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 |
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Pregnant Women |
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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 |
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File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Jessica Schubel |
File Modified | 0000-00-00 |
File Created | 2021-01-26 |