(1) Except as provided in (4) through (6) each recipient must pay to the provider a copayment of $100 per discharge for inpatient hospital services, not to exceed the cost of the services.

(2) Except as provided in (4) through (6) each recipient must pay to the provider a cost sharing payment for outpatient drugs not to exceed the cost of the service. The rate of cost sharing payment is a minimum of $1 per prescription up to a maximum of $5 per prescription based on 5% of the Medicaid allowed amount. The maximum total cost sharing payment per recipient for outpatient drugs shall not exceed $25 per month.

(3) Except as provided in (4) through (6) each recipient must pay to the provider a cost sharing payment not to exceed the cost of the service. For the following service providers, the rate of cost sharing is a minimum of $1 per visit up to a maximum of the lesser of $5 per visit or 5% of the average Medicaid allowed amount for that provider type, rounded to the nearest dollar:

(a) outpatient hospital services;

(b) podiatry services;

(c) physical therapy services;

(d) speech therapy services;

(e) audiology services;

(f) hearing aid services;

(g) occupational therapy services;

(h) home health services;

(i) ambulatory surgical center services;

(j) public health clinic services;

(k) dental services;

(l) denturist services;

(m) durable medical equipment, orthotics, prosthetics, and medical supplies;

(n) optometric and optician services;

(o) physician services;

(p) mid-level practitioner services;

(q) federally qualified health center services;

(r) rural health clinic services;

(s) freestanding dialysis clinic services;

(t) licensed psychiatrist services;

(u) licensed psychologist services;

(v) licensed clinical social worker services;

(w) licensed professional counselor services;

(x) independent diagnostic testing facility services; and

(y) home infusion therapy services.

(4) For purposes of this rule, "Medicaid allowed amount" means the amount allowed in accordance with the reimbursement methodology for the particular service, before third party liability, incurment and other such payments are applied.

(5) The following individuals are exempt from cost sharing:

(a) individuals under 21 years of age;

(b) pregnant women; and

(c) institutionalized individuals for services furnished to any individual who is an inpatient in a hospital, skilled nursing facility, intermediate care facility or other medical institution if such individual is required to spend for the cost of care all but their personal needs allowance, as defined in ARM 37.82.1320.

(6) Cost sharing may not be charged for services provided for the following purposes:

(a) emergencies;

(b) family planning;

(c) hospice;

(d) personal assistance services;

(e) home dialysis attendant services;

(f) home and community based waiver services;

(g) nonemergency medical transportation services;

(h) eyeglasses purchased by the Medicaid program under a volume purchasing arrangement;

(i) early and periodic screening, diagnostic and treatment (EPSDT) services;

(j) independent laboratory and x-ray services;

(k) services for Medicare crossover claims where Medicaid is the secondary payor under ARM 37.85.406(18) . If a service is not covered by Medicare but is covered by Medicaid, cost sharing will be applied; and

(l) services for third party liability (TPL) claims where Medicaid is the secondary payor under ARM 37.85.407. If a service is not covered by TPL but is covered by Medicaid, cost sharing will be applied.