CMS-10190 6043 Cost Sharing Preprint

OMB Approved # 0938-0993

Revision: Attachment 4.18-H

April 2006 Page 1

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State/Territory:

1. Under section 1916A(e) of the Act, States are permitted to allow hospitals to impose cost sharing for non-emergency services furnished in an emergency department for groups of individuals subject to the following conditions:

• The individual has actually available and accessible an alternate non-emergency services provider with respect to such services;

• The hospital has performed an appropriate medical screening examination under section 1867 of the Social Security Act and has determined that the individual does not have an emergency medical condition;

• Before providing the non-emergency services, the hospital has informed the individual that:

• it may require payment of specified cost sharing before the service can be provided;

• the name and location of an alternate emergency services provider that is available and accessible;

• the fact that the alternate provider can provide the services without the imposition of the higher cost sharing amount permitted for the inappropriate use of the emergency room (i.e., a lesser copayment for the service may be allowed and required under 1916A(a) at the alternate non-emergency provider); and

• it can provide a referral to coordinate treatment.

1. The State will impose the following:

Groups of Individuals Cost Sharing **

** For individuals with incomes above 100% of the Federal Poverty Level (FPL) but at or below 150%, cost sharing cannot exceed twice the nominal cost sharing amount under section 1916.

TN No. ______ Approval Date _________________

Supersedes TN No. _______ Effective Date _________________

CMS-101090 (09/06)

OMB Approved # 0938-0993

Revision: Attachment 4.18-H

April 2006 Page 2

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State/Territory:

** Cost sharing can be imposed upon individuals otherwise exempt from alternative cost sharing under section 1916A of the Act so long as no cost sharing is imposed to receive such care through an outpatient department or alternative health provider, but such cost sharing cannot exceed a nominal amount under section 1916.

** Cost sharing is included in the aggregate cap of 5 percent of family income for premiums and cost sharing under section 1916A (based on a monthly or quarterly schedule as determined by the State).

** Cost sharing under this provision is instead of any cost sharing that may be imposed under section 1916A(a).

2. A list of hospitals implementing this cost sharing can be found at (list Web site, etc.):

TN No. ______ Approval Date _________________

Supersedes TN No. _______ Effective Date _________________

CMS-101090 (09/06)