Form CMS-10190 6043 Costsharing Preprint

OMB Approved # 0938-0993
Attachment 4.18-H
Page 1

Revision:
April 2006

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
State/Territory:
A. 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 of
the following:
o the hospital may require payment of specified cost sharing before the service can be
provided;
o the name and location of an alternate emergency services provider that is actually
available and accessible;
o the fact that the alternate non-emergency services provider can provide the services
without the imposition of the higher cost sharing amount permitted for the nonemergency use of the emergency room (however, a lesser copayment for the service
may be allowed and required under 1916 or 1916A(a) at the alternate non-emergency
provider); and
o the hospital provides a referral to coordinate scheduling of this treatment.

1. The State will impose the following:
Groups of Individuals

Cost Sharing **

** For individuals with family income 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. ______
Supersedes TN No. _______
CMS-101090 (09/06)

Approval Date _________________
Effective Date _________________

OMB Approved # 0938-0993
Attachment 4.18-H
Page 2

Revision:
April 2006

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. However, such cost sharing
cannot exceed a nominal amount under section 1916.
** Cost sharing for all individuals in the family is included in the aggregate cap of 5 percent of
family income for premiums and cost sharing (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 (specify Web site, etc.):

TN No. ______
Supersedes TN No. _______
CMS-101090 (09/06)

Approval Date _________________
Effective Date _________________