SER-
6 VICES FOR WHICH NO COPAYMENTS SHALL BE CHARGED, TO PROVIDE THE MAXIMUM
7 AMOUNT OF A COPAYMENT, TO PROVIDE FOR THE INABILITY TO MAKE REQUIRED
8 COPAYMENT, TO PROVIDE FOR WAIVERS AND TO PROVIDE FOR RULES; AND AMENDING
9 SECTION 56-209g, IDAHO CODE, TO REVISE THE MEDICAID PHARMACY REIMBURSEMENT
11 Be It Enacted by the Legislature of the State of Idaho:
12 SECTION 1. That Chapter 2, Title 56, Idaho Code, be, and the same is
13 hereby amended by the addition thereto of a NEW SECTION, to be known and des-
14 ignated as Section 56-209q, Idaho Code, and to read as follows:
15 56-209q. MEDICAL ASSISTANCE RECIPIENTS TO PAY ALLOWABLE NOMINAL
16 COPAYMENTS. (1) The department of health and welfare shall institute nominal
17 copayments or similar charges as provided in subsection (3) of this section to
18 be paid by medical assistance recipients, their spouses, or parents, under the
19 provisions of section 1916 of title XIX of the federal social security act, 42
20 U.S.C. section 1396o.
21 (2) Copayments or similar charges shall not be imposed for the following
23 (a) All services provided to children under eighteen (18) years of age;
24 (b) All services furnished to pregnant women, if the services relate to
25 the pregnancy or to any other medical condition which may complicate the
27 (c) Emergency services including hospital, clinic, office, or other
28 facility services which are necessary to prevent the death or serious
29 impairment of the individual;
30 (d) Services furnished to institutionalized individuals if the individual
31 is required, as a condition of receiving services, to spend all but a min-
32 imal amount of income for personal needs;
33 (e) Services furnished for an individual who is receiving hospice care as
34 defined under section 1905 of title XIX of the federal social security
35 act, 42 U.S.C section 1396d(o); and
36 (f) Other services excluded from cost sharing by federal law or regula-
38 (3) A standard nominal copayment per service, not to exceed amounts
39 allowable under section 1916 of title XIX of the federal social security act,
40 42 U.S.C. section 1396o, shall be collected by the provider and charged for
41 prescription and over-the-counter drugs. Any copayment for a prescription or
42 over-the-counter drug shall not exceed one dollar ($1.00).
43 (4) No provider participating in the medical assistance program shall
1 deny services to any eligible recipient due to the inability of a recipient to
2 make the required copayment. This provision shall not excuse the recipient
3 from liability for payment of the charge.
4 (5) This section shall not limit copayments by eligible populations if
5 pilot programs or waivers are permitted by the federal government.
6 (6) The director of the department of health and welfare shall promulgate
7 rules to implement the provisions of this section.
8 SECTION 2. That Section 56-209g, Idaho Code, be, and the same is hereby
9 amended to read as follows:
10 56-209g. PHARMACY REIMBURSEMENT. Medicaid pharmacy reimbursement levels
11 are a combination of the cost of the drug and a dispensing fee which includes
12 such pharmaceutical care services as counseling, obtaining a patient history,
13 documentation, and dispensing. From and after January 1, 1995, through June
14 30, 1998 July 1, 2005, it shall be the policy of the state of Idaho that there
15 be no a one dollar ($1.00) reduction of all dispensing fees. The director of
16 the department of health and welfare shall set pharmacy reimbursement levels
17 through state rule promulgation for medicaid under title XIX of the social
18 security act except as necessary to comply with federal regulations, 42 CFR
19 447.331 through 447.334 , as implemented in the state of Idaho. Effective July
20 1, 1998, pharmacy reimbursement levels, except for dispensing fees, may be
21 adjusted in accordance with rules promulgated by the director through negoti-
22 ated rulemaking with interested parties including representatives of the phar-
23 macy profession.
STATEMENT OF PURPOSE
This legislation would provide that certain medical assistance
recipients, their spouses or parents pay copayments for certain
medical procedures. In addition, this legislation would provide
for exceptions, for the maximum amount of copayment, the
inability to make required payment, and revision of the Medicaid
pharmacy reimbursement level.
At a minimum, the saving to the general fund is estimated to be
$525,000. The Department of Health and Welfare reports there
were 2.6 million prescriptions filled during calendar year 2004.
A conservative estimate is that of that total 1.75 million are
subject to a dispensing fee. The savings generated by requiring
a co-payment are shared with the federal government.
1.75 million x $1.00=$1,750,000 x 30%= $525,000 savings to general fund
Name: Representative Block
STATEMENT OF PURPOSE/FISCAL NOTE H 321