10A NCAC 22D .0101. CO‑PAYMENT

(a)  Co‑payment Requirements.  The following requirements are imposed on all Medicaid recipients for the following services:

(1)           Outpatient Hospital Services.  Co‑payment shall be charged at the rate of three dollars ($3.00) per outpatient visit.

(2)           Chiropractic Services.  Co‑payment shall be charged at the rate of one dollar ($1.00) per chiropractic visit.

(3)           Podiatric Services.  Co‑payment shall be charged at the rate of one dollar ($1.00) per podiatric visit.

(4)           Optometric Services.  Co‑payment shall be charged at the rate of two dollars ($2.00) per optometric visit.

(5)           Optical Supplies and Services.  Co‑payment shall be charged at the rate of two dollars ($2.00) per item.  Co‑payment for repair of eyeglasses and other optical supplies will be charged at the rate of two dollars ($2.00) per repair exceeding five dollars ($5.00).

(6)           Prescribed Drugs.  Co-payment shall be charged at the rate of one dollar ($1.00) per dispensing for Generic drugs and three dollars ($3.00) for dispensing for Brand Name drugs, including refills.

(7)           Dental Services.  Co‑payment shall be charged at the rate of three dollars ($3.00) per visit, or if more than one visit is required but the service is billed under one procedure code with one date of service, then only one co‑payment shall be collected.  Full and partial dentures are examples of when more than one visit is required but the service is billed under one procedure code.

(8)           Physicians.  Co-payment will be charged at the rate of three dollars ($3.00) per visit.

(b)  Co‑payment Exemptions.  No co‑payment shall be charged for the following services:

(1)           EPSDT related services;

(2)           Family Planning Services;

(3)           Services in state owned mental hospitals;

(4)           Services covered by both Medicare and Medicaid;

(5)           Services to persons under age 21;

(6)           Services related to pregnancy;

(7)           Services provided to residents of ICF, ICF‑MR, SNF, Mental Hospitals; and

(8)           Hospital emergency room services.

 

History Note:        Authority G.S. 108A‑25(b); S.L. 1985, c. 479, s. 86; 42 C.F.R. 440.230(d);

Tax Equity and Fiscal Responsibility Act of 1982, Subtitle B; Section 95 of Chapter 689, 1991 Session Laws;

Eff. January 1, 1984;

Temporary Amendment Eff. August 15, 1991 For a Period of 180 Days to Expire on February 15, 1992;

Amended Eff. February 1, 1992;

Temporary Amendment Eff. September 15, 1992 For a Period of 180 Days or Until the Permanent Rule Becomes Effective, Whichever is Sooner;

Amended Eff. February 1, 1993;

Temporary Amendment Eff. January 1, 2002;

Amended Eff. April 1, 2003.