Common use of Cost Sharing Obligations Clause in Contracts

Cost Sharing Obligations. The MCO, through the MCO’s providers, must impose copayments for covered services in the amounts that are determined by the Department in accordance with the requirements specified in the State Plan and the requirements set forth in 42 CFR §§447.50 -447.57. The MCO must reduce payments to the network providers by the amount of the member’s copay, regardless of whether the provider successfully collects the copay. The MCO, or the MCO’s providers, may not routinely waive required copays. Pharmacy co-payments must be assessed on the total allowed charge for the prescription, regardless of preferred or non-preferred status. The MCO must have a process to track a quarterly household maximum for the cost-sharing obligations based on the members’ Federal Poverty Level (FPL). Members exempt from cost-sharing obligations The MCO and the MCO’s providers may not charge copays to the following MCO members or on the following services: • Family planning services; • Emergency services; • 72-hour emergency supply of medication; • Following pharmacy services: diabetic testing supplies, syringes and needles, and home infusion supplies approved by the Department; • Members under age 21; • Pregnant women (including the 60-day postpartum period following the end of pregnancy); • American Indians and Alaska Natives; • Members receiving hospice care; • Members in nursing homes; • Any additional members or services excluded under the State Plan authority; and • Members who have met their household maximum limit for the cost-sharing obligations per calendar quarter. Services and members subject to cost-sharing obligations The MCO and the MCO’s providers must charge copays for the following MCO services or members: • Inpatient and outpatient services; • Physician office visits, including but not limited to, office visits to a psychiatrist or a nurse practitioner; • Pharmacy medications; • Non-emergency use of an emergency department; • Caretaker relatives age 21 and up; • Transitional Medicaid members age 21 and up; and • Any other members identified by the MCOs that are not specifically exempt.

Cost Sharing Obligations. The MCO, through the MCO’s providers, must impose copayments for covered services in the amounts that are determined by the Department in accordance with the requirements specified in the State Plan and the requirements set forth in 42 CFR §§447.50 -447.57. The MCO must reduce payments to the network providers by the amount of the member’s copay, regardless of whether the provider successfully collects the copay. The MCO, or the MCO’s providers, may not routinely waive required copays. Pharmacy co-payments The MCO, or the MCO’s providers, must impose the same copayment amount for a non- preferred drug as for a preferred drug in the same therapeutic category, when the prescribing physician determines that the preferred drug for treatment of the same condition would not be assessed on the total allowed charge as effective for the prescription, regardless of preferred or member as a non-preferred statusdrug, would have adverse effects for the member or both. The MCO must have a process to track a quarterly household maximum for the cost-sharing obligations based on the members’ Federal Poverty Level (FPL)obligations. Members exempt from cost-sharing obligations The MCO and the MCO’s providers may not charge copays to the following MCO members or on the following servicesmembers: • Family planning services; • Emergency services; • 72-hour emergency supply of medication; • Following pharmacy services: diabetic testing supplies, syringes and needles, and home infusion supplies approved by the Department; •  Members under age 21; •  Pregnant women (including the 60-day postpartum period following the end of pregnancy); •  American Indians and Alaska Natives; •  Members receiving hospice care; • Members in nursing homes; •  Any additional members or services excluded under the State Plan authority; and •  Members who have met their household annual maximum limit for the cost-sharing obligations per calendar quarterobligations. Services and members subject to cost-sharing obligations The MCO and the MCO’s providers must charge copays for the following MCO services or and members: •  Inpatient and outpatient services; • Physician office visits, including but not limited to, office visits to a psychiatrist or a nurse practitioner; • Pharmacy  Non-Preferred Drug List medications; •  Non-emergency use of an emergency department; •  Caretaker relatives age 21 and up; •  Transitional Medicaid members age 21 and up; and •  Any other members identified by the MCOs that are not specifically exempt.

Cost Sharing Obligations. The MCO, through the MCO’s providers, must impose copayments for covered services in the amounts that are determined by the Department in accordance with the requirements specified in the State Plan and the requirements set forth in 42 CFR §§447.50 -447.57. The MCO must reduce payments to the network providers by the amount of the member’s copay, regardless of whether the provider successfully collects the copay. The MCO, or the MCO’s providers, may not routinely waive required copays. Pharmacy co-payments The MCO, or the MCO’s providers, must impose the same copayment amount for a non- preferred drug as for a preferred drug in the same therapeutic category, when the prescribing physician determines that the preferred drug for treatment of the same condition would not be assessed on the total allowed charge as effective for the prescription, regardless of preferred or member as a non-preferred statusdrug, would have adverse effects for the member or both. The MCO must have a process to track a quarterly household maximum for the cost-sharing obligations based on the members’ Federal Poverty Level (FPL)obligations. Members exempt from cost-sharing obligations The MCO and the MCO’s providers may not charge copays to the following MCO members or on the following servicesmembers: • Family planning services; • Emergency services; • 72-hour emergency supply of medication; • Following pharmacy services: diabetic testing supplies, syringes and needles, and home infusion supplies approved by the Department; • Members under age 21; • Pregnant women (including the 60-day postpartum period following the end of pregnancy); • American Indians and Alaska Natives; • Members receiving hospice care; • Members in nursing homes; • Any additional members or services excluded under the State Plan authority; and • Members who have met their household annual maximum limit for the cost-sharing obligations per calendar quarterobligations. Services and members subject to cost-sharing obligations The MCO and the MCO’s providers must charge copays for the following MCO services or and members: • Inpatient and outpatient services; • Physician office visits, including but not limited to, office visits to a psychiatrist or a nurse practitioner; • Pharmacy Non-Preferred Drug List medications; • Non-emergency use of an emergency department; • Caretaker relatives age 21 and up; • Transitional Medicaid members age 21 and up; and • Any other members identified by the MCOs that are not specifically exempt.

Cost Sharing Obligations. The MCO, through the MCO’s providers, must impose copayments for covered services in the amounts that are determined by the Department in accordance with the requirements specified in the State Plan and the requirements set forth in 42 CFR §§447.50 -447.57. The MCO must reduce payments to the network providers by the amount of the member’s copay, regardless of whether the provider successfully collects the copay. The MCO, or the MCO’s providers, may not routinely waive required copays. Pharmacy co-payments must be assessed on the total allowed charge for the prescription, regardless of preferred or non-preferred status. The MCO must have a process to track a quarterly household maximum for the cost-sharing obligations based on the members’ Federal Poverty Level (FPL). Members exempt from cost-sharing obligations The MCO and the MCO’s providers may not charge copays to the following MCO members or on the following services: •  Family planning services; •  Emergency services; •  72-hour emergency supply of medication; •  Following pharmacy services: diabetic testing supplies, syringes and needles, and home infusion supplies approved by the Department; •  Members under age 21; •  Pregnant women (including the 60-day postpartum period following the end of pregnancy); •  American Indians and Alaska Natives; •  Members receiving hospice care; •  Members in nursing homes; •  Any additional members or services excluded under the State Plan authority; and •  Members who have met their household maximum limit for the cost-sharing obligations per calendar quarter. Services and members subject to cost-sharing obligations The MCO and the MCO’s providers must charge copays for the following MCO services or members: •  Inpatient and outpatient services; •  Physician office visits, including but not limited to, office visits to a psychiatrist or a nurse practitioner; •  Pharmacy medications; •  Non-emergency use of an emergency department; •  Caretaker relatives age 21 and up; •  Transitional Medicaid members age 21 and up; and •  Any other members identified by the MCOs that are not specifically exempt.