AZ

"41.  MEDICARE SERVICES AND COST SHARING
AHCCCS has members enrolled who are eligible for both Medicaid and Medicare.  These members are referred to as “dual eligible”.  Generally, Contractors are responsible for payment of Medicare coinsurance and/or deductibles for covered services provided to dual eligible members.  However, there are different cost sharing responsibilities that apply to dual eligible members based on a variety of factors.  The Contractor is responsible for adhering to the cost sharing responsibilities presented in the AHCCCS Medicare Cost Sharing policy.  Effective 10/1/97, the Contractor shall have no cost sharing obligation if the Medicare payment exceeds what the Contractor would have paid for the same service of a non-Medicare member."  Arizona Contract, page 44.

"64.  KIDSCARE...
Effective October 1, 1999, KidsCare members in families with gross household income over 150% and up to 200% of the federal poverty limit shall pay a premium to AHCCCSA.  The premium amount shall be based on the number of members in the household and the gross family income in accordance with 9A.A.A.C., Article 14.

Title XXI Parent/Guardian Health Insurance Coverage:  ARS §36.2984 mandates that the Contractor offer health insurance coverage to the parent(s) or legal guardian(s) of a child who is eligible for Title XXI...
Title XXI funds or any other federal or state funds shall not be used to subsidize family coverage.  The full cost of the premium shall be paid by the parent or legal guardian who elects this coverage…"  Arizona Contract, page 54.

"3.  LIMITATIONS ON BILLING AND COLLECTION PRACTICES
The Subcontractor shall not bill, nor attempt to collect payment directly or through a collection agency from a person claiming to be AHCCCS eligible without first receiving verification form AHCCCSA that the person was ineligible for AHCCCS on the date of service, or that services provided were not AHCCCS covered services.  This provision shall not apply to patient contributions to the cost of services delivered by nursing homes."  Arizona Contract, pages A1-A2.

AZBH

"28.  METHOD OF PAYMENT...
ADHS or its subcontracted RBHAs shall collect any permitted copayment from Title XIX and Title XXI members but service will not be denied for inability to pay the copayment.  Except for permitted copayments, ADHS or its subcontracted RBHAs shall not bill or attempt to collect any fee from, or for, a Title XIX and Title XXI member for the provision of covered services.  Any required copayments collected shall belong to ADHS or its subcontractors, as appropriate."  Arizona Behavioral Health Contract, pages 27-28.

"36.  MEDICARE SERVICES AND COST SHARING
AHCCCS has members enrolled who are eligible for both Title XIX and Medicare.  These members are referred to as 'dual eligible'.  Generally, ADHS is responsible for payment of Medicare coinsurance and/ or deductibles for covered services provided to duel eligible members.  However, there are different cost sharing responsibilities that apply to dual eligible members based on a variety of factors.  ADHS is responsible for adhering to the cost sharing responsibilities presented in the AHCCCS Medicare Cost Sharing policy.  ADHS has no cost-sharing obligation if the Medicare payment exceeds what ADHS would have paid for the same service of a non-Medicare member."  Arizona Behavioral Health Contract, page 30.

"ATTACHMENT A
MINIMUM ADHS CONTRACT (SUBCONTRACT) PROVISIONS...
3.  LIMITATIONS ON BILLING AND COLLECTION PRACTICES
The Contractor shall not bill, nor attempt to collect payment directly or through a collection agency from a person claiming to be AHCCCS eligible without first receiving verification from AHCCCS that the person was ineligible for AHCCCS on the date of service, or that service provided were not AHCCCS covered services.  This provision shall not apply to patient contributions to the cost of services delivered by nursing homes."  Arizona Behavioral Health Contract, Attachment A,  page 1.

"ATTACHMENT G
AHCCCS BEHAVIORAL HEALTH SERVICES GUIDE...
The following provisions regarding general service specifications and limitations apply to all Title XIX and Title XXI services...
- Service providers must not charge, submit a claim, demand, or otherwise collect payment from a member for any covered service except to collect authorized co-payments or payment for additional services."  Arizona Behavioral Health Contract, Attachment G, page 1.

CA

"3.17.2  Turnover Requirements
 Prior to the termination or expiration of this Contract and upon request by DHS, the Contractor will assist DHS in the orderly transfer of Member medical care.  In doing this, the Contractor will make available to DHS copies of Medical Records, patient files, and any other pertinent information...  Costs of reproduction will be borne by DHS.  In no circumstances will a Medi-Cal Member be billed for this service."  California Contract, page 22.

"3.41 COST AVOIDANCE AND POST-PAYMENT RECOVERY OF OTHER HEALTH COVERAGE SOURCES
A. Contractor shall Cost Avoid or make a Post-Payment Recovery for the reasonable value of services paid for by Contractor... However, in no event shall Contractor Cost Avoid or seek Post-Payment Recovery for the reasonable value of services from a TPTL action or make a claim against the estates of deceased Members."  California Contract, page 45.

CO

"V.  COSTS AND REIMBURSEMENT…
7.  When the Contractor is responsible for providing a Member with Covered Services pursuant to this Contract, prior to receiving nonemergency medical care, the Member shall comply with the protocols of the Contractor, including using providers within the Contractor’s network. Any Member failing to follow the Contractor’s protocols shall be liable for the payment or cost of any care or services that the Contractor would have been liable to pay; except that, if the Contractor fails to communicate the protocols to the Member, the items or services are nonreimbursable under this Contract and the Member is not liable to the Contractor or the provider for payment or cost of the care or services.

8.  When a third party is primarily liable for the payment of the costs of a Member’s medical benefits, prior to receiving nonemergency medical care, the Member shall comply with the protocols of the third party, including using providers within the third party’s network. Any Member failing to follow the third party’s protocols is liable for the payment or the cost of any care or any service that the third party would have been liable to pay; except that, if the third party or the service provider substantively fails to communicate the protocols to the Member, the items or services are non-reimbursable and the Member is not liable to the provider."  Colorado Contract, page 24.

CT

"3.46  Co-payment Limits and Member Charges for Noncovered Services
No deductibles or co-payments are permitted for Medicaid covered services.
A provider shall be permitted to charge an ineligible Member for goods or services which are not coverable only if the Member knowingly elects to receive the goods or services and enters into an agreement in writing to pay for such goods or services prior to receiving them…"  Connecticut Contract, page 54.

DE

"8.3.  Describe how the public will be notified of this cost-sharing and any differences based on income:
The public will be notified of cost sharing requirements and any other aspects of the SCHIP program through the State's Administrative Procedures Act which requires publishing everything that has an impact on State citizens and provides an opportunity for public comment...

8.4.  The state assures that it has made the following findings with respect to the cost sharing and payment aspects of its plan:  (Section 2103(e))

8.4.1.  'X'  Cost sharing does not favor children from higher income families over lower income families.  (Section 2103(e)(1)(B))
8.4.2.  'X'  No cost-sharing applies to well-baby and well-child care, including age-appropriate immunizations.  (Section 2103(e)(2))
8.4.3.  'X'  No child in a family with income less than 150% of the Federal Poverty Level will incur cost-sharing that is not permitted under 1916(b)(1)...

8.4.5.  'X'  No premiums or cost-sharing will be used toward state matching requirements.  (Section 2105(c)(5))...

8.4.7.  'X'  Income and resource standards and methodologies for determining Medicaid eligibility are not more restrictive than those applied as of June 1, 1997.  (Section 2105)(d)(1))."  Delaware RFP, Appendix A (SCHIP), page A.35.

DC

"ARTICLE X - PAYMENT...
K.  Provider shall not impose co-payment requirements, or other fees on enrollees."  District of Columbia Contract, pages 38-39.

FL

"6.  Copayments.  The plan shall not require any copayment or cost sharing for services listed in Section A.1., Services To Be Provided, of this attachment nor may the plan charge members for missed appointments...

8.  Member Payment Liability Protection.  The plan shall not hold members liable for the following in accordance with Section 1932(b)(6), Social Security Act (enacted by Section 4704 of the 1997 Balanced Budget Act):

a. For debts of the plan, in the event of the plan's insolvency.

b. For payment of covered services provided by the plan if the plan has not received payment from the agency for the services, or if the health care provider, under or other arrangement with the plan, fails to receive payment from the agency or the plan.

c. For payments to the health care provider that furnished covered services under a contract, or other arrangement with the plan, that are in excess of the amount that normally would be paid by the member if the service had been received directly from the plan."  Florida Contract, pages 56-57.

FLMH

"2.8  Cost Sharing for Services
The contractor shall not require any co-payment or cost sharing for service categories listed in section 2.2A, nor for the services listed in section 5.1.F.1.  Nor may the contractor charge enrollees for missed appointments."  Florida Mental Health RFP, page 31.

"The following is a summary list of the optional services which may be provided under the prepaid health plan contract as a downward substitution of care... if the plan chooses to provide an optional service, it cannot require payments from recipients for such a service provided under this contract, excepting room and board payments of residential treatment programs."  Florida Mental Health RFP, page 94.

HI

"20.130  QUEST-Net...
During the first 6 months these individuals and families will not pay any premiums or co-payments.  During the second 6 month period, those whose income exceed 200% of the FPL will be responsible for premium share and co-payments…"  Hawaii RFP, pages 5-6.

"40.460  Collection of Recipient's Share of Premiums
DHS shall be responsible for billing and collecting the recipient's premium share in the Hawaii Administrative Rules."  Hawaii RFP, page 49.

"41.020  Emergency Room...
Therefore, the health plan is obligated, at a minimum, to provide reimbursement for emergency room screening and assessment services.  The facility may 'balance bill' the recipient for inappropriate use of the emergency room…" Hawaii RFP, page 55.

"42.010  Assessment of the Co-Payments
The recipient may be assessed a co-payment for certain services… Co-payments shall not be assessed on maintenance drugs, prenatal vitamins and birth control pills.  The health plan will be allowed to submit its listing of maintenance drugs to DHS for review.

Co-payments are not assessed to all recipients.
There will be no co-payment amounts for service provided to recipients with incomes below 100% of the federal poverty level, all children (up to age 19) and pregnant women.  Foster children and children in subsidized adoptions up to age 21 years are no assessed co-payments.  Co-payments are assessed for all self-employed persons and their spouses, regardless of income, provided they are not AFDC or GA recipients, or pregnant.

42.020  Co-payment Amounts
The co-payment amounts are provided in Exhibit 1.

SERVICE CATEGORY… CO-PAYMENT
Inpatient Hospital
Medical… None
Surgical… None
Rehabilitation… None
Psychiatric… None
Detoxification… None
Maternity… None
Nursery… None
Outpatient Hospital
Emergency Room… $25/Visit
Ambulatory Surgery Center… None
Urgent Care… $7/Visit
Psychiatric… None
Prescription Drugs… $2/generic and single source… $5/Multisource Brand
Radiology/ Laboratory/Diagnostic Tests… None
Physician… $7/visit
Other Practitioners… $7/visit
Home Health Agency Service… None
Durable Medical Equipment… 20% of Cost...

42.030  Co-Payment Data
DHS will identify which members are to be assessed a co-payment on the daily and monthly enrollment data.  Unless the plan can demonstrate other ways to notify providers of members with co-payment requirements, the plan will be required to indicate on the recipient's member card whether co-payments may be collected.

42.040  Co-Payment Collection
The health plan or the provider shall collect the co-payments in a consistent manner from qualifying recipients and retain all co-payments collected.  The health plan shall not deny the provision of services to recipients who do not or are unable t pay the co-payment...

42.110  Finance Charges
Providers may assess finance charges on non-payments of copayments at the time of the visit…"  Hawaii RFP, pages 55-56.

"Will DHS… notify the health plans of changes to the co-payments and the expiration of the 12 months?

ANSWER:  Yes, the State… will inform the health plans of changes in co-payments and eligibility."  Hawaii RFP, Q&A, page 3.

"Are all the services included in this section to be provided free of charge or is some co-payment allowed?  (particularly for DME, medical supplies, transplants)

ANSWER:
Co-payment may only be applied in accordance with the co-payment table listed between pages 55 and 56.  Only certain individuals are subject to co-payment and they are identified on the enrollment tapes."  Hawaii RFP, Q&A, page 9.

"Please confirm that the health plan can assess copayments for adult physical exams, annual note pap and pelvic exams and mental health office visits for members who can be assessed copayments.

ANSWER:
Co-payments may be assessed for adult physical examinations.  Likewise, annual pelvic examinations are considered physician services and are subject to co-payments.  However, pap smears are laboratory tests and therefore NOT subject to co-payments.  Mental health office visits for recipients in the BHMC plan are not subject to co-payments.  Mental health office visits for recipients not in the BHMC plan are subject to co-payments...

Is there any recourse for the providers if they have members who repeatedly failed to pay their copayments particularly if the member uses the ER for non emergent services?

ANSWER:
No.  HCFA does not allow disenrollment or termination from the program.  In fact, the member handbook must state that nonpayment should not be a cause for disenrollment."  Hawaii RFP, Q&A, pages 37-38.

"Is there a co-payment for psychiatric care?  The table says 'None', but Footnote 3 explains which psychiatric patients must pay.  A $25 charge applies to emergency room (except in emergencies).  If a member who meets co-payments requirements uses an emergency room in a situation other than an emergency, will the plan pay only the stabilization or assessment fee--less $25--and let the provider balance-bill?

ANSWER:
The 'none' in this area relates to outpatient hospital services such as day treatment.  A co-payment may be applied for physician (psychiatrist) or other practitioner (psychologist) office visits.  The plan may let the provider bill the recipient for the co-payment amount and the balance of the bill for the emergency room services."  Hawaii RFP, Q&A, page 44.

HIBH

"QUEST-Net members may be billed directly for any non-covered services and for covered services exceeding the established limits."  Hawaii Behavioral Health RFP, page 7.

"41.020  Emergency Room...
Therefore, the BHMC plan is obligated , at a minimum, to provide reimbursement for emergency room screening and assessment services.  The facility may 'balance bill' the member for inappropriate use of the emergency room...

42.000  Assessment and Collection of Fees and Penalties
Members of the BHMC plan shall not be assessed finance charges, co-payments for services or no-show fees.  Members must be informed that they cannot be terminated from the program for non-payment of co-payments, finance charges, no-show fees, non-covered services or for the receipt of services from unauthorized non-plan providers."  Hawaii Behavioral Health RFP, page 44.

"61.660  Payment of Subcontractors and Providers...
The State and plan member shall bear no liability for the offeror's failure or refusal to pay valid claims of subcontractors or providers.  The offeror shall indemnify and hold the State and the plan members harmless from any and all liability arising from such claims and shall bear all costs in defense of any action over such liability, including attorney's fees."  Hawaii Behavioral Health RFP, page 75.

IL

"(x)  Fees to Beneficiaries Prohibited
The Contractor shall not seek nor obtain funding through fees or charges to any Beneficiary receiving Covered Services pursuant to this Contract, except as permitted or required by the Department in its implementation of KidCare Phase II...

(d)  Premiums and Copayments under KidCare Phase II
(1)  The Department reserves the right to establish premiums or copayments for KidCare Phase II Participants.  The Contractor may be subject to collect such premiums or copayments as determined by the Department.

(2)  The Contractor may charge copayments to KidCare Phase II Participants in a manner consistent with 89 Illinois Administrative Code, Part 125.  If the Contractor wishes to charge such copayments, the Contractor must provide written notice to the Department before changing such copayments.  Such written notice to the Department shall include a copy of the policy the Contractor intends to give the Providers in its network.  This policy must set forth the amount, manner and circumstances in which copayments may be charged.  Such policy is subject to the prior written approval of the Department.  In the event the Contractor wishes to impose a charge for copayments after enrollment of a KidCare Phase II Participant, no copayment may be charged without providing at least sixty 960) days prior written notice to such KidCare Phase II Participant.  The Contractor shall be responsible for promptly refunding to a KidCare Phase II Participant any copayment that, in the sole discretion of the Department, has been inappropriately collected for Covered Services."  Illinois HMO Contract, pages 51-57.

IN

"4.4.2.7  Copayments
Certain services such as transportation, non-emergency use of the emergency room, and pharmacy are subject to a recipient copayment under the fee-for-service Indiana Medicaid program.  However, individuals enrolled with an MCO are not subject to copayment requirements and may not be charged any copayments or other cost-sharing fees for covered services...

5.1.3.6  Adjustments for Changes in Copayment Policy.  Copayments, which are permitted for specified services in the fee-for-service environment, will not be permitted in RBMC for the Pregnancy Medicaid, TANF Medicaid and Children’s Medicaid population categories.  Adjustments have been made to historical PMPM data to account for this policy difference."  Indiana RFP, pages 4-10, 5-6.

"4.4.2...
Children who are found not eligible for Medicaid under Title XIX, are enrolled in the Title XXI Medicaid expansion if they are up to 150% FPL and do not have other insurance... Children who are above 150% but not more than 200% FPL, who do not have other health coverage and who meet the other CHIP eligibility requirements, will be enrolled in the Phase II CHIP program if they agree to the cost sharing obligation."  Indiana SCHIP Amendment, pages 18-19.

IA

"4.1.2  Statutory Requirements
Enrollees shall not be held liable for the following:
- the debts of the HMO if it should become insolvent
- payment for services provided by the HMO if the HMO has not received payment from the State for the services, or if the Provider fails to receive payment from the State or HMO.
- the payments to Providers that furnish Covered Services that are in excess of the amount that normally would be paid by the Enrollee if the service had been received directly from the HMO."  Iowa Contract, page 17.

"4.23  Subcontracts with Providers and Other Subcontractors...
Subcontracts with Providers shall ensure that payment by the HMO to the Provider for Covered Services is payment in full and the Enrollee shall not be responsible for any additional charges or fees."  Iowa Contract, page 18.

IABH

"6.0  TERMINATION...

In the event of termination, the contractor is prohibited from making any claim against any eligible person or SPP member served through the Iowa Plan for any costs incurred through the provision of services."  Iowa Behavioral Health Contract, page 2.

"54.0  COST SHARING PROHIBITED
The Contractor shall not require enrollee co-payment or cost sharing by any Medicaid enrollee for any of the services covered within the scope of this contract.  The Contractor shall assure that enrollee cost sharing is not required by any provider reimbursed for services through the Iowa Plan.  The contractor shall require that providers accept negotiated rates as full payment of services provided under this contract and do not charge enrollees for services when payment is denied by the Contractor due to the provider's failure to adhere to contractual requirements.

The Contractor shall not allow, nor permit those who provide services to Iowa Plan enrollees to charge enrollees for missed appointments...

56.0  DPH PARTICIPANTS
Participants in the non-Medicaid population will cost share on the basis of a sliding fee scale.  The sliding fee shall be based on income and family size.  A standardized sliding fee scale approved by DPH shall be used by the Contractor.  There shall be no charge for missed appointments, but a one-time no-show fee maybe assessed by the substance abuse provider to the client."  Iowa Behavioral Health Contract, pages 39-40.

KS

"B.  ENROLLMENT RESPONSIBILITIES
HMO Responsibilities...
The HMO may not require copayments for any services provided to members."  Kansas Contract, page 47.

"I.  A.  PAYMENT IN FULL FOR COVERED SERVICES.  Contract Sections VIIIA.1., A.2. and XIA are amended to add the following language:
       1.  MCO is responsible for ensuring none of its assigned beneficiaries is charged for all, or any part (i.e., balance of bill), of services provided by network or non-network providers when such service provision was secured through a network primary care physician (PCP); network specialist with appropriate referral from the PCP; non-network specialist or other provider of services when an appropriate referral for such services has been made by the PVP; or when MCO member obtains services (emergency or otherwise) that are covered by MCO under this contract.
       2. ... MCO members must follow established referral rules to ensure protection from inappropriate provider billing.  When an HMO member secures services outside MCO network without following required referral procedures, or secures specialist service in-network without following required referral procedures, the member may be billed for such services by the direct service provider...
       4.  MCO shall ensure that enrollees are protected against liability for payments to providers or entities when the State does not pay MCO for any reason."  Kansas Contract, Amendment One.

KY

"VII.  FINANCIAL CONDITIONS...
A.  Capitated Payments...
  7.  Co-Pays or Deductibles
  The Contractor and all Subcontractors are prohibited from receiving payment or any type of compensation from Members for providing Covered Services authorized or deemed authorized by Contractor."   Kentucky Contract, pages 30, 32.

ME

"C.  SPECIAL REQUIREMENTS
1.  Emergency Services...
C.  Payment.  The Contractor shall not charge Enrollees for non-emergency care provided in an emergency room..."  Maine Contract, pages 21-22.

"D.  PROVIDER CONTRACTS...
The Contractor shall ensure that providers agree not to bill an Enrollee for services covered under this Contract and provided during the Enrollee's period of HMO enrollment...

F.  INSOLVENCY PROTECTION
The Contractor shall require that, in the event it becomes insolvent, subcontractors continue to provide services until the end of the month in which the Contractor's insolvency occurs. The Contractor shall prevent subcontractors from looking to Enrollees for payment by requiring all subcontracts to contain ‘hold harmless’ and ‘continuation of benefits’ clauses that survive the termination of the subcontract due to insolvency."  Maine Contact, page 57.

MD

"THE MCO AGREES: …
M.  Not to hold Enrollees, the Department, or DHHS liable for the debts of the MCO or any of its subcapitated providers in the event of the MCO's insolvency or the insolvency of its subcapitated provider, but nothing in this paragraph shall waive the MCO's right to be paid for the services that it has provided to its members.

N.  Not to hold Enrollees or DHHS liable for the debts of the MCO for services provided to the Enrollee:
  a.  in the event that the MCO fails to receive payment from the Department for such services, or
  b.  in the event that a health care provider with a contractual, referral, or other arrangement with the MCO fails to receive payment from the Department or the MCO for such services."  Maryland Contract, pages 1, 3.

".01  Required Benefits Package-In General...
C.  Cost Sharing and Prohibitions.
(1)  An MCO may not charge its enrollees any copayments, premiums, or cost sharing of any kind."  Maryland COMAR 10.09.67.01.

MA

"SECTION 5.  ADDITIONAL TERMS AND CONDITIONS
Section 5.1  Administration...
K.  No Enrollee Liability for Payment
1.  The Contractor shall:
a.  Ensure, in accordance with 42 USC 1396 u-2(b)(6), that an Enrollee will not be held liable:
1)  for debts of the Contractor, in the event of the Contractor's insolvency;

2)  for services (other than Excluded Services) provided to the Enrollee in the event that:
  a)  the Contractor fails to receive payment from the Division for such services; or
  b)  a Provider fails to receive payment from the Division or the Contractor for such services; or

3)  for payments to a provider in excess of the amount that would be owned by the Enrollee if the Contractor had directly provided the services.
  b)  Not charge Enrollees coinsurance, co-payments, deductibles, financial penalties or any other amount in full or part, for any service provided under this Contract, except as otherwise provided in Section 5.1.K.2. Below.
  c)  Not deny any service provided under this Contract to an Enrollee for failure or inability to pay any such charge.
  d)  Not deny any service provided under this Contract to an Enrollee who, prior to becoming MassHealth eligible, incurred a bill that has not been paid.
  e)  Ensure Provider compliance with all Enrollee payment restrictions, including balance billing and co-payment provisions, and develop and implement a plan to sanction any Provider that does not comply with such provisions.

2.  Notwithstanding Section 5.1.K.1.b. above, the Contractor may charge Enrollees co-payments in accordance with the Division's co-payment regulations, provided that the Contractor informs the Division of its co-payment policy within 90 days prior to the effective date of said co-payment policy, which effective date shall coincide with the beginning of a calendar quarter…"  Massachusetts Contract, pages 120-124.

MABH

"B. Delegation to Subcontractors
The Contractor shall: ...
4. include the following language in all Provider Agreements, agreements with non-Network providers and other agreements with providers:
'Providers shall not seek or accept any payment from any Recipient for any Covered Services rendered, nor shall providers have any claim against, or seek any payment from the Division. Instead, providers shall look solely to the Partnership for payment with respect to Covered Services rendered to Recipients. Furthermore, providers shall not maintain any action at law or in equity against any Recipient or the Division to collect any sums that are owed by the Partnership under this Agreement, for any reason, even in the event that the Partnership fails to pay, becomes insolvent or otherwise breaches the terms and conditions of this Agreement. This Section shall survive termination of this Agreement' (where 'Agreement' shall refer to the agreement between the Contractor and any subcontractor and where 'provider' shall refer to the subcontractor, including Network and non-Network providers, with whom the Contractor is contracting,)…"  Massachusetts MH/SAP Contract, Appendix A, pages 18-19.

MI

"II-I SPECIAL COVERAGE PROVISIONS...
6.  Co-payments
The Contractor may subject enrollees to co-payment requirements, consistent with state and federal guidelines.  In regard to co-payments, the Contractor agrees that it will not implement co-payments without DCH approval and that co-payments will only be implemented following the annual open enrollment period.  Enrollees must be informed of co-payments during the open enrollment period…"  Michigan Contract, pages 22, 26.

"II-M CONTRACTOR ORGANIZATIONAL STRUCTURE, ADMINISTRATIVE SERVICES, FINANCIAL REQUIREMENTS AND PROVIDER NETWORKS...
6. Provider Network in the CHCP...
(f)  Provider Contracts
In addition to HMO licensure requirements, Contractor provider contracts will meet the following criteria: ...
*Prohibit the provider from seeking payment from the Enrollee for any Covered Services provided to the Enrollee within the terms of the Contract and require the provider to look solely to the Contractor for compensation for services rendered.  No cost-sharing or deductibles can be collected from Enrollees.  Co-payments are only permitted with DCH approval…"  Michigan Contract, pages 32, 35, 38.

"II-N  PAYMENT TO PROVIDERS...
6.  Total Payment
The Contractor or its providers may not require any co-payments, patient-pay amounts, or other cost-sharing arrangements unless authorized by DCH.  The Contractor's providers may not bill Enrollees for the difference between the provider's charge and the Contractor's payment for Covered Services.  The Contractor's providers will not seek nor accept additional or supplemental payment from the Enrollee, his/her family, or representative, in addition to the amount paid by the Contractor even when the Enrollee has signed an agreement to do so..."  Michigan Contract, pages 41, 47.

MN

"Section 2.49.  Premium Payment means, for MinnesotaCare, the payment made by a MinnesotaCare applicant or Enrollee and received by the STATE as required under Minnesota Statutes, Section 256L.06 and Minnesota Rules, Part 9506.0040."  Minnesota Contract, page 15.

"Section 4.3.1. The STATE shall collect any insurance premiums from Enrollees.

Section 4.3.2. The HEALTH PLAN agrees that no copayments or deductibles shall be charged to MinnesotaCare/MA Enrollees for covered services or services provided as alternatives to covered services as part of the HEALTH PLAN's case management plan.

Section 4.3.3. MinnesotaCare Enrollees must make copayments to the provider of the following services:

A. prescription drugs ($3 per prescription),

B. eyeglasses ($25 per pair) and

C.  inpatient hospitalization (10% of paid charges subject to an annual calendar year maximum of $1,000 per individual and $3,000 per family).

D.  Nonpregnant adults whose income does not exceed 175% of the Federal Poverty Guidelines will have a 50% copay based on the MinnesotaCare fee schedule of the restorative dental services (not including orthodontia).

E.  The HEALTH PLAN may delegate to the providers of these services the responsibility to collect the copayment. The HEALTH PLAN may not reduce or waive the copayment as an inducement to MinnesotaCare Enrollees to enroll or continue membership in the HEALTH PLAN."  Minnesota Contract, pages 39-40.

"Section 6.12. Enrollee Liability. The HEALTH PLAN, and its subcontractor, agrees that, except for Section 4.3.3., the Enrollee shall not be billed or be held responsible in any way for any charges, including copayments or deductibles, for Medically Necessary covered services or services provided as alternatives to covered services as part of the HEALTH PLAN's Care Management plan… In addition, the HEALTH PLAN shall not make payment to an Enrollee in reimbursement for a service provided under this Contract where the provider of the service refuses to accept assignment. See 42 CFR 447.25."  Minnesota Contract, page 66.

"Section 8.4.3. Costs of Appeal. The HEALTH PLAN shall provide reimbursement for transportation, child care, photocopying, medical assessment, witness fee, and other necessary and reasonable costs incurred by the Enrollee or former Enrollee in connection with a STATE Appeal. Necessary and reasonable costs shall not include the Enrollee's legal fees and costs, or other consulting fees and costs incurred by the Enrollee."  Minnesota Contract, page 82.

"Section 9.2.11. Except for MinnesotaCare copays pursuant to Section 4.3.3., the HEALTH PLAN shall ensure that the Enrollee is not held responsible for any fees associated with the Enrollee's medical care received from the HEALTH PLAN subcontractor or an out-of-plan provider with whom the HEALTH PLAN has negotiated a rate for providing the Enrollee services covered under this Contract. Where an Enrollee receives Medical Emergency Services, Post-Stabilization Care Services or Urgent Care Out of Area or Out of Plan, the HEALTH PLAN shall pay the Out of Area or Out of Plan provider on the condition that the provider hold the Enrollee harmless for any financial liability."  Minnesota Contract, page 86.

MO

"c.  Cost Sharing
Parents and guardians of uninsured children with available incomes between one hundred eighty-six and two hundred twenty-five percent of the federal poverty level are responsible for five-dollar copayment.  The parents and guardians of eligible uninsured children with incomes above two-hundred twenty-five and below three hundred percent of the federal poverty level are responsible for copayments equal to the average copayments required in the current Missouri Consolidated Health Care Plan rounded to the nearest dollar, and a monthly premium equal to the average premium required for the Missouri Consolidated Health Care Plan; provided that the total aggregate cost-sharing shall not exceed five percent of such family's income for the years involved.  No copayments or other cost sharing is permitted with respect to benefits for well-baby and well-child care including age appropriate immunizations."  Missouri RFP, page 7.

"d.  Cost sharing
Copayments will apply to increase participant responsibility, move coverage closer to that found in the commercial market, and help reduce the chance of crowd out.  Copayments will be $10.00 at  the time of each provider visit and $5.00 per prescription."  Missouri RFP, page 13.

MT

"SECTION 34  PROTECTING ENROLLEES FROM LIABILITY FOR PAYMENT
Per SSA 1932(b)(6), Balanced Budget Amendment (BBA) Section 4704(a):

A.  The CONTRACTOR shall provide that an ENROLLEE may not be held liable for:
1.  the debts of the CONTRACTOR in the event of the CONTRACTOR's insolvency;
2.  Covered services provided to an ENROLLEE in the event of:
  c.  the CONTRACTOR failing to receive payment from the DEPARTMENT for a covered service; or
  d.  the PARTICIPATING PROVIDER with a contractual, referral, or other arrangement with the CONTRACTOR failing to receive payment from the DEPARTMENT OR CONTRACTOR for a covered service, or

3.  payments to a PARTICIPATING PROVIDER that furnishes covered services under a contractual, referral or other arrangement with the organization in excess of the amount that would be owed by the ENROLLEE if the CONTRACTOR had directly provided the covered service.

B. Neither the CONTRACTOR nor any of its PARTICIPATING PROVIDERS may charge an ENROLLEE money or other consideration at a rate in excess of the rate permitted under any SUBCONTRACT to this con-tract for a covered service."  Montana Contract, pages 24-25.

"2.4.2  Participating Providers:...
B.  Providers Contracts Must be Extended to or Contractors Must Allow Access to:...
2)  Federally Qualified Health Centers (FQHCs) and Rural Health Clinics RHCs:...

2) If a recipient voluntarily chooses to participate in an HMO with an FQHC or RHC as a plan participant; and then chooses to go to an FQHC or RHC that is not a plan participant, then the recipient will be responsible to pay for services received from the FQHC or RHC."  Montana Contract, pages 35-37.

"2.5  PROVISION OF SERVICES
2.5.1  COVERED SERVICES...
7.  The CONTRACTOR shall not impose ENROLLEE co-payments for covered services and special programs."  Montana Contract, page 40.

NE

"8.34.1 Client Protection: Clients shall not be held liable for payments to providers or entities in the following situations:

(a) The plan or subcontractor’s insolvency;

(b) The Department, as authorized by the contract, does not pay the plan; or

(c) Payments under an arrangement with the plan in excess of the amount that would be owed if the plan directly provided the service…"  Nebraska Contract, page 24.

"13.44.1 Copayments: Copayments are not required for clients enrolled in NHC, with the exception of prescription drugs or other Medicaid-covered services not included in the Basis Benefits Package. Copayments are not required for Mental Health/Substance Abuse (MH/SA) services for clients enrolled in the NHC, except for services not included in the MH/SA Package."  Nebraska Contract, page 93.

"13.53.2 Billing the Client: The plan or any provider shall not bill the client for services in the NHC benefits package while the client is enrolled in the NHC.

A provider of service may only bill the client pursuant to 471 NAC."  Nebraska Contract, page 101.

NEBH

"8.34  Hold Harmless: ...
8.34.1 Client Protection:  Clients may not be held liable for payments to providers or PHPs in the following situations:
  (a)  The PHP or subcontractor’s insolvency;
  (b)  The Department, as authorized by the contract, does not pay the PHP; or
  (c) Payments under an arrangement with the PHP are in excess of the amount that would be owed if the PHP directly provided the service."  Nebraska Behavioral Health Contract, page 25.

"11.52.2  Copayments:  The PHP shall ensure that copayments are not required for MH/SA services for clients enrolled in the NHC.  Applicable copayments are only required for services not included in the MH/SA Package."  Nebraska Behavioral Health Contract, page 64.

"11.58.5  Billing the Client: The PHP may not bill the client for a Medicaid coverable service, regardless of the circumstances.

A provider of service may only bill the client pursuant to 471 NAC."  Nebraska Behavioral Health Contract, page 71.

NV

"14.  Contractor must not accept compensation for work performed under this contract from any other department of the State of Nevada, from Medicaid recipients nor from any other source including the federal government or other clients except for the collection of third party liability (TPL) as described herein in paragraph 39, and in Section IX.C. in Attachment B."  Nevada Contract, pages 8-9.

"16.  Section II.  Enrollment, Paragraph N.  Premium Notification and Disenrollment is added to page 49 of the Contract as follows:
  'For the Nevada Check Up Program a quarterly premium will be charged per family based on annual gross income.  The premium will be due on the first day of each quarter (January 1, April 1, July 1, and October 1).  Families will be informed at the time of enrollment notification of the timing and amount of premiums.  A reminder premium notice will be sent approximately 3 weeks prior to the due date.  DHCFP will send the health plan a listing of the families who have not paid the quarterly premium by the 10th day of the month the premium is due and encourage the health plan to contact the family by letter or phone.  If payment is not received by the 45th day of the quarter, the family will be sent a notice of disenrollment to be effective the first day of the next month.
If the family pays the quarterly premium within 60 days from the due date of the quarter and no later than the end of the month prior to disenrollment, the family will be considered enrolled and the payment will be adjusted retroactively.  If the family pays the premium after the administrative cut-off (9 days prior to the end of the month), DHCFP will submit an exception report to the managed care Contractor identifying those families who paid their premium and continue to remain eligible.  If the family fails to pay the premium they will be disenrolled.

A participant who is disenrolled due to failure to pay a premium will be reinstated into the program once premium payments are made current.'"  Nevada Amendment #1, page 9.

NH

"Article II
Functions and Duties of Contractor ...

2.3  COLLECTING PAYMENT-----To refrain, and to cause Physicians and Subcontractors of Contractor to refrain, from charging or collecting any payment from an Enrollee for Covered Services furnished to him or her while enrolled in Contractor under this Agreement."  New Hampshire General Service Agreement, page 7.

"Exhibit B. ...

C.  Prohibition Against Charging Enrollees
  (1) The Contractor shall not charge Enrollees co-payments, deductibles, financial penalties or any other amount for Covered Services provided under this Agreement.
  (2)  Contractor shall hold Enrollees and the state harmless for any claims for payment other than the Capitation payment resulting from the delivery of Covered Services provided under this Agreement."  New Hampshire General Service Agreement, Exhibit B, page 11.

NJ

"ARTICLE 16
MONITORING AND EVALUATION...
  F.  The contractor shall not impose, or allow its subcontractors or participating providers to impose, copayment charges of any kind upon Medicaid recipients enrolled in the contractor's plan pursuant to this contract…"  New Jersey Contract, pages 84-89.

"ARTICLE 20
PROVIDER CONTRACTS...
20.7  All provider contracts must obligate the provider to comply with the following items...
  J.  A clear statement that there are no co-payments or deductibles for Medicaid enrollees…"  New Jersey Contract, pages 110-113.

"APPENDIX R
COST-SHARING REQUIREMENTS FOR NJ KIDCARE. PLAN C  BENEFICIARIES

PREMIUMS
A monthly premium of $15 per month, per family, regardless of family size, will be required of beneficiaries eligible solely through NJ KidCare - Plan C whose family income is between 150°/a and up to and including 200% of the federal poverty level...

PERSONAL CONTRIBUTION TO CARE (PCC) FOR NJ KIDCARE - PLAN C
For beneficiaries solely eligible through NJ KidCare - Plan C, PCCs will be required for certain services provided to individuals whose family income is between 150% and up to and including 200% of the federal poverty level.

The total family (regardless of family size) limit on all cost-sharing may not exceed 5% of the annual family income…"  New Jersey Contract, Appendix R, page 231.

“APPENDIX T
COST-SHARING REQUIREMENTS FOR
NJ KIDCARE PLAN D BENEFICIARIES

PREMIUMS
Eligibles participating in NJ KidCare - Plan D whose family income, regardless of family size, is between 201 °/a and up to and including 250% of the federal poverty level, will pay a monthly premium of $30; for eligibles participating in NJ KidCare - Plan D whose family income, regardless of family size, is between 251% and up to and including 300% of the federal poverty level, the monthly premium will be $60; for eligibles participating in NJ KidCare - Plan D whose family income, regardless of family size, is between 301% and up to and including 350% of the federal poverty level, the monthly premium will be $100...

COPAYMENTS FOR NJ KID CARE - PLAN D
For beneficiaries solely eligible through NJ KidCare - Plan D, copayments will be required for certain services provided to individuals whose family income is between 201 % and up to and including 350% of the federal poverty level.

The total family limit (regardless of family size) on all cost-sharing may not exceed 5% of the annual family income…"  New Jersey Contract, Appendix T, page 238.

NM

"5.D.9  Members shall not be charged for services covered under the terms of this Agreement, except as provided in the Medical Assistance Program Provider Policy Manual Section MAD-701.7, Acceptance of Recipient or Third Party Payments."  New Mexico Contract, page 75.

"23.4  The CONTRACTOR including its subcontractors agrees that in no event including but not limited to nonpayment by CONTRACTOR insolvency of CONTRACTOR or breach of this Agreement shall CONTRACTOR or its subcontractor bill, charge, collect a deposit from, seek compensation, remuneration, or reimbursement from or have any recourse against an enrollee or persons (other than CONTRACTOR) acting on their behalf for services provided pursuant to this Agreement.  In no case will the State. HSD and/or Medicaid beneficiaries be liable for any debts of the CONTRACTOR."  New Mexico Contract, page 97.

"ARTICLE 24 - LIABILITY
24.1  The CONTRACTOR shall be wholly at risk for all covered services. No additional payment shall be made by HSD, nor shall any payment be collected from an enrollee except for co-payments authorized by HSD or State laws or regulation."  New Mexico Contract, page 98.

"22.  New Article 41 is created and certain provisions of the Agreement are amended to include participants of the State Children Health Insurance Program (SCHIP) as members:  ...

  The CONTRACTOR may enforce, against participants of the SCHIP Program only, any cost sharing requirements approved by HCFA...

Article 5.A. is amended as follows:
5.A.   Medicaid and SCHIP members shall be held harmless against any liability for debts of an MCO which were incurred within the Agreement in providing health care to the Medicaid or SCHIP member, excluding any member's liability for copayments or member's liability for an overpayment resulting from benefits paid pending the results of a fair hearing.  CONTRACTOR has no obligation to continue to see members for treatment if the member fails to meet copayment obligations."  New Mexico Contract, Amendment #1, page 11.

NC

"11.1  State's Indemnity
In no event will the State, the Division, or a Recipient be liable for the payment of any debt or fulfillment of any obligation of the…Out-of-Plan Provider…for any reason, whatsoever, including the insolvency of the Plan or any of its subcontractors..."  North Carolina Contract, page 20.

ND

"2.2  Provision of Covered Services...
(8)  The Contractor shall not impose enrollee copayments for covered services and special programs…"  North Dakota Contract, Attachment C, pages 8-9.

OH

"APPENDIX J…
MODEL MEDICAID ADDENDUM…

ADDENDUM PROVISIONS...
Participating providers providing health care services to (MCP Name's) members enrolled pursuant to a Medicaid contract agree to abide by all of the following specific terms: ...
6.  Provider agrees not to charge the member or ODHS any  copayments for covered services.
7.  Provider agrees to hold harmless both ODHS and the member in  the event that the MCP cannot or will not pay for covered  services performed by the provider pursuant to the Agreement..."  Ohio RFP, Appendix J, pages 1-3.

OK

"2.19  Payments from Health Plan...
2.19.2.2  Seeking Payment/Reimbursement From Member
Under no circumstances may Health Plan or any provider or subcontractor of the Health Plan seek payment or reimbursement from a member for all or part of the cost of a SoonerCare Plus covered service…"  Oklahoma RFP, pages 59-60.

"2.19.4  Co-Payments
Unless authorized by the Authority and HCFA, Health Plan is prohibited from collecting co-payments and from imposing any other cost sharing requirements on members for delivery of services included in the pre-paid benefit package…"  Oklahoma RFP, page 62.

ORMH

"V. Statement of Work...
2.  Provision of Covered Services...
C.  Contractor shall provide all Covered Services to OMAP Members but may require, except in an emergency, that OMAP Members obtain such covered services from Contractor or providers affiliated with Contractor…Contractor shall ensure that neither Division nor the OMAP Member receiving services is held liable for any costs or charges related to Covered Services rendered to an OMAP Member whether in an Emergency or otherwise."  Oregon Mental Health Contract, pages 6-7.

"d.  Contain a provision that the subcontractor shall not bill, charge, seek compensation, remuneration or reimbursement from, or have recourse against Division or any OMAP Member for Covered Services provided during the period for which Capitation Payments were made by the Division through OMAP to Contractor with respect to said OMAP Member, even if contractor becomes insolvent."  Oregon Mental Health Contract, page 38.

PA

"P.  PAYMENTS TO AND FROM HMOs...
3.  Member Cost-Sharing
The Department may choose to include cost-sharing requirements and co-payments to the HealthChoices Program after initial implementation which may vary depending upon the criteria by which a member attains eligibility.  Should the Department implement this procedures, the HMO must agree to assume the responsibility for collecting cost-shares directly from its member and co-payments through its providers.  The HMO may not deny a service to a member should the member be unable to pay the co-payment, however, the member will be held responsible for the fee and can be billed by the provider.  The HMO must also agree not to bill or attempt to collect any other fee from, or for, a program member.  All premiums and co-payments collected, should the Department implement future cost sharing requirements, shall belong to the HMO."  Pennsylvania RFP, pages 90-93.

PABH

"3)  The MCO must publish and distribute a member handbook to all members and make it available to other interested parties upon request.  The handbook must be printed at no higher than a fourth grade reading level, delineating a member's rights and responsibilities, as well as covering: ...
  d)  no co-pay or cost sharing obligation by the member…"  Pennsylvania Behavioral Health RFP, page 55.

RI

"2.15.03  Member Cost-Sharing
2.15.03.01  General
The RIte Care program includes cost-sharing requirements (premiums and copayments) that vary depending on the criteria by which a member attains eligibility...

2.15.03.02  Cost-Sharing For RIte Care Members With Income Above 185 Percent Of The FPL (Except Extended Family Planning Group)
RIte Care members with income above 185 percent of the FPL (except the Extended Family Planning group) will be offered the choice of paying a portion of their premium each month along with a short schedule of copayments, or paying no premiums and being subject to a longer schedule of copayments.  The two options ('Premium Share' and 'Copayment') have been designed to be actuarially equivalent...

2.15.03.03  Cost-Sharing For RIte Care Members Enrolled In Extended Family Planning
RIte Care members who are enrolled into the Extended Family Planning Group will be subject to a schedule of copayments...

2.15.03.04  Cost-Sharing For Related Groups
Individuals who elect coverage through one of the related groups will be responsible for making full premium payments unless otherwise designated by the State...

2.15.03.05  Cost-Sharing For Pregnant Women In Excess Of 250 Percent Of The FPL
Pregnant women in excess of 250 percent of the FPL will be required to pay the full monthly premium directly to Contractor...

2.15.03.06  Cost-Sharing For Members In Extended Family Planning In Excess Of 250 Percent Of The FPL
RIte Care members enrolled in Extended Family Planning who were previously enrolled as eligible in 2.15.03.05 shall be required to pay full monthly premium directly to Contractor…"  Rhode Island RFP, pages 46-50.

SC

"2.3  Co-payments
No co-payments for Medicaid HMO Program members will be allowed under this Contract." South Carolina Contract, page 5.

TN

"2-3.  Benefits/Service Requirements and Limitations...
k.  Cost Sharing for Services
  The CONTRACTOR and all providers and subcontractors shall not require any deductibles, copayments and/or special fees for TennCare covered services except to the extent that deductibles, copayments and/or special fees are required for those services by TENNCARE nor may the CONTRACTOR and all providers and subcontractors charge enrollees for missed appointments unless otherwise approved by TENNCARE.  The CONTRACTOR may impose deductibles, copayment and/or special fees for non-TennCare covered services provided at the option and expense of the CONTRACTOR.  Such optional services include, but are not limited to, routine adult vision services, routine adult dental services, etc.

   Deductibles and copayments shall apply to services other than the preventive services described in Section 2-3.a.2. of this Agreement.  Deductibles and general copayments shall be applied on a sliding scale according to the enrollee's income.  The only special fee that can be applied is a $ 25 fee for non-emergency use of hospital emergency rooms by non-Medicaid eligible enrollees...

   Deductibles and copayments charged the enrollee shall be based upon the rate negotiated between the MCO and the provider. (e.g., an enrollee with a six percent (6%) copayment level would be charged $ .60 if the MCO negotiated rate for the service was $10.00.)

  Providers may not bill enrollees for amounts other than applicable deductibles, coinsurance and special fees for TennCare covered services except as permitted by TennCare rule 1200-13-12-.08 and as described below. Providers may seek payment from an enrollee in the following situations:
  1.  if the services are not covered by TennCare and the provider informed the enrollee the services were not covered prior to providing the service...
  2.  if the enrollee’s TennCare eligibility is pending at the time services are provided if the provider informs the person they will not accept TennCare assignment whether or not eligibility is established retroactively...
  3.  if the enrollee’s TennCare eligibility is pending at the time services are provided...
  4.  the enrollee requests services that are non-TennCare covered services provided at the option of the CONTRACTOR...

m.  Out of Area or Out of Plan Use...
  6.  The CONTRACTOR shall include provisions in the notice described in Section 2-6.b.1. of this Agreement which clearly explain that the enrollee is liable for any copayments, deductibles and special fees required by the plan and the providers and/or CONTRACTOR may utilize whatever legal actions are available to collect these amounts…"  Tennessee Contract, pages 7-24.

2-10.    Administration and Management...
e.  Fiscal Management
  If the service was provided by a non-contract provider, the CONTRACTOR shall assure that the enrollee is held harmless by the provider for the costs of the service or procedure except for applicable deductible and copayment amounts…"  Tennessee Contract, pages 46-48.

TX

"7.2  PROVIDER CONTRACTS…
7.2.8.3…  Federal and State laws provide severe penalties for any provider who attempts to collect any payment from or bill a Medicaid recipient for a covered service..."  Texas Contract, pages 54, 56-57.

UT

"B.  Enrollee Liability
  1.  The CONTRACTOR will not hold an enrollee liable for the following: ...
  b.  Payment for services provided by the CONTRACTOR if the CONTRACTOR has received payment from the DEPARTMENT for the services, or if he provider, under contract with the CONTRACTOR, fails to receive payment from the CONTRACTOR.
  c.  The payments to providers that furnish Covered Services under a contract or other arrangement with the CONTRACTOR that are in excess of the among that normally would be paid by the Enrollee if the service had been received directly from the CONTRACTOR."  Utah Contract, Attachment B, page 28.

"G.  Billing Enrollees
  1.  In General...
  No claim for payment will be made at any time by the CONTRACTOR or CONTRACTOR provider to an Enrollee accepted by the provider as a Medicaid Enrollee for any service covered under this Contract.  When a provider accepts an Enrollee as a patient he or she will look solely to third party coverage or the CONTRACOR for reimbursement.  If the provider fails to receive payment form the CONTRACTOR, the Enrollee cannot be held responsible for these payments.

  2.  Circumstances When an Enrollee May be Billed
  An Enrollee may in certain be billed by the CONTRACTOR provider for non-Covered Services.  A non-Covered Service is one that is not covered under this Contract, or includes special features or characteristics that are desired by the Enrollee, such as more expensive eyeglass frames, hearing aids, custom wheelchairs, etc., but do not meet the Medical Necessity criteria for amount, duration, and scope...

  An Enrollee may be billed for a service not covered under this Contract only when the following conditions are met:
  a.  The CONTRACTOR has an established policy for billing all patients for services not covered by a third party...
  b.  The CONTRACTOR will inform Enrollees of its policy and the services and items that are non covered under this Contract and include this information in the Enrollee's member handbook.
  c.  The CONTRACTOR provider will advise the Enrollee prior to rendering the service that the service is not covered under this Contract and that the Enrollee will be personally responsible for making payment.
  d.  The Enrollee agrees to be personally responsible for the payment and an agreement is made in writing between the CONTRACTOR provider and the Enrollee which details the service and the amount to be paid by the Enrollee."  Utah Contract, Attachment B, pages 30-31.

"C.  Medicare...
  3.  Must Not Balance Bill Enrollees
  The CONTRACTOR and CONTRACTOR provider will not Balance Bill the Enrollee and will consider the reimbursement from Medicare and from the CONTRACTOR payment in full."    Utah Contract, Attachment. B, pages 37-38.

UTMH

"2.  Charges - The CONTRACTOR will not charge Enrollees for any Covered Services under this Contract.  No claim for payment will be made at any time by the CONTRACTOR or the CONTRACTOR's subcontracting providers to an Enrollee for any Covered Service under this Contract…When the CONTRACTOR's subcontracting providers accept an Enrollee as a client, they must look solely to third party coverage and the CONTRACTOR for reimbursement.

  a.  The CONTRACTOR (or its subcontractors) will not hold an Enrollee liable for the following:
  1)  The debts of the CONTRACTOR (or one of its subcontractors) if it should become insolvent;
  2)  Payment for services provided by the CONTRACTOR  if the CONTRACTOR has not received payment from the DEPARTMENT for services, or if the provider under contract with the CONTRACTOR fails to receive payment from the CONTRACTOR; or
  3)  The payments to providers that furnish covered services under a contract or other arrangement with the CONTRACTOR that are in excess of the amount that normally would be paid by the Enrollee if the service has been received directly from the CONTRACTOR.

  b.  The CONTRACTOR and the CONTRACTOR's subcontracting providers shall not balance bill Enrollees who are dually eligible for Medicare and Medicaid, but must consider reimbursement from Medicare and Medicaid payment for Medicare crossover claims as payment in full."  Utah Mental Health Contract, page 9.

VA

"E.  BILLING ENROLLEES FOR MEDICALLY NECESSARY SERVICES
The Contractor and its subcontractors are subject to criminal penalties if providers knowingly and willfully charge, for any service provided to a recipient under the State Plan or under this Contract, money or other consideration at a rate in excess of the rate established by the Department, as specified in Section 1128(d)(1) of the Social Security Act (42 U.S.C. § 1320a-7b as amended...

Pursuant to Section 1932(b)(6), (42 U.S.C. § 1396u-2 (b)(6)) the contractor and all of its subcontractors shall not hold a recipient liable for:
1.  Debts of the Contractor in the event of the Contractor's insolvency;
2.  Payment for services provided by the Contractor if the Contractor has not received payment from the Department for the services or if the provider, under contract or other arrangement with the Contractor, fails to receive payment from the Department or the Contractor; or
3.  Payments to providers that furnish covered services under a contract or other arrangement with the contractor that are in excess of the amount that normally would be paid by the recipient if the service had been received directly from the Contractor.

F.  BILLING ENROLLEES FOR OTHER SERVICES
The Contractor, including its network providers and subcontracts, shall not bill an enrollee for any services provided under this Contract.  However, if an enrollee agrees, in advance of receiving the service and in writing, to pay for a service that is not a State Plan covered service, then the Contractor, directly or through its network provider or subcontractor, can bill the enrollee for the service."  Virginia Contract, page 94.

WA

"7.2  Required Provisions:  Subcontracts must be in writing, consistent with the provisions of 42 CFR 434.6…
b.  Health care provider subcontracts, including those for facilities, must also contain the following provisions:
4.  The subcontractor accepts payment from the Contractor as payment in full and shall not request from DSHS or any member for covered services performed under the subcontract..."  Washington Contract,  pages 30-31.

"4.15  Prohibition on Member Charges for Covered Services:  Under no circumstances shall the Contractor, or any of the providers used to deliver services covered under the terms of this agreement, charge enrollees for covered services (SSA 1932(b)(6), SSA 1128B(d)(1))."  Washington Contract, page 19.

"AMENDMENT 1
1.  The purpose of this amendment is to add coverage for Children's Health Insurance Program (CHIP) clients.
2.  The terms and conditions of the department's Request for Qualifications and Quotation (RFQQ) for CHIP, including the amendment and questions and RFQQ answers, are incorporated by reference, except as specifically modified below: ...
  d.  Provision 2.41 of Section 3 of the CHIP RFQQ is modified as follows:  Office visit copays do not apply to office visits for consultations.  For purposes of applying copays, consultations means CPT codes 99241-99275…"  Washington Contract, Amendment 1, page 1.

"AMENDMENT 1
1.  The purpose of this amendment is to add coverage for Children's Health Insurance Program (CHIP) clients...
5.  The following terms and conditions of this contract are modified as follows for CHIP enrollees: ...
  d.  Section 4.15, Prohibition on Member Charges for Covered Services.  For CHIP, the prohibition does not include charging members for the required copays."  Washington Contract, Amendment 1, pages 1-2.

"2.4  Client Cost -Sharing
2.41  CHIP clients will have cost-sharing in the form of monthly premium payments and service copays as follows, except that American Indian/Alaska Native clients will have no cost-sharing:
  •  The premium payment is $10 per child per month, up to a maximum of $30 per month per family. DSHS will collect this from clients.
  •  An office visit copay of $5 per visit applies to office visits with physicians, physician assistants, and advanced registered nurse practitioners, except for well child exam and childhood immunization visits. The copay does not apply to inpatient visits.
  •  A $5 copay applies to non-generic prescriptions only.
  •  A $25 copay applies to emergency room visits, but is waived if the enrollee is admitted to the hospital from the emergency room.

2.42  The annual maximum out-of-pocket expenses for a family are $300 per child and $900 per family. This includes premium payments and service copays...
  •  The copay can be billed to the client
  •  The copay can be waived
  •  The service can be denied. This option does not apply to emergency department services provided to enrollees with emergency medical conditions.

2.44  The MAA will cancel coverage for CHIP clients when client premiums are at least ninety (90) days in arrears. To have coverage reinstated, the account must be brought up to date and the client must wait a period equal to the period of payment delinquency (e.g., if 3 months delinquent, must wait 3 months before coverage begins again). Coverage will be restored on a prospective basis only."  Washington CHIP RFQQ, pages 8-9.

WV

"Enrollee Liability. The Managed Care Plan cannot hold an enrollee liable for the following:
*  The debts of the Managed Care Plan if it should become insolvent;

*  Payment for services provided by the Managed Care Plan if the Managed Care Plan has not received payment from the Department for the services, or if the provider, under contract or other arrangement with the Managed Care Plan, fails to receive payment from the Department or the Managed Care Plan; or

*  The payments to providers that furnish covered services under a contract or other arrangement with the Managed Care Plan that are in excess of the amount that normally would be paid by the enrollee if the service had been received directly from the Managed Care Plan.

3.30 Co-payment Limits
No deductibles or copayments are permitted for Medicaid covered services…"  West Virginia Contract, pages 28-29.

"6.1  Solvency Requirements
6.1.1  General
The MCP must make provisions against the risk of insolvency and assure that neither enrollees nor DHHR are held liable for debts in the event of the MCP's insolvency or the insolvency of any subcontractors."  West Virginia RFA, page 42.

"2.1.1 Covered MCP Services...
The MCP will be paid a fixed rate per member per month (PMPM) and will not be permitted to collect any additional copayments or premiums from enrollees…"  West Virginia RFA, page 7.

"2.3   Other Requirements Pertaining to Covered Services...
Additionally, MCPs cannot impose any enrollee copayments or fees for contracted services. MCPs and their participating providers may not bill or collect any payment from Medicaid enrollees for care that was determined not to be medically necessary. Also, if emergency room care is later deemed non-emergency, the MCP is not permitted to bill the Medicaid patient....

3.1.3  Contract Requirements
The MCP's provider contracts or addenda to provider contracts must be consistent with the requirements of the statement of work and must include the following provisions:
*  enrollees will be held harmless for the costs of all Medicaid-covered services provided…"  West Virginia RFA, pages 14-15.

WI

"III.  FUNCTIONS AND DUTIES OF THE HMO
In consideration of the functions and duties of the Department contained in this Contract the HMO shall: ...

B.  PROVISION OF CONTRACT SERVICES...
13. HMO and its providers and subcontractors shall not bill a Medicaid enrollee for medically necessary services covered under the Medicaid/HMO Contract and provided during the enrollee's period of HMO enrollment. HMO and its providers and subcontractors shall not bill a Medicaid enrollee for copayments and/or premiums for medically necessary services covered under the Medicaid/HMO Contract and provided during the enrollee's period of HMO enrollment. This provision shall continue to be in effect even if the HMO becomes insolvent.

However, if an enrollee agrees in advance in writing to pay for a non-Medicaid covered service, then the HMO, HMO provider, or HMO subcontractor may bill the enrollee. The standard release form signed by the enrollee at the time of services does not relieve the HMO and its providers and subcontractors from the prohibition against billing a Medicaid enrollee in the absence of a knowing assumption of liability for a non-Medicaid covered service…"  Wisconsin Contract, pages 5, 11.