(a) The agency may establish differential cost sharing for preferred and non-preferred drugs. The provisions in § 447.56(a) shall apply except as the agency exercises the option under paragraph (d) of this section. All drugs will be considered preferred drugs if so identified or if the agency does not differentiate between preferred and non-preferred drugs.
(b) At state option, cost sharing for drugs may be established at or below the amounts shown in the following table (except that the maximum allowable cost sharing shall be increased each year, beginning October 1, 2015, by the percentage increase in the medical care component of the CPI-U for the period of September to September of the preceding calendar year, rounded to the next higher 5-cent increment. Such increase shall not be applied to any cost sharing that is based on the amount the agency pays for the service):
| Services | Maximum allowable cost sharing |
|---|
| Individuals with family income ≤150% of the FPL | Individuals with family income >150% of the FPL |
|---|
| Preferred Drugs | $4 | $4. |
| Non-Preferred Drugs | 8 | 20% of the cost the agency pays. |
(c) In states that do not have fee-for-service payment rates, cost sharing for prescription drugs imposed on individuals at any income level may not exceed the maximum amount established for individuals with income at or below 150 percent of the FPL in paragraph (b) of this section.
(d) For individuals otherwise exempt from cost sharing under § 447.56(a), the agency may impose cost sharing for non-preferred drugs, not to exceed the maximum amount established in paragraph (b) of this section.
(e) In the case of a drug that is identified by the agency as a non-preferred drug within a therapeutically equivalent or therapeutically similar class of drugs, the agency must have a timely process in place so that cost sharing is limited to the amount imposed for a preferred drug if the individual's prescribing provider determines that a preferred drug for treatment of the same condition either will be less effective for the individual, will have adverse effects for the individual, or both. In such cases the agency must ensure that reimbursement to the pharmacy is based on the appropriate cost sharing amount.
Notes of Decisions
Szewczyk v. Dep't of Soc. Servs., 881 A.2d 259 (Conn. 2005).
· cites it 6× “The language defining emergency medical condition, as set forth in § 1396b (v)(3), first appeared in 42 C.F.R. § 447.53 (b)(4). [11] That regulation, which was adopted in 1985, implemented a 1982 amendment to the federal medicaid provisions that prohibited the states from…”
Arellano v. Dep't of Human Servs., 943 N.E.2d 631 (Ill. App. Ct. 2010).
· cites it 4× “) 42 C.F.R. §447.53 (b)(4) (2006). Thus, it appears that the Cost Sharing Regulation served as the model for the regulation we now interpret, 42 C.”
Kansas Hosp. Ass'n v. Whiteman, 835 F. Supp. 1556 (D. Kan. 1993).
· cites it 5× “§ 1396o(a)(2)(D), (b)(2)(D); 42 C.F.R. § 447.53 (b)(4). Nor does it apply to children under age 18, pregnant women for pregnancy-related services, institutionalized persons subject to spend-down requirements, or certain HMO enrollees.”
Kansas Hosp. Ass'n v. Whiteman, 835 F. Supp. 1548 (D. Kan. 1993).
· cites it 3× “The court nevertheless has reservations concerning whether 42 U.S.C. § 1983 permits the plaintiffs to bring this particular cause of action.”
Fulkerson v. Comm'r, Maine Dep't of Human Servs., 802 F. Supp. 529 (D. Me. 1992).
· cites it 2× “See also 42 C.F.R. § 447.53 . The Secretary has established a maximum co-payment chargeable for each service determined in relation to the amount paid by the state for the service.”
McAmis v. Wallace, 980 F. Supp. 181 (W.D. Va. 1997).
“42 C.F.R. § 447.53 (1996). Plaintiff argues that she may have paid these written-off expenses "up front" in the form óf copayments or paying down her assets.”
Nebraska Pharmacists Ass'n v. Nebraska Dep't of Soc. Servs., 863 F. Supp. 1037 (D. Neb. 1994).
· cites it 2× “§ 1396o(a)(3); 42 C.F.R. §§ 447.53 & 447.57. However, in the event the recipient of aid is unable to pay, “no provider participating under the State plan may deny care or services to an individual eligible for such care or services under the plan on account of such individual’s…”
Potter v. James, 499 F. Supp. 607 (M.D. Ala. 1980).
“HEW promulgated 42 CFR § 447.53 (a)(1) to implement § 1396(a)(14)(A)(i).”
Sweeney v. Bane, 996 F.2d 1384 (2d Cir. 1993).
· cites it 2× “” 42 C.F.R. § 447.53 (d)(4). B. New York’s Statutory Scheme In April 1992, New York amended Social Services Law Section 367-a(6)(a) to reduce payments to medical providers “by an amount not to exceed the maximum amount authorized by federal law and regulations as a co-payment…”
Fulkerson v. Comm'r, Maine Dep't of Human Servs., 628 A.2d 661 (Me. 1993).
“See 42 C.F.R. §§ 447.53 , 447.54(d) (1992). 8 The Superior Court did not err in finding that plaintiffs failed to establish that the co-payment rules are arbitrary, capricious, or unlawful.”
Beeker v. Olszewski, 415 F. Supp. 2d 734 (E.D. Mich. 2006).
“An individual’s inability to pay does not eliminate his or her liability for the cost sharing charge”); 42 C.F.R. § 447.53 (e) (stating that “[n]o provider may deny services, to an individual who is eligible for the services, on account of the individual’s inability to pay the…”
— 42 C.F.R. § 447.53(b)(4) — 1 case
Arellano v. Dep't of Human Servs., 943 N.E.2d 631 (Ill. App. Ct. 2010).
“) 42 C.F.R. §447.53 (b)(4) (2006). Thus, it appears that the Cost Sharing Regulation served as the model for the regulation we now interpret, 42 C.”
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