If the United States Preventive Services Task Force (USPSTF) grade A or B service is an integral part of the office visit that includes other services, and will not be billed separately, the state may permit providers to charge a copay for the office visit, as the office visit is not eligible for the one percentage point FMAP increase. If the USPSTF grade A or B service is billed separately, or is the only service furnished during the office visit, the state may not permit the provider to charge a copay. The state should work with providers to establish the appropriate billing codes and claims processing guidelines for these situations.
Supplemental Links:
- This FAQ was released as part of a larger set. View the full set. (PDF, 159.52 KB)
Date
Topic
Sub Topic
FAQ ID
92121
FAQ Page
FAQ Question
Providers are permitted to charge a copay for a member's office visit. This visit may include a variety of services including preventive and non-preventive services. The State Medical Director (SMD) letter indicates the enhanced federal medical assistance percentage (FMAP) is available if cost-sharing is eliminated for preventive services. We believe this to mean that the doctor cannot collect a copay for any visit in which preventive services are provided, regardless of whether the majority of services provided during the visit are non-preventive services. We would like CMS verification.