PM 20-03-04-a: Client Copays

WAG 20-03-04-a.

HFS reduces the payment made to the hospital, doctor, or pharmacy by the amount of the copay. The hospital, doctor, or pharmacy is responsible for collecting the copay from the client.

Hospitals, doctors, and pharmacies cannot refuse to care for someone who has not paid their copay.

Inpatient Hospital Care

Some persons may be required to pay part of their inpatient hospital costs as a copay. Clients age 18 or younger, pregnant women, women who had a baby in the last 6 weeks, and clients in nursing homes do not have to pay copays.

Copays are figured by days in the hospital, rather than the cost. Copay amounts are:

• $3 per day for inpatient hospital services in hospitals with an alternate cost per diem rate (as described in Ill. Adm. Code, Section 148.270) of $235.00 or more;
• $3 per day for inpatient hospital services paid under DRG methodology (as described in 89 Ill. Adm. Code, Section 149);
• $0 for inpatient hospital services in hospitals with an alternate cost per diem rate (as described in 89 Ill. Adm. Code, Section 148.27) of $275 or less.

Medical Services Other Than Inpatient Hospital Care for Adults

Some adults may have to pay a $2.00 copay for each visit to a doctor. This includes visits to physicians, chiropractors, podiatrists, and optometrists. In addition, adults may have to pay $3.00 for each brand name prescription. There is no copay for prescribed generic drugs.

The following is a complete list of persons excluded from copays. Copays do not apply to a person who:

• is pregnant(including 60 days postpartum);
• is under age 19;
• is in a category 98 case;
• receives hospice care;
• lives in an institution (hospitals, nursing facilities, or intermediate care facilities for the mentally retarded);
• lives in a supported living facility;
• lives in a sheltered care facility; or
• lives in a State certified, licensed, or contracted residential setting. These settings include DHS approved Home and Community-based Residential Settings and a residence provided by an agency licensed for Community Integrated Living Arrangement (CILA) services.

There are no copays for the following, even if they are provided to an adult:

• family planning services;
• emergency services;
• services paid by Medicare; and
• certain medications, including insulin, AIDS drugs, chemotherapy drugs, hemophilia drugs, certain cardiovascular drugs, and over-the-counter drugs.