Highlight on Montana: Medicaid copay increases kick in; providers worry about burden

Planned increases for Montana’s Medicaid copayments went into effect on June 1, 2016. The changes set forth a copayment amount for certain Medicaid members, with copayments not to exceed a combined limit of 5 percent of the family’s household income quarterly. Some are concerned that the increases could burden low-income patients.

Copayment increases

Under the changes, which were spurred by a provision in Montana’s Medicaid expansion plan, members will income above 100% of the federal poverty level (FPL) will be responsible for a 10 percent copayment of the provider’s reimbursed amount for any Medicaid-covered service. For members with income at or below 100 percent of the FPL will be responsible for a copay of $4 for preferred brand drugs and an $8 copay for non-preferred brand and specialty drugs; $3-$4 copay for dental, home health, licensed professional counselor, psychologist, licensed clinical social worker, and speech therapy services; $2-$4 copay for audiology, hearing aids, occupational therapy, optician/optometric, and physical therapy services; $1-$4 copay for public health clinic services; and $0-$4 copay for home dialysis attendant, personal assistance, independent lab and x-ray, mental health clinic, chemical dependency, and targeted case management services. Provider preventable healthcare acquired conditions, generic drugs, and approved preventive services no longer require a copayment. Providers may not deny services if the member is at or below 100 percent of the FPL and is unable to pay copayments. The member remains responsible for paying any copayments owed to the provider.

American Indians and Alaska Natives who are eligible for or have received a service from a Tribal health, Urban Indian clinic, or Indian Health Service provider; terminally ill members receiving hospice services; and members who are receiving services under the Medicaid breast and cervical cancer treatment category will no longer have copayments.

Burden to low-income members

Barb Mettler, executive director of the Mental Health Center in Billings, Montana, expressed concern that the increases will affect the poorest and most vulnerable Medicaid members, who may use Medicaid-covered services several times a week. “The way I see it is they have three options. They find an additional way to pay, they don’t pay, or they stop using the services,” Mettler said. Even with caps on the total copay, she worries that clients will choose not to seek the care they need.

The burden on patients translates to a burden on health care providers. Under the new changes, providers cannot and will not turn away people at or below 100 percent of the FPL who are unable to pay the copayments, requiring the facility to make up the costs. According to Mettler, the Mental Health Center had to make up a shortfall of about $500,000 of unpaid patient charges in 2015, after already having to factor charity care and bad debt into its budget.