(1) Except as provided in this rule each participant in the HELP Plan must pay to the provider of service copayments as described below not to exceed the cost of service.

(2) All HELP Plan participants receive a credit in the amount of their premium obligation towards the first copayments accrued up to two percent of household income.

(3) Premiums and copayments combined may not exceed an aggregate limit of five percent of the annual family household income.

(4) Participants with incomes at or below 100 percent of the FPL are responsible for the following copayments:

(a) inpatient hospital - $75 per discharge;

(b) nonemergency services provided in an emergency room - $8;

(c) pharmacy-preferred brand drugs - $4;

(d) pharmacy-non-preferred brand drugs, including specialty drugs - $8;

(e) professional services - $4;

(f) outpatient facility services - $4;

(g) durable medical equipment - $4; and

(h) lab and radiology - $4.

(5) Participants with incomes above 100 percent of the FPL are responsible for the following copayments:

(a) inpatient hospital - 10 percent of provider reimbursed amount;

(b) nonemergency services provided in an emergency room - $8;

(c) pharmacy-preferred brand drugs - $4;

(d) pharmacy-non-preferred brand drugs, including specialty drugs - $8;

(e) professional services - 10 percent of provider reimbursed amount;

(f) outpatient facility services - 10 percent of provider reimbursed amount;

(g) durable medical equipment - 10 percent of provider reimbursed amount; and

(h) lab and radiology - 10 percent of provider reimbursed amount.

(6) Copayments are subject to a quarterly aggregate cap of one-quarter of three percent of the annual household income. Copayments may not be charged in a quarter after a household has met the quarterly aggregate cap.

(7) Copayments may not be charged for:

(a) preventative health care services;

(b) immunizations provided according to a schedule established by the department that reflects guidelines issued by the Centers for Disease Control and Prevention;

(c) medically necessary health screenings ordered by a health care provider;

(d) generic pharmaceutical drugs;

(e) eyeglasses purchased by the Medicaid program under a volume purchasing agreement; and

(f) other services exempt by applicable federal authority.

(8) Copayments may not be charged for services rendered in circumstances of third party liability (TPL) claims where the HELP Plan is the secondary payer under ARM 37.85.407. If a service is not subject to TPL, but is covered by the HELP Plan, copayments are applied.

(9) Copayments may not be charged to the participant until the claim has processed through the claims adjudication process and the provider has been notified of payment and amount owing.

(10) Providers may only charge participants for the following services if the participant signs an ABN for the specific service prior to services being provided:

(a) noncovered services;

(b) experimental services;

(c) unproven services;

(d) services performed in an inappropriate setting;

(e) services that are not medically necessary; and

(f) investigational services.