Medicaid Premiums and Cost Sharing (#29)

G2b - Cost Sharing Amounts – Medically Needy
Statute: 1916, 1916A
Regulation: 42 CFR 447.52 - 447.54

INTRODUCTION
This state plan page (fillable PDF) G2b is used to indicate if the state charges cost sharing
(deductibles, co-insurance or co-payments) to all medically needy individuals covered under the
state plan, and if so, the provisions for administering this cost sharing. Cost sharing imposed on
medically needy individuals and targeted cost sharing are covered in separate state plan pages
(G2a for categorically needy and G2c for targeted cost sharing).
State plan page G2b must be submitted by states implementing cost sharing for the first time or
for the initial cost sharing state plan amendment submission in MMDL for existing cost sharing
in the state plan. For subsequent state plan amendment submissions, state plan page G2b need
only be submitted when changes are being proposed to provisions contained on page G2b.

BACKGROUND
For background information related to the cost sharing state plan pages, including state plan page
G2b, please see separate Implementation Guide, titled “Background - Medicaid Cost Sharing.”

TECHNICAL GUIDANCE
PREREQUISITES:
If the state is proposing to establish new cost sharing or modify existing cost sharing in the state
plan, it must submit the following pages prior to or concurrently with state plan page G2b. These
prerequisites do not apply to states proposing to discontinue cost sharing currently charged to
medically needy individuals under the state plan.
•
•
•

G1- Cost Sharing Requirements
G2a – Cost Sharing Amounts for the Categorically Needy
G3 - Cost Sharing Limitations

This state plan page is divided into 3 major sections:
•
•
•

Cost Sharing to All Medically Needy Individuals
Cost Sharing For Non-Preferred Drugs Charged to Otherwise Exempt Individuals
Cost Sharing For Non-Emergency Services Provided in the Emergency Department (ED)
Charged to Otherwise Exempt Individuals
Review Criteria

G2b - Cost Sharing Amounts – Medically Needy

For each Yes or No question, if Yes or No is not selected by the state, this state plan page
cannot be approved.
Cost Sharing to All Medically Needy Individuals
For its initial cost sharing submittal in MMDL, a state electing to impose or amend cost sharing
must complete and submit this state plan page. The state must first indicate Yes or No as to
whether it charges cost sharing (deductibles, co-insurance or co-payments) to all medically
needy individuals covered under the state plan.
If a state currently charges cost sharing to other populations in addition to medically needy
individuals and wants only to discontinue cost sharing currently charged to medically needy
individuals under the state plan, they should submit G2b and indicate No. If a state wants to
discontinue all cost sharing currently imposed under the state plan, the state need submit only
state plan page G1 and no other state plan page.
States modifying existing cost sharing or proposing to impose cost sharing under 1916 authority
(i.e. nominal amounts to all medically needy individuals) must select Yes. States currently
imposing or proposing to impose cost sharing under both 1916 and 1916 A
authority (i.e. nominal cost sharing charged to all medically needy individuals and higher than
nominal cost sharing charged to specified eligibility groups with incomes greater than 100% of
the FPL) must also select Yes to this question.
States currently imposing or proposing to impose cost sharing under 1916A authority only (i.e.
cost sharing is charged only to specified eligibility groups with incomes greater than 100% of the
FPL) must select No.
If No, no additional information is requested. If Yes, the state must then indicate Yes or No as to
whether the cost sharing charged to medically needy individuals is the same (i.e. same services
or items, amounts, unit; and or variations by income or cost of the service or unit) as that charged
to categorically needy individuals.
If the state selects No, that is, cost sharing charged to medically needy individuals is different
than cost sharing charged to categorically needy individuals, additional text is displayed for the
state to provide specifics regarding cost sharing to medically needy individuals.
The state then completes either or both of the following two subsections, whichever applies:
• Services or items with the Same Cost Sharing Amount for All Incomes
• Services or items with Cost Sharing Amounts that Vary by Income
Regardless of which of the two subsections the state completes, based on whether or not the state
varies cost sharing by income, the state must indicate the services or items for which cost sharing
is charged and then provide the cost sharing specifics associated with the services or items
entered.

G2b - Cost Sharing Amounts – Medically Needy

Services or items with the Same Cost Sharing Amount for All Incomes
The state completes this subsection only if cost sharing amounts for medically needy
individuals are not varied by income. If cost sharing amounts are varied by income, skip this
subsection and go to the next subsection, labeled “Services or items with Cost Sharing
Amounts that Vary by Income.”
Each service or item for which cost sharing will be charged and its corresponding
information must be entered on a separate row. Rows can be added by clicking on the +
(plus) sign on the left side of a row. To remove rows, click on the “X” key on the right side
of the row. Please see section labeled “Instructions for Required Information” below.
If the cost sharing amount varies by what the agency pays for the service or item, re-enter
the service or item on a separate row for each cost sharing amount. The cost of the service or
item to which the cost sharing applies should be written to the right of the name of the
service or item. See example 1.
Example 1
Service or item

Amount

Dollars or
Percentage

Unit

Office Visit reimbursed at $30 or
less

2.00

$

Per Visit

Office Visit reimbursed at more
than $30

4.00

$

Per Visit

For review criteria, please see section titled “Review Criteria for Cost Sharing Specifics”
below.
Services or items with Cost Sharing Amounts that Vary by Income
The state completes this subsection only if cost sharing amounts are varied by family
income.
The information for each service or item subject to cost sharing varied by income must be
entered separately.
Services or items can be added by clicking on the “Add Service or Item” button on the
bottom left hand corner underneath the table. To remove services, click on the “Remove
Service or Item” button on the right side of the “Service” field.

G2b - Cost Sharing Amounts – Medically Needy
For each service or item, the state first enters the income range in the table. The cost sharing
information for each income range must be entered on a separate row, beginning with the
lowest income range on the first row. Each additional income increment is entered in the
succeeding rows. Rows can be added by clicking on the + (plus) sign on the left side of a
row. To remove rows, click on the “X” key on the right side of the row.
There are two fields for household income ranges, labeled “Incomes Greater than” for the
lower end of the income range and “Incomes Less than or Equal to” for the upper bound of
the income range. In these fields, the state enters the Federal Poverty Level (FPL)
percentages or dollar amounts for household incomes, for which there are varying cost
sharing amounts. For entry of FPL levels, the state should include the percentage symbol
(%) and “FPL” to the right of the number entered in the field (e.g. 150% FPL). For dollar
entries, the state should include the dollar sign ($) to the left of the number entered in the
field (e.g. $700). For dollar entries, the state should enter if it is per month, quarter, year, etc.
($700/month).
Note: When using FPL levels, “Incomes Greater than” (i.e. the lower end of the income
range) should be read to mean the dollar amount represented by the FPL percentage entered
plus one cent (e.g. if 100% FPL for a family of 2 equals $15,510, 100% in the “Incomes
Greater than” field means $15,510.01). This same rule applies to dollar amounts entered in
this field (e.g. $700 entered in the “Incomes Greater than” field should be read to mean
$700.01). The one exception to this is for states whose lowest income range starts at zero. In
this case the first entry for “Incomes Greater than “should be 0 (zero) and read as zero and
not as one cent.
“Incomes Less than or Equal to” (i.e. the upper end of the income range) should be read to
mean the actual dollar amount entered or the dollar amount represented by the FPL
percentage. For example, if 100% FPL for a family of 2 equals $15,510, 100% entered for
“Incomes Less than or Equal to” means $15,510.
If the highest income level does not have an upper bound (e.g. the income range is greater
than150% FPL or greater than $700, with no upper limit then enter “No upper limit” in the
“Incomes Less than or Equal to” field.
To avoid any gaps in the population subject to cost sharing, the same number as entered in
the previous “Incomes Less than or Equal to” field should be entered in the subsequent
“Incomes Greater than” field. See example 2 below.
Review Criteria
The income ranges entered must not overlap nor include gaps from one income range to
the next and must be inclusive of all the qualifying income levels used by the state for

G2b - Cost Sharing Amounts – Medically Needy
individuals covered under the state plan or this state plan page cannot be approved. Even
if the state charges $0 for a particular income range, for example 0-25% of poverty, that
should be indicated.
Example 2
Service or Item: Physician Services
Incomes
Greater than
0%
50%
100%

Incomes Less
than or Equal to
50%
100%
133%

Amount
2.00
3.00
4.00

Dollars or
Percentage
$
$
$

Unit
Service
Service
Service

If the cost sharing amount varies by what the agency pays for the service or item, each range
with different cost sharing amounts should be added as a separate service or item, with its
own table. The amount the agency pays for the service or item to which the cost sharing
applies should be written to the right of the name of the service or item , e.g. physician
services reimbursed at less than $40; physician services reimbursed at $40 or more. See
example 3.
Example 3
Service or Item: Physician
Services for which the agency
reimburses less than $40
Incomes
Greater than
0%
50%
100%

Incomes Less
than or Equal to
50%
100%
133%

Amount
0
2.00
3.00

Dollars or
Percentage
$
$
$

Unit
Service
Service
Service

Service or Item: Physician
Services for which the agency
reimburses $40 or more
Incomes
Greater than
0%
50%
100%

Incomes Less
than or Equal to
50%
100%
133%

Amount
1.00
3.00
4.00

Dollars or
Percentage
$
$
$

Unit
Service
Service
Service

For instructions on completing the information for the remainder of the table, please see
section labeled “Instructions for Required Information” below.

G2b - Cost Sharing Amounts – Medically Needy

For review criteria, please see section titled “Review Criteria for Cost Sharing Specifics”
below.
Cost Sharing for Non-Preferred Drugs Charged to Otherwise Exempt Individuals
States charging cost sharing for non-preferred drugs to medically needy individuals must answer
the next question by indicating Yes or No as to whether the state charges cost sharing for nonpreferred drugs to otherwise exempt medically needy individuals.
States not charging cost sharing for non-preferred drugs to medically needy individuals need not
answer this question.
If Yes, the state must then indicate Yes or No as to whether the cost sharing charges for nonpreferred drugs imposed on otherwise exempt individuals are the same as the charges for nonpreferred drugs imposed on non-exempt individuals.
If No is answered to the second question, the state must then enter the information requested in
the table: amount; dollar or percentage; unit of service or item; and explanation. For instructions
on completing the table, please see section labeled “Instructions for Required Information”
below.
If the cost sharing amount varies by what the agency pays for the drugs, each range with
different cost sharing amounts should be entered on a separate row. The amount the agency pays
for the drug to which the cost sharing applies should be written in the explanation column, e.g.
“per non-preferred drug for which the agency pays less than $40”.
For review criteria, please see section titled “Review Criteria for Cost Sharing Specifics” below.
Cost Sharing for Non-emergency Services Provided in the ED Charged to Otherwise
Exempt Individuals
States charging cost sharing for non-emergency services provided in the emergency department
to medically needy individuals must answer the next question by indicating Yes or No as to
whether the state charges cost sharing for non-emergency services provided in the ED to
otherwise exempt medically needy individuals.
States not charging cost sharing for non-emergency services provided in the ED to medically
needy individuals need not answer this question.
If Yes, the state must then indicate Yes or No as to whether the cost sharing charges for nonemergency services provided in the ED imposed on otherwise exempt individuals are the same as
the charges for non-emergency services provided in the ED imposed on non-exempt individuals.
If No is answered to the second question, the state must then enter the information requested in
the table: amount; dollar or percentage; unit for the service or item; and explanation. For

G2b - Cost Sharing Amounts – Medically Needy
instructions on completing the table, please see section labeled “Instructions for Required
Information” below.
If the cost sharing amount varies by what the agency pays for the service, each range with
different cost sharing amounts should be entered on a separate row. The amount the agency pays
for the service to which the cost sharing applies should be written in the explanation column, e.g.
“per non-emergency service for which the agency pays less than $40”.
For review criteria, please see section titled “Review Criteria for Cost Sharing Specifics” below.
Instructions for Required Information
The state must first enter the name of the individual service to which cost sharing applies.
Note: To the extent possible, and if applicable, names entered for services or items should be as
specific as possible and not the broader benefit name under which the service or item is
categorized. For example, if the cost sharing charge is imposed for eyeglasses, then the service or
item is eyeglasses and not vision services. Likewise if the cost sharing is imposed for certain
dental services or items, such as dentures or crowns, the service or item is dentures or crowns
and not dental services.
After entering the name of the benefit, service or item:
• Enter the cost sharing charge (amount) for that service or item;
• Select either dollars or percentage associated with the amount entered from the drop
down list in the dollars or percentage column;
• Select the applicable unit for the service or item from the drop down list in the unit
column; and
• Enter information in the explanation column that is pertinent to the state’s imposition of
cost sharing to this population for the service or item, including but not limited to, the
average amount the agency pays for the service or item, whether any aggregate limits
apply to that benefit (for example, cost sharing for preferred drugs will not exceed $15 in
a month). If “Other” was selected as the unit for the service or item, the state must enter a
name for, or explanation of the “Other” unit used for the service or item.
Example 4
Service or Item
Preferred Drugs

Amount
2.00

Dollars or
Percentage
$

Unit
Other

Explanation
Unit=1 month
supply; Preferred
Drugs aggregate
limit = $15/month.

G2b - Cost Sharing Amounts – Medically Needy
Review Criteria for Cost Sharing Specifics
For cost sharing to all medically needy individuals, the state must include all the services or
item s for which the state charges cost sharing. At least one service or item must be entered.
The cost sharing amount and whether the charge is a percentage or dollar amount must be
indicated for each service or item entered.
The cost sharing amounts entered must be within the regulatory maximum allowable amounts
as described in 42 CFR 447.52 for inpatient and outpatient services or items (Individuals with
Family Income <100% of the FPL); 447.53 for prescribed drugs (Individuals with Family
Income < 150% of the FPL) and 447.54 for non-emergency services provided in the
emergency department (Individuals with Family Income < 150% of the FPL) or this state plan
page cannot be approved.
The Unit used for the service or item must be indicated. If “Other” was selected as the unit of
service or item, an explanation of the unit used must be included in the explanation column.
The average cost of the service or item and benefit aggregate limit, if applicable, must also be
entered.
All the elements of the review criteria must be met or this state plan page cannot be approved.