56-257 COPAYMENTS.
PUBLIC ASSISTANCE AND WELFARE
CHAPTER 2
PUBLIC ASSISTANCE LAW
56-257. Copayments. (1) The department of health and welfare shall establish enforceable cost sharing in order to increase the awareness and responsibility of medicaid participants for the cost of their health care and to encourage use of cost-effective care in the most appropriate setting. Copayments established by department rule may include, but not be limited to, the following:
(a) Inappropriate emergency room utilization. "Inappropriate emergency room utilization" means the use of the emergency room for services that are nonemergency and that can be delivered in a regular clinic setting. If a hospital provider determines that it is reasonable that any prudent layperson would have sought emergency treatment in the same circumstances, a copayment will not be applied to such an individual even if the care rendered is nonemergency;
(b) Inappropriate use of emergency medicaid funded medical transportation. "Inappropriate use of emergency medical transportation" means the use of emergency medical transportation for conditions that do not meet the criteria for emergency conditions specified in department rule;
(c) Missed appointments with health care providers. The department may limit the types of providers for which copayments for missed appointments are applicable. No such provider will be required by the department to collect copayments as required in this section; and
(d) Nonpreferred prescription drugs. A nonpreferred drug is a drug for which an alternative therapeutically interchangeable drug in the same pharmacological class is available whose use provides advantages to the medicaid program based on relative safety, effectiveness, clinical outcomes and cost. Pharmacy providers may be required to collect copayments at the point of service. Pharmacy providers shall not be required to dispense any prescribed medication unless a medicaid participant provides for any applicable copayment under this paragraph. Copayments shall not constitute a reduction of overall reimbursement to pharmacists for the dispensing of prescribed medicine.
(2) The director may exempt, subject to federal approval, any group of medicaid participants from the cost-sharing provisions in this section.