1115-Copayment Waiver Amendment Attachments

Attachment 1: Request for addition of language 
Section 115 will be added to the STCs for the Demonstration as follows:
XIII. Medi-Cal Mandatory Copayments 
STC 115. Mandatory Copayments. The state may impose mandatory copayments on Medi-Cal beneficiaries for the following services:
a. all nonemergency services received in an emergency room
b. emergency services received in an emergency room
c. each hospital inpatient day, with a maximum per admission
d. preferred drugs prescription or refill
e. non preferred drugs prescription or refill
f. each visit for services including dental services received on an outpatient basis
Attachment 2: Required Information on the Amendment Request 
The following information supplements the request for an amendment to the Bridge to Reform Demonstration Project (11-W-00193/9) to impose mandatory copayments on Medi-Cal beneficiaries, and permit providers to require that individuals meet their copayment prior to receiving services. This information is submitted as required by paragraph 7 of the STCs of the Demonstration Project.

1. Explanation of the State?s public process regarding the requested amendment. 

The proposal has been analyzed by legislative staff, and discussed in several public hearings conducted by the health program and budget committees in the Assembly and Senate of the California Legislature. DHCS is planning to provide the amendment request to the Tribal Organizations to allow them to conduct a review and provide comments.
2. Analysis of the impact of the requested amendment on the currently  budget neutrality. 
The attached chart demonstrates that implementing mandatory copayments will include federal savings.
3. Revised CHIP allotment neutrality worksheet (if necessary). 
Mandatory co-payments will not affect CHIP beneficiaries; therefore, no revisions to the CHIP neutrality worksheets are necessary.
4. Detailed description of the amendment, including impact on beneficiaries,  with sufficient supporting documentation. 
The requested amendment would allow the State impose mandatory copayments on Medi-Cal beneficiaries.
The mandatory copayments will be imposed on Medi-Cal beneficiaries regardless of eligibility category, age or whether they are participating in the Medi-Cal fee-for-service or the managed care model of service delivery. Exclusions include those enrolled in the Family Planning, Access, Care and Treatment (F-PACT) Program, Senior Care Action Network (SCAN), Program of All-Inclusive Care for the Elderly (PACE), and the AIDS Healthcare Foundation. The Low Income Health Population (LIHP) is also exempt from this requirement.

Providers will collect the copayment from the beneficiary at the time of service. In the event the beneficiary does not pay the copayment at the time of service, the provider has the option to deny services, waive the copayment, or provide the service without waiving the copayment and hold the beneficiary liable for the amount owed. Providers will be reimbursed at the appropriate Medi-Cal reimbursement rates less the copayment amount.

Copayments will be imposed for the following services:
  • all nonemergency services received in an emergency room;
  • emergency services received in an emergency room;
  • each hospital inpatient day, with a maximum per admission;
  • preferred drugs prescription or refill;
  • non-preferred drug prescription or refill;
  • each visit for services including dental services received on an outpatient basis;
5. Description of how the evaluation design will be modified
This question does not apply to the requested amendment.

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