#10: Section 1115 Demonstration and Waiver Application

Generic Clearance for Medicaid and CHIP State Plan, Waiver, and Program Submissions (CMS-10398)

Information on Cost Sharing Requirements

#10: Section 1115 Demonstration and Waiver Application

OMB: 0938-1148

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Information on Cost Sharing Requirements

States have the option under section 1916 of the Social Security Act (the Act) to establish nominal cost sharing for Medicaid beneficiaries. Under section 1916A of the Act, States have greater flexibility to establish alternative cost sharing amounts, including copayments that exceed nominal as well as premiums for certain beneficiaries.


Populations

Exempt from 1916 Cost Sharing

Exempt from 1916A Cost Sharing

Exempt under both 1916 & 1916A

Children

  • Children under age 18

  • At the State’s option, children under 21, 20, or 19, or any reasonable category of children aged 18 or older but younger than age 21

  • Mandatory categorically needy children under age 18

  • Optional disabled children eligible under the Family Opportunity Act (per sections 1902(a)(10)(A)(ii)(XIX) and 1902(cc) of the Act)

  • Children with family income at or below 100% FPL

  • Mandatory categorically needy children under age 18

  • Optional disabled children eligible under the Family Opportunity Act

Pregnant Women

  • Services related to pregnancy or to any medical condition which may complicate the pregnancy, including counseling and pharmacotherapy for smoking cessation

  • States may elect to exempt pregnant women from all cost sharing

Services related to pregnancy or to any other medical condition which may complicate the pregnancy, including counseling and pharmacotherapy for smoking cessation

Services related to pregnancy or to any other medical condition which may complicate the pregnancy, including counseling and pharmacotherapy for smoking cessation

Terminally Ill

Individuals

Individuals who are inpatients in a hospital, nursing facility, ICF-MR or other medical institution if subject to post-eligibility treatment of income rules

Individuals who are inpatients in a hospital, nursing facility, ICF-MR or other medical institution if subject to post-eligibility treatment of income rules

Individuals who are inpatients in a hospital, nursing facility, ICF-MR or other medical institution if subject to post-eligibility treatment of income rules

Individuals in Institutions

Terminally ill individuals receiving hospice care

Terminally ill individuals receiving hospice care

Terminally ill individuals receiving hospice care

Indians

Indians who are currently or have ever received services from an Indian health care provider or through referral under contract health services

Indians who are currently or have ever received services from an Indian health care provider or through referral under contract health services

Indians who are currently or have ever received services from an Indian health care provider or through referral under contract health services

Women with Breast or Cervical Cancer


N/A

Women who need treatment for breast or cervical cancer and are enrolled in Medicaid under 1902(a)(10)(A)(ii)(XVIII) and 1902(aa) of the Act

Women who need treatment for breast or cervical cancer and are enrolled in Medicaid under 1902(a)(10)(A)(ii)(XVIII) and 1902(aa) of the Act

Other Individuals

N/A – due to comparability requirements States cannot elect to exempt other groups of individuals

Any additional classes of individuals specified by a State in its Medicaid State plan


N/A

Services

  • Emergency services

  • Family planning services and supplies

  • Pregnancy-related services

  • Emergency services

  • Family planning services and supplies

  • Pregnancy-related services

  • Preventive services for children

  • Emergency services

  • Family planning services and supplies

  • Pregnancy-related services

  • Preventive services for children


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorJessica Schubel
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File Created2021-01-26

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