Title 40
Human Services

Chapter 8
Medical Assistance

§ 40-8-4.1. Lowest price.

(a) Notwithstanding any provision of law to the contrary, no medical assistance provider shall bill or charge the department of human services more than the provider’s usual and customary charge, as defined within.

(b) The term “usual and customary” means the lowest charge, fee, or rate charged by a provider for any product or service at the time the product or service was provided. For the purpose of determining the lowest charge, fee, or rate:

(1) If the provider offers discounts or rebates, the amount after applying discounts or rebates shall be utilized;

(2) If the provider offers a sale for a limited period of time on any good or service, the sale price shall be utilized during the sale period;

(3) If the provider regularly accepts less than its full charge from any customer, that amount accepted shall be utilized;

(4) If any good or service is offered free of charge by the provider, no charge shall be made to the department for the provision of the product or service to the department or a client of the department who satisfies the terms of the offer;

(5) If any good or service is covered under any warranty or guarantee offered by the provider, the amount charged to the department shall not exceed the amount that would otherwise be payable solely by the customer; and

(6) If a provider structures or packages its goods or services in a manner that is exclusively or primarily used for Medicaid, Medicare, or other third-party payors, the charge for the most similar good or service offered to any other consumer shall be utilized.

(c) The following items shall not be utilized in determining the “usual and customary” or lowest charge, fee, or rate:

(1) Discounts offered solely to bona fide employees or family members of employees;

(2) Discounts offered solely on the basis of age shall be utilized in determining the usual and customary charge only when the client of the department satisfies the age requirement;

(3) Free goods or services or discounts provided to a limited number of persons on the basis of financial hardship;

(4) Charges by an organization on a sliding-fee scale for a good or service where the organization’s charge is based on ability to pay;

(5) Charges not collected as a result of bad debts incurred by the provider. A bad debt exists where sound business judgment indicates that there is no reasonable likelihood of recovery of the amount owed; and

(6) Charges for educational-related services governed by 42 U.S.C. § 1396b(c).

(d) The department may waive the application of this section if the department determines the action is necessary to ensure a continuum of care and service to persons served by community mental health centers, or to avert serious economic hardships to mental health centers.