Form CMS-10190 DRA 6041 Costsharing Preprint

OMB Approved # 0938-0993

Revision: Attachment 4.18-F

April 2006 Page 1

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State/Territory:

It should be noted that States can select one or more options in imposing cost-sharing (including co-payments, co-insurance, and deductibles) and premiums.

A. For groups of individuals with family income above 100 percent but below 150 percent of the FPL:

1. Cost sharing

a. Amount of Cost Sharing

i. __/ No cost sharing is imposed.

ii. __/ Cost sharing is imposed under section 1916A of the Act as follows (specify the amounts by group and services (see below)):

Type of Charge

Group of Item/Service Deductible Coinsurance Copayment *Method of Individuals Determining

Family

Income (including monthly or quarterly period)

*Describe the methodology used to determine family income if it differs from your methodology for determining eligibility.

Attach a schedule of the cost-sharing amounts for specific items and services and the various eligibility groups.

TN No. ______ Approval Date _________________

Supersedes TN No. _______ Effective Date _________________

CMS-101090 (09/06)

OMB Approved # 0938-0993

Revision: Attachment 4.18-F

April 2006 Page 2

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State/Territory:

b. Limitations:

• The total aggregate amount of cost sharing and premiums imposed for all individuals in the family may not exceed 5 percent of the family income of the family involved, as applied on a monthly and quarterly basis as specified by the State above.

• Cost sharing with respect to any item or service may not exceed 10 percent of the cost of such item or service.

c. No cost sharing will be imposed for the services specified at section 1916A(b)(3) of the Act.

TN No. ______ Approval Date _________________

Supersedes TN No. _______ Effective Date _________________

CMS-101090 (09/06)

OMB Approved # 0938-0993

Revision: Attachment 4.18-F

April 2006 Page 3

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State/Territory:

d. Enforcement

i. __/ Providers are permitted to require, as a condition for the provision of care, items, or services, the payment of any cost sharing.

ii. __/(If above box selected) Providers are permitted to reduce or waive cost sharing on a case-by-case basis.

iii. State payments to providers must be reduced by the amount of the beneficiary cost-sharing obligations, regardless of whether the provider successfully collects the cost-sharing.

2. Premiums

a. Amount of Premiums

i. No premiums may be imposed for individuals with family income above 100 percent but below 150 percent of the FPL.

B. For groups of individuals with family income above 150 percent of the FPL:

1. Cost sharing

a. Amounts of Cost Sharing

i. __/ No cost sharing is imposed.

ii. __/ Cost sharing is imposed under section 1916A of the Act as follows (specify amounts by groups and services (see below)):

Type of Charge

Group of Item/Service Deductible Coinsurance Copayment *Method of Individuals Determining

Family

Income

(including monthly or quarterly period)

TN No. ______ Approval Date _________________

Supersedes TN No. _______ Effective Date ________________

CMS-101090 (09/06)

OMB Approved # 0938-0993

Revision: Attachment 4.18-F

April 2006 Page 4

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State/Territory:

*Describe the methodology used to determine family income if it differs from your methodology for determining eligibility.

Attach a copy of the schedule of the cost-sharing amounts for specific items and the various eligibility groups.

b. Limitations:

• The total aggregate amount of all cost sharing and premiums imposed for all individuals in the family may not exceed 5 percent of the family income of the family involved, as applied on a monthly or quarterly basis as specified by the State above.

• Cost sharing with respect to any item or service may not exceed 20 percent of the cost of such item or service.

c. No cost sharing shall be imposed for the services specified at section 1916A(b)(3) of the Act.

TN No. ______ Approval Date _________________

Supersedes TN No. _______ Effective Date _________________

CMS-101090 (09/06)

OMB Approved # 0938-0993

Revision: Attachment 4.18-F

April 2006 Page 5

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State/Territory:

d. Enforcement

i. __/ Providers are permitted to require, as a condition for the provision of care, items, or services, the payment of any cost sharing.

ii. __/ (If above box selected) Providers are permitted to reduce or waive cost sharing on a case-by-case basis.

iii. State payments to providers must be reduced by the amount of the beneficiary cost-sharing obligations, regardless of whether the provider successfully collects the cost-sharing.

2. Premiums

a. Amount of Premiums

i. __/ No premiums are imposed.

ii. __/ Premiums are imposed under section 1916A of the Act as follows (specify the premium amount by group and income level.

Group of Individuals Premium Method for Determining

Family Income

(including monthly or

quarterly period)

Attach a schedule of the premium amounts for the various eligibility groups.

b. Limitation:

• The total aggregate amount of premiums and cost sharing imposed for all individuals in the family may not exceed 5 percent of the family income of the family involved, as applied on a monthly or quarterly basis as specified by the State above.

TN No. ______ Approval Date _________________

Supersedes TN No. _______ Effective Date ________________

CMS-101090 (09/06)

OMB Approved # 0938-0993

Revision: Attachment 4.18-F

April 2006 Page 6

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State/Territory:

c. No premiums shall be imposed for the individuals specified at section 1916A(b)(3) of the Act.

d. Enforcement

i. __/ Prepayment required for the following groups of individuals who are applying for Medicaid:

ii. __/ Eligibility terminated after failure to pay for 60 days for the following groups of individuals who are receiving Medicaid:

iii. __/ Payment will be waived on case-by-case basis for undue hardship.

C. Period of determining aggregate 5 percent cap

Specify the period for which the 5 percent maximum would be applied.

__/ Quarterly

__/ Monthly

TN No. ______ Approval Date _________________

Supersedes TN No. _______ Effective Date ________________

CMS-101090 (09/06)

OMB Approved # 0938-0993

Revision: Attachment 4.18-F

April 2006 Page 7

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State/Territory:

D. Method for tracking cost-sharing amounts

Describe the State’s process used for tracking cost-sharing and informing beneficiaries and providers of the beneficiary’s liability and informing providers when an individual has reached his/her maximum so further costs are no longer charged.

Also describe the State’s process for informing beneficiaries and providers of the allowable cost-sharing amounts.

TN No. ______ Approval Date _________________

Supersedes TN No. _______ Effective Date ________________

CMS-101090 (09/06)