360-7.12 Co-payments by recipients.

    (a) In accordance with section 367-a(6) of the Social Services Law, nominal co-payments must be imposed upon recipients for certain care, services and supplies furnished under the medical assistance program. Payments for claims for services specified in subdivision (d) of this section will be reduced by the amounts determined in subdivision (f) of this section. The providers of such services may charge recipients the co-payments. However, providers may not deny services to recipients because of their inability to pay the co-payments.

    (b) Definitions.

        (1) For purposes of this section, drugs with FDA-approved indications for the treatment of tuberculosis means aminosalicylate sodium (para-aminosalicylate sodium), capreomycin sulfate, cycloserine, ethambutol, ethionamide, isoniazid, pyrazinamide, rifampin, and streptomycin.

        (2) Medical facility means residential health care facility or an intermediate care facility for the developmentally disabled.

        (3) For purposes of this section, psychotropic drugs means acetazolamide, acetophenazine, alprazolam, amantadine, amitriptyline, amoxapine, benztropine, biperiden, bupropion, buspirone, butabarbital, cabamazepine, chloral hydrate, chlordiazepoxide, chlormezanone, chlorpromazine, chlorprothixene, clomipramine, clonazepam, clorazepate dipotassium, clozapine, desipramine, diazepam, diphenhydramine, doxepin, estazolam, ethopropazine HCl, ethosuximide, ethotoin, fluoxetine, fluphenazine, flurazepam, halazepam, haloperidol, hydroxyzine HCl, hydroxyzine pamoate, imipramine, isocarboxazid, lithium, lorazepam, loxapine, maprotiline, mephenytoin, mephobarbital, meprobamate, methsuximide, mesoridazine, molindone, nortriptyline, oxazepam, paraldehyde, paramethadione, pentobarbital, perphenazine, phenacemide, phenelzine, phenobarbital, phensuximide, phenytoin, pimozide, prazepam, primidone, prochlorperazine, procyclidine, promazine, protriptyline, quazepam, secobarbital, sertraline, temazepam, thioridazine, thiothixene, tranylcypromine, trazodone, triazolam, trifluoperazine, triflupromazine, trihexyphenidyl HCl, trimethadione, trimipramine, and valproic acid and its derivatives.

        (4) X-ray services means diagnostic radiology, diagnostic ultrasound, nuclear medicine or radiation oncology.

    (c) Co-payments apply to all recipients except:

        (1) individuals under 21 years of age;

        (2) pregnant women;

        (3) individuals who are in-patients in medical facilities or residents of community based residential facilities licensed by the Office of Mental Health or the Office of Mental Retardation and Developmental Disabilities who have been required to spend all of their incomes for medical care, except their personal needs allowances;

        (4) individuals enrolled in health maintenance organizations or other entities which provide comprehensive health services, or other managed care programs; and

        (5) any other individuals required to be excluded by federal law or regulations.

    (d) Co-payments only apply to the following services:

        (1) in-patient care in a general hospital, as defined in subdivision 10 of section 2801 of the Public Health Law;

        (2) out-patient hospital and clinic services, except for mental health services, mental retardation and developmental disability services, alcohol and substance abuse services and methadone maintenance services;

        (3) sickroom supplies;

        (4) drugs, except psychotropic drugs and drugs with FDA-approved indications for the treatment of tuberculosis as defined in subdivision (b) of this section;

        (5) clinical laboratory services, except those provided by and payable to a physician or podiatrist;

        (6) x-ray services, except those provided by and payable to physicians, podiatrists or dentists; and

        (7) emergency room services provided for non-urgent or non-emergency medical care.

    (e) Co-payments do not apply to emergency services or family planning services and supplies or tuberculosis directly observed therapy services provided by programs approved by the Department of Health.

    (f) The amount of the co-payment for each service specified in subdivision (d) of this section, except for paragraph (1) relating to in-patient care, must not exceed the amount specified in paragraph (1) of this subdivision. The amount of the co-payment for each service specified in subdivision (d) is a standard co-payment amount based upon the average or typical payment for the service by the MA program, as set forth in paragraph (2) of this subdivision. The co-payment for each service specified in paragraph (1) of subdivision (d) of this section is $25.00 for each discharge.

        (1) Schedule of co-payments:
Average or typical MA payment                 Co-payment
    $10 or less                                                  $   .50
    $10.01 to $25                                             $1.00
    $25.01 to $50                                             $2.00
    $50.01 or more                                           $3.00

        (2) Standard co-payment amounts:

Service                                                           Co-payment
In-patient care                                            $25.00 per discharge
Out-patient hospital and clinic services       $3.00 per visit
Sickroom supplies                                      $1.00 per order
Enteral and parenteral formulae/supplies     $1.00 per claim
Brand name prescription drugs                   $2.00 for each prescription dispensed
Generic prescription drugs                           $ .50 for each prescription dispensed
Non-prescription drugs                               $ .50 for each order dispensed
Clinical laboratory procedures                     $ .50 for each procedure billed
Radiology procedures                                 $1.00 for each procedure code billed
Emergency room services
provided for non-urgent
or non-emergency care                               $3.00 per visit

Return to DSS Regs Table of Contents | Search DSS Regs