Ga. Medicaid Part II Policies & Procedures for Hospice Services, Appendix I

A. The co-payment does not apply to the following members:

i. Pregnant women

ii. Members under 21 years of age

iii. Nursing Facility residents

iv. Hospice Care members

v. Women diagnosed with breast or cervical cancer and receiving Medicaid under the Women’s Health

Medicaid Program, aid categories 245 and 800 only. This change is effective January 1, 2007. It applies

to all services rendered, beginning January 1, 2007 and thereafter.

B. The co-payment does not apply to the following services:

i. Emergency services, and

ii. Family Planning services

iii. Waiver services

iv. Dialysis

The provider may not deny services to any eligible Medicaid member because of the member’s inability to pay

the co-payment.

The provider should check the Eligibility Certification (Medicaid card) each month to identify those individuals

who may be responsible for the co-payment. The Eligibility Certification has been modified to include a co-payment column adjacent to the date-of-birth section. When “yes” appears in this column for a specified

member, the member may be subject to the co-payment.

The Division may not be able to identify all members who are exempt from the co-payment. Therefore,

providers should identify the members by entering the following indicators in field 24(I) of CMS-1500 claim

form:

P = Pregnant

S = Nursing Facility Members

H = Hospice

E = Emergency Services

PeachCare for Kids® Co-payments: For children ages 6 and over, the following copayments apply for

fee for service and CMOs:

Category of Service Co-Payment

Ambulatory Surgical Centers / Birthing $3.00

Durable Medical Equipment $2.00

Federally Qualified Health Centers $2.00

Free Standing Rural Health Clinic $2.00

Home Health Services $3.00

Hospital-based Rural Health Center $2.00

Inpatient Hospital Services $12.50

Oral Maxillofacial Surgery Cost-Based

Orthotics and Prosthetics $3.00

Outpatient Hospital Services $3.00

Pharmacy - Preferred Drugs $0.50

Pharmacy - Non-Preferred Drugs Cost-Based

Physician Assistant Services Cost-Based

Physician Services Cost-Based

Podiatry Cost-Based

Vision Care Cost-Based

Cost-Based Co-Payment Schedule

Cost of Service Co-Payment

$10.00 or less $0.50

$10.01 to $25.00 $1.00

$25.01 to $50.00 $2.00

$50.01 or more $3.00

NOTE:

There are no co-payments for children below the age of 6 years old, for children in Foster Care, or for

children who are American Indians or Alaska Natives.