Section 125.310  Copayments

a)         Copayments may be charged to the family by a health care professional whenever the service is performed in an office or home setting, except for visits scheduled for well-baby care, well-child care or age-appropriate immunizations. Copayments may also be charged to the family by hospitals, once per inpatient admission or outpatient encounter (including the emergency room).  No copayment is permitted for visits to health care professionals or hospitals made solely for speech, occupational or physical therapy, audiology, radiology or laboratory services (including APL Group 2 procedures).  Families with an enrolled individual who is an American Indian or Alaska Native shall not be charged copayments.

b)         Copayment requirements are as follows:

1)         Practitioner office visit:

A)        KidCare/FamilyCare Share copayment: $2 per visit.

B)        KidCare/FamilyCare Premium copayment: $5 per visit.

2)         Home health care visit:

A)        KidCare/FamilyCare Share copayment: $2 per visit.

B)        KidCare/FamilyCare Premium copayment: $5 per visit.

3)         Inpatient hospitalization:

A)        KidCare/FamilyCare Share copayment: $2 per admission.

B)        KidCare/FamilyCare Premium copayment: $5 per admission.

4)         Outpatient encounter (including the emergency room):

A)        KidCare/FamilyCare Share copayment: $2 per visit.

B)        KidCare/FamilyCare Premium copayment: $5 per visit.

5)         Prescription drugs:

A)        KidCare/FamilyCare Share copayment: $2 for a 1- to 30-day supply on both generic and brand name drugs.

B)        KidCare/FamilyCare Premium copayments: $3 for a 1- to 30-day supply on generic drugs or $5 for 1- to 30-day supply on brand name drugs.

6)         Nonemergency visit to an emergency room:

A)        KidCare/FamilyCare Share copayments: $2 per visit.

B)        KidCare/FamilyCare Premium copayment: $25 per visit.

c)         The maximum out-of-pocket expense a family will incur for copayments during a 12-month eligibility period is $100.

d)         Once the family has satisfied the copayment cap, the family is responsible for submitting receipts, to the Department, documenting the payment of copayments.  The Department may return partial documentation received on copayments to the family.

e)         Upon the Department determining that the copayment cap has been satisfied, the following will occur:

1)         A notice stating that the copayment cap has been satisfied, and the date satisfied, will be sent to the family.

2)         A message that the copayment cap has been satisfied, and the date satisfied, will be available through the family's identification card.

3)         REV will be updated to reflect that the copayment cap has been reached.

f)          Providers will be responsible for collecting copayments under the KidCare/FamilyCare Health Plan.

g)         Providers may elect not to charge copayments.   If copayments are charged, the copayment must comply with the requirements in this Section.

h)         Providers shall be responsible for refunding to the family copayments they collect after the family has reached the copayment cap.

i)          The Department will not require providers to deliver services when copayments properly charged under the KidCare/FamilyCare Health Plan are not paid.

(Source:  Amended at 30 Ill. Reg. 10328, effective May 26, 2006)