#29: Medicaid Cost Sharing (CMS-R-53)

G2c - Cost Sharing Amounts – Targeting
Statute: 1916, 1916A
Regulation: 42 CFR 447.52 - 447.54

INTRODUCTION
This state plan page (fillable PDF) G2c is used to indicate if the state targets cost sharing charges
(deductibles, co-insurance or co-payments) to specific groups of individuals covered under the
state plan, and if so, the provisions for administering targeted cost sharing. Non-targeted cost
sharing imposed on categorically and medically needy individuals are covered in separate state
plan pages (G2a for categorically needy and G2b for medically needy).
State plan page G2c need only be submitted when changes are being proposed to provisions
contained on page G2c.

BACKGROUND
For background information related to the cost sharing state plan pages, including state plan page
G2c, please see separate Implementation Guide, titled “Background - Medicaid Cost Sharing.”

TECHNICAL GUIDANCE
PREREQUISITES:
If the state is proposing to establish new targeted cost sharing or modify existing targeted cost
sharing in the state plan, it must submit the following pages prior to or concurrently with state
plan page G2c. These prerequisites do not apply to states proposing to discontinue cost sharing
currently charged to targeted populations under the state plan.
•
•

G1 - Cost Sharing Requirements
G3 - Cost Sharing Limitations

This state plan page is divided into 3 major sections:
• Option for Targeting Cost Sharing to Specific Groups of 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
For each Yes or No question, if Yes or No is not selected by the state, this state plan page
cannot be approved.

G2c - Cost Sharing Amounts – Targeting

Option for Targeting Cost Sharing to Specific Groups of Individuals
The state must first indicate Yes or No as to whether it targets cost sharing to a specific group or
groups of individuals.
If a state currently charges cost sharing to other populations in addition to targeted cost sharing
and wants only to discontinue targeted cost sharing currently charged under the state plan, they
should submit G2c 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 1916A
authority (i.e. targeted cost sharing charged to specified eligibility groups with incomes greater
than 100% of the FPL) 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
categorically and/or medically needy individuals and also 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.
If No, no additional information is requested. If the state selects Yes, that is the state targets cost
sharing to specific groups of individuals, additional text is displayed for the state to provide
specifics regarding targeted cost sharing.
Note: States may not target cost sharing to specific groups of individuals with incomes equal to
or less than 100% FPL. This state plan page is used only for targeting cost sharing to specific
groups of individuals with incomes greater than 100% FPL.
The following subsections must be completed for each targeted group:

Targeting Criteria
This section begins with, at state option, entry of a name for the population being targeted.
A population is a group of individuals that has the exact same cost sharing provisions. If cost
sharing amounts vary by eligibility group(s) and/or family income, each combination of
eligibility groups and/or income ranges with different cost sharing amounts are considered
as separate populations. If a state targets more than one population, the information for each
population must be entered separately. Populations/Eligibility Groups can be added by
clicking on the “Add Population” button on the bottom left hand corner immediately below
the section of the last population entered. To remove a population, click on the “Remove

G2c - Cost Sharing Amounts – Targeting
Population” button located on the bottom right corner of the section of the population to be
removed.
The state must then enter the name(s) of the eligibility group(s) and income range of the
targeted population. The name(s) of the eligibility group(s)s should correspond to the names
of the eligibility group(s) covered under the state plan and must not include eligibility
groups which are exempt from cost sharing.
Review Criteria
The state must enter the names of the eligibility group(s) being targeted and must not
include an exempt eligibility group(s) or this state plan page cannot be approved.
Next, the state must enter the income range being targeted.
There are two fields to enter the income range, 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 income of the targeted group. For entry of FPL levels, the
state should include the percentage symbol (%) and “FPL” to the right of the number entered
in the fields (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% FPL entered
for “Incomes Less than or Equal to” means $15,510.
If the highest income level of the target population does not have an upper bound (e.g. the
income range is greater than 150% FPL or greater than $700, with no upper limit then enter
“No upper limit” in the “Incomes Less than or Equal to” field.

G2c - Cost Sharing Amounts – Targeting

Review Criteria
The state must enter the targeted income range or this state plan page cannot be
approved. If the state uses FPL percentages for family income, the FPL entered for
“Incomes Greater than” must not be less than 100% FPL and the FPL entered for
“Incomes Less than or Equal to” must be greater than that entered for “Incomes Greater
than” or “No upper limit” or this state plan page cannot be approved. If the state uses
dollar amounts for family income, the dollar amount entered for “Incomes Greater than”
must not equal less than 100% of the FPL and the dollar amount entered for “Incomes
Less than or Equal to” must be greater than that entered for “Incomes Greater than” or
“No upper limit” or this state plan page cannot be approved. As the Federal Poverty Level
increases each year, the state must ensure that if a dollar amount is used for the lower
bound of the income range, it remains at greater than 100% of the FPL.
Next, the state must enter the specifics of the cost sharing for the eligibility group entered,
including services; amounts; dollars or percentage; unit of service; and other relevant
information in the cost sharing table.
Cost Sharing Table
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 the cost of 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
Office Visit reimbursed at $30 or
less
Office Visit reimbursed at more
than $30

Amount

Dollars or
Percentage

Unit

2.00

$

Per Visit

4.00

$

Per Visit

If the state does not vary the cost sharing charge based on what the agency pays for the
service, the state must include in the explanation column the average amount the agency

G2c - Cost Sharing Amounts – Targeting
pays for the service or item. The amount of cost sharing for individuals with income great
than 100% FPL but at or below 150% of the FPL must not exceed 10% of what the agency
pays for the service. The amount of cost sharing for individuals with income great than
150% of the FPL must not exceed 20% of what the agency pays for the service. See
Example 2
Note: For non-preferred drugs, the cost sharing is limited to nominal amounts as defined in
the regulation at 42 CRF 447.53 for individuals with income at or below 150% of the FPL,
and 20% of what the agency pays for individuals with income over 150% of the FPL. For
non-emergency services provide in a hospital ED, there is no limit on the cost sharing for
individuals with income greater than 150% of the FPL, other than the fact that the cost
sharing cannot be equal to or more than what the agency pays for the service and premiums
and cost sharing for all services have a 5% of family income aggregate limit).
Example 2
Service or item

Amount

Office Visit

6.00

Dollars or
Percentage
$

Laboratory

7.00

$

Unit
Per Visit

Per Visit

Explanation
The average
reimbursement
for office visits
is $65
The average
reimbursement
for laboratory
is $85

For review criteria, please see section titled “Review Criteria for Cost Sharing Specifics”
below.
Requiring Payment as Condition to Receiving Services
The state must first indicate Yes or No as to whether it permits providers to require nonexempt individuals with family income above 100% FPL to pay cost sharing as a condition
of receiving items or services.
Review Criteria
If Yes or No is not selected, this state plan page cannot be approved.
If Yes, the state must then indicate Yes or No to as to whether providers may require
payment of cost sharing as a condition for receiving all items or services for which cost
sharing is charged.

G2c - Cost Sharing Amounts – Targeting
Review Criteria
If Yes or No is not selected, this state plan page cannot be approved.
If the state answers No, and providers may require payment of cost sharing as a condition for
receiving some, but not all, items or services for which cost sharing is charged, the state must
then list the services for which providers may require payment of cost sharing as a condition of
receiving the service or item.
Review Criteria
At least one service or item must be entered or this state plan page cannot be approved.

Cost Sharing for Non-Preferred Drugs Charged to Otherwise Exempt Individuals
States charging cost sharing for non-preferred drugs to the targeted group(s) must indicate Yes or
No as to whether the state charges cost sharing for non-preferred drugs to otherwise exempt
individuals.
States not charging cost sharing for non-preferred drugs to the targeted group(s) 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 the non-exempt individuals.
Review Criteria
States which entered amounts higher than the maximum at 42 CFR 447.53(Individuals with
Family Income < 150% of the FPL) cannot indicate Yes and must select No to the question of
whether the cost sharing charges for non-preferred drugs imposed on otherwise exempt
individuals are the same as the charges imposed on the non-exempt individuals or this state
plan page cannot be approved.
If the state answers No 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 drug, each range with different
cost sharing amounts should be entered on a separate row. The amount the agency pays for the

G2c - Cost Sharing Amounts – Targeting
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 ED to the targeted
group(s) 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 individuals.
States not charging cost sharing for non-emergency services provided in the ED to the targeted
group(s) 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 the non-exempt
individuals.
Review Criteria
States which entered amounts higher than themaximum at 42 CFR 447.54(Individuals with
Family Income < 150% of the FPL) cannot indicate Yes and must respond No to the question
of whether the cost sharing charges for non-emergency services provided in and ED imposed
on otherwise exempt individuals are the same as the charges s imposed on the non-exempt
individuals or this state plan page cannot be approved.
If the state answers No 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 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.

G2c - Cost Sharing Amounts – Targeting
Instructions for Required Information
The state must first enter the name of the individual service or item 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 or 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.

Review Criteria for Cost Sharing Specifics
For each targeted group, the state must include all the services or items 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 (Individuals with Family Income 101-150% of the FPL and
Individuals with Family Income >150% of the FPL) for inpatient and outpatient services;

G2c - Cost Sharing Amounts – Targeting
447.53(Individuals with Family Income < 150% of the FPL for otherwise exempt populations
and Individuals with Family Income >150% of the FPL for non-exempt population) for
prescribed drugs; and 447.54 (Individuals with Family Income < 150% of the FPL for
otherwise exempt populations and Individuals with Family Income >150% of the FPL for
non-exempt population) for non-emergency services provided in the ED 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 in the explanation column.
All the elements of the review criteria must be met or this state plan page cannot be approved.