CMS-R-53 Medicaid Premiums and Cost Sharing

Medicaid Premiums and Cost Sharing
State Name:

drop-down with 50 states

Transmittal Number:

OMB Control Number: 0938-1148
Expiration Date: 10/31/2014

Cost Sharing Requirements
1916
1916A
42 CFR 447.50 through 447.57 (excluding 447.55)
Y/N The state charges cost sharing (deductibles, co-insurance or co-payments) to individuals covered
under Medicaid.
If Yes, display the following:
 The state assures that it administers cost sharing in accordance with sections 1916 and 1916A of
the Social Security Act and 42 CFR 447.50 through 447.57.
General Provisions
 The cost sharing amounts established by the state for services are always less than the
amount the agency pays for the service.
No provider may deny services to an eligible individual on account of the individual's inability
to pay cost sharing, except as elected by the state in accordance with 42 CFR 447.52(e)(1).
The process used by the state to inform providers whether cost sharing for a specific item or
service may be imposed on a beneficiary and whether the provider may require the
beneficiary to pay the cost sharing charge, as a condition for receiving the item or service, is
(check all that apply):
The state includes an indicator in the Medicaid Management Information System (MMIS)
The state includes an indicator in the Eligibility and Enrollment System
The state includes an indicator in the Eligibility Verification System
The state includes an indicator on the Medicaid card, which the beneficiary presents to
the provider
Other process
If Other process is selected, display:

+ Description:

Contracts with managed care organizations (MCOs) provide that any cost-sharing charges
the MCO imposes on Medicaid enrollees are in accordance with the cost sharing specified in
the state plan and the requirements set forth in 42 CFR 447.50 through 447.57.

Medicaid Premiums and Cost Sharing
Cost Sharing for Non-Emergency Services Provided in a Hospital Emergency Department
Y/N The state imposes cost sharing for non-emergency services provided in a hospital
emergency department.
If Yes, display:
 The state ensures that before providing non-emergency services and imposing cost
sharing for such services, that the hospitals providing care:
Conduct an appropriate medical screening under 42 CFR 489.24, subpart G to
determine that the individual does not need emergency services;
Inform the individual of the amount of his or her cost sharing obligation for nonemergency services provided in the emergency department;
Provide the individual with the name and location of an available and accessible
alternative non-emergency services provider;
Determine that the alternative provider can provide services to the individual in a
timely manner with the imposition of a lesser cost sharing amount or no cost
sharing if the individual is otherwise exempt from cost sharing; and
Provide a referral to coordinate scheduling for treatment by the alternative provider.

The state assures that it has a process in place to identify hospital emergency
department services as non-emergency for purposes of imposing cost sharing. This
process does not limit a hospital's obligations for screening and stabilizing treatment of
an emergency medical condition under section 1867 of the Act; or modify any
obligations under either state or federal standards relating to the application of a prudentlayperson standard for payment or coverage of emergency medical services by any
managed care organization.
The process for identifying emergency department services as non-emergency for
purposes of imposing cost sharing is:

Cost Sharing for Drugs
Y/N The state charges cost sharing for drugs.
If Yes, display:
Y/N The state has established differential cost sharing for preferred and non-preferred drugs.
If No, display:
All drugs will be considered preferred drugs.

If Yes, display:

Medicaid Premiums and Cost Sharing
The state identifies which drugs are considered to be non-preferred.
 The state assures that it has a timely process in place to limit cost sharing to the
amount imposed for a preferred drug in the case of a non-preferred drug within a
therapeutically equivalent or similar class of drugs, if the individual's prescribing provider
determines that a preferred drug for treatment of the same condition either will be less
effective for the individual, will have adverse effects for the individual, or both. In such
cases, reimbursement to the pharmacy is based on the appropriate cost sharing
amount.
Beneficiary and Public Notice Requirements
 Consistent with 42 CFR 447.57, the state makes available a public schedule describing
current cost sharing requirements in a manner that ensures that affected applicants,
beneficiaries and providers are likely to have access to the notice. Prior to submitting a SPA
which establishes or substantially modifies existing cost sharing amounts or policies, the
state provides the public with advance notice of the SPA, specifying the amount of cost
sharing and who is subject to the charges, and provides reasonable opportunity for
stakeholder comment. Documentation demonstrating that the notice requirements have
been met are submitted with the SPA. The state also provides opportunity for additional
public notice if cost sharing is substantially modified during the SPA approval process.
Other Relevant Information

Medicaid Premiums and Cost Sharing
State Name:

drop-down with 50 states

OMB Control Number: 0938-1148

Transmittal Number:

Expiration Date: 10/31/2014

Cost Sharing Amounts - Categorically Needy Individuals
1916
1916A
42 CFR 447.52 through 54
Y/N The state charges cost sharing to all categorically needy (Mandatory Coverage and Options for
Coverage) individuals.
If Yes, display the following:
Services or Items with the Same Cost Sharing Amount for All Incomes

Service or Item

Amount

Dollars or
Percentage

+
Amount is a Drop down:
numeric field. $ or %

Service is a text field.

Unit
p
options
listed below

Explanation
Explanation is a text
field.

Services or Items with Cost Sharing Amounts that Vary by Income
One set of rows 25-32 always appears. Users can display additional sets of these rows
by selecting "Add". All but the last set of rows can be deleted by selecting "Remove".
Service or Item :

Remove

Indicate the income ranges by which the cost sharing amount for this service or item varies.
Incomes Greater
than

Incomes Less
than or Equal to

Amount

Dollars or
Percentage

Unit

Explanation

+
The Incomes Greater than and
Incomes Less than or Equal to fields
are a numeric field showing a
Amount is a Drop down:
numeric field. $ or %
percentage
Add Service or Item

Drop down
options
listed below

Explanation is a text
field.

Cost Sharing for Non-preferred Drugs Charged to Otherwise Exempt Individuals
If the state charges cost sharing for non-preferred drugs (entered above), answer the following question:
Y/N The state charges cost sharing for non-preferred drugs to otherwise exempt individuals.
If Yes, display the following:
Y/N The cost sharing charges for non-preferred drugs imposed on otherwise exempt individuals are the
same as the charges imposed on non-exempt individuals.
If No, display the following:
Amount

Percentage

Unit

Explanation

Medicaid Premiums and Cost Sharing
+
Cost Sharing for Non-emergency Services Provided in the Hospital Emergency Department Charged
to Otherwise Exempt Individuals
If the state charges cost sharing for non-emergency services provided in the hospital emergency department
(entered above), answer the following question:
Y/N The state charges cost sharing for non-emergency services provided in the hospital emergency
department to otherwise exempt individuals.
If Yes, display the following:
Y/N The cost sharing charges for non-emergency services provided in the hospital emergency
department imposed on otherwise exempt individuals are the same as the charges imposed on nonexempt individuals.
If No, display the following:
Amount

Percentage

+

Drop down options for Unit:
• Day
• Month
• Visit
• Prescription
• 15 minute
• 30 minute
• Hour
• Trip
• Encounter
• Pair
• Item
• Procedure
• Entire Stay
• Other

Unit

Explanation

Medicaid Premiums and Cost Sharing
State Name:

drop-down with 50 states

OMB Control Number: 0938-1148

Transmittal Number:

Expiration Date: 10/31/2014

Cost Sharing Amounts - Medically Needy Individuals
1916
1916A
42 CFR 447.52 through 54
Y/N The state charges cost sharing to all medically needy individuals.
If Yes, display the following:
Y/N The cost sharing charged to medically needy individuals is the same as that charged to
categorically needy individuals.
If No, display:
Services or Items with the Same Cost Sharing Amount for All Incomes

Service or Item

Amount

Dollars or
Percentage

Unit

Explanation

+
Service is a text field.

Amount is a Drop down:
numeric field. $ or %

Drop down
options

Explanation is a text
field.

Services or Items with Cost Sharing Amounts that Vary by Income
One set of rows 27-34 always appears. Users can display additional sets of these rows
by selecting "Add". All but the last set of rows can be deleted by selecting "Remove".
Service or Item:

Remove

Indicate the income ranges by which the cost sharing amount for this service or item varies.
Incomes Greater
than

Incomes Less
than or Equal to

Amount

Dollars or
Percentage

Unit

Explanation

+
The Incomes Greater than and
Incomes Less than or Equal to fields
are a numeric field showing a
Amount is a Drop down:
percentage
numeric field. $ or %
Add Service or Item

Drop down
options
listed below

Explanation is a text
field.

Cost Sharing for Non-preferred Drugs Charged to Otherwise Exempt Individuals
If the state charges cost sharing for non-preferred drugs (entered above), answer the following question:
Y/N The state charges cost sharing for non-preferred drugs to otherwise exempt individuals.
If Yes, display the following:
Y/N The cost sharing charges for non-preferred drugs imposed on otherwise exempt individuals are the
same as the charges imposed on non-exempt individuals.
If No, display the following:

Medicaid Premiums and Cost Sharing
Amount

Percentage

Unit

Explanation

+
Cost Sharing for Non-emergency Services Provided in the Hospital Emergency Department Charged
to Otherwise Exempt Individuals
If the state charges cost sharing for non-emergency services provided in the hospital emergency department
(entered above), answer the following question:
Y/N The state charges cost sharing for non-emergency services provided in the hospital emergency
department to otherwise exempt individuals.
If Yes, display the following:
Y/N The cost sharing charges for non-emergency services provided in the hospital emergency
department imposed on otherwise exempt individuals are the same as the charges imposed on nonexempt individuals.
If No, display the following:
Amount

Percentage

+
Drop down options for Unit:
• Day
• Month
• Visit
• Prescription
• 15 minute
• 30 minute
• Hour
• Trip
• Encounter
• Pair
• Item
• Procedure
• Entire Stay
• Other

Unit

Explanation

Medicaid Premiums and Cost Sharing
State Name:

drop-down with 50 states

OMB Control Number: 0938-1148

Transmittal Number:

Expiration Date: 10/31/2014

Cost Sharing Amounts - Targeting
1916
1916A
42 CFR 447.52 through 54

Y/N The state targets cost sharing to a specific group or groups of individuals.
If Yes, the state defines a population and its cost sharing provisions below. The state must be
allowed to describe cost sharing for multiple populations.
+ Population Name (optional):
free-form text field

Optional field

Eligibility Group(s) Included

Incomes Greater than

Service

free-form text box
Incomes Less than or
Equal to

TO

Amount

Dollars or
Percentage

Unit

Explanation

+

Service is a text field.

Amount is a
numeric
Drop down:
field.
$ or %

Drop down
options
listed below

Explanation is a
text field.

Y/N The state permits providers to require individuals to pay cost sharing as a condition for receiving
items or services, subject to the conditions specified at 42 CFR 447.52(e)(1). This is only
permitted for non-exempt individuals with family income above 100% FPL.
If Yes, display:
Y/N Providers may require payment of cost sharing as a condition for receiving all items or
services listed above.
If No, display:
List the services or items for which providers may require payment of cost sharing as a
condition of receiving the service or item.

free-form text

Cost Sharing for Non-preferred Drugs Charged to Otherwise Exempt Individuals
If the state targets cost sharing for non-preferred drugs to specific groups of individuals (entered
above), answer the following question:

Medicaid Premiums and Cost Sharing

Y/N The state charges cost sharing for non-preferred drugs to otherwise exempt individuals.
If Yes, display the following:
Y/N The cost sharing charges for non-preferred drugs imposed on otherwise exempt
individuals are the same as the charges imposed on non-exempt individuals.
If No, display the following:

Amount

Dollars or
Percentage

Unit

Explanation

+
Cost Sharing for Non-emergency Services Provided in the Hospital Emergency Department
Charged to Otherwise Exempt Individuals
If the state charges cost sharing for non-emergency services provided in the hospital emergency
department to specific individuals (entered above), answer the following question:
Y/N The state charges cost sharing for non-emergency services provided in the hospital
emergency department to otherwise exempt individuals.
If Yes, display the following:
Y/N The cost sharing charges for non-emergency services provided in the hospital
emergency department imposed on otherwise exempt individuals are the same as the
charges imposed on non-exempt individuals.
If No, display the following:

Amount

Dollars or
Percentage

Unit

Explanation

+
Add Population
Drop down options for Unit:
• Day
• Month
• Visit
• Prescription
• 15 minute
• 30 minute
• Hour
• Trip
• Encounter

Remove Population

Medicaid Premiums and Cost Sharing
• Pair
• Item
• Procedure
• Entire Stay
• Other

Medicaid Premiums and Cost Sharing
State Name:

drop-down with 50 states

Transmittal Number:

OMB Control Number: 0938-1148
Expiration Date: 10/31/2014

Cost Sharing Limitations
42 CFR 447.56
1916
1916A
 The state administers cost sharing in accordance with the limitations described at 42 CFR 447.56, and
1916(a)(2) and (j) and 1916A(b) of the Social Security Act, as follows:
Exemptions
Groups of Individuals - Mandatory Exemptions
The state may not impose cost sharing upon the following groups of individuals:
Individuals ages 1 and older, and under age 18 eligible under the Infants and Children under
Age 18 eligibility group (42 CFR 435.118).
Infants under age 1 eligible under the Infants and Children under Age 18 eligibility group (42
CFR 435.118), whose income does not exceed the higher of:
133% FPL; and
If applicable, the percent FPL described in section 1902(l)(2)(A)(iv) of the Act, up to 185
percent.
Disabled or blind individuals under age 18 eligible for the following eligibility groups:
SSI Beneficiaries (42 CFR 435.120).
Blind and Disabled Individuals in 209(b) States (42 CFR 435.121).
Individuals Receiving Mandatory State Supplements (42 CFR 435.130).
Children for whom child welfare services are made available under Part B of title IV of the
Act on the basis of being a child in foster care and individuals receiving benefits under Part E
of that title, without regard to age.
Disabled children eligible for Medicaid under the Family Opportunity Act
(1902(a)(10)(A)(ii)(XIX) and 1902(cc) of the Act).
Pregnant women, during pregnancy and through the postpartum period which begins on the
last day of pregnancy and extends through the end of the month in which the 60-day period
following termination of pregnancy ends, except for cost sharing for services specified in the
state plan as not pregnancy-related.
Any individual whose medical assistance for services furnished in an institution is reduced by
amounts reflecting available income other than required for personal needs.
An individual receiving hospice care, as defined in section 1905(o) of the Act.

Medicaid Premiums and Cost Sharing
Indians who are currently receiving or have ever received an item or service furnished by an
Indian health care provider or through referral under contract health services.
Individuals who are receiving Medicaid because of the state's election to extend coverage to
the Certain Individuals Needing Treatment for Breast or Cervical Cancer eligibility group (42
CFR 435.213).
Groups of Individuals - Optional Exemptions
The state may elect to exempt the following groups of individuals from cost sharing:
Y/N The state elects to exempt individuals under age 19, 20 or 21, or any reasonable category of
individuals 18 years of age or over.
If Yes, display:
Indicate below the age of the exemption:
• Under age 19
• Under age 20
• Under age 21
• Other reasonable category
If Other,.. is selected, display:
Description:

Y/N The state elects to exempt individuals whose medical assistance for services furnished in a
home and community-based setting is reduced by amounts reflecting available income other
than required for personal needs.
Services - Mandatory Exemptions
The state may not impose cost sharing for the following services:
Emergency services as defined at section 1932(b)(2) of the Act and 42 CFR 438.114(a).
Family planning services and supplies described in section 1905(a)(4)(C) of the Act,
including contraceptives and pharmaceuticals for which the state claims or could claim
federal match at the enhanced rate under section 1903(a)(5) of the Act for family planning
Preventive services, at a minimum the services specified at 42 CFR 457.520, provided to
children under 18 years of age regardless of family income, which reflect the well-baby and
well child care and immunizations in the Bright Futures guidelines issued by the American
Academy of Pediatrics.
Pregnancy-related services, including those defined at 42 CFR 440.210(a)(2) and
440.250(p), and counseling and drugs for cessation of tobacco use. All services provided to
pregnant women will be considered pregnancy-related, except those services specifically
identified in the state plan as not being related to pregnancy.
Provider-preventable services as defined in 42 CFR 447.26(b).

Medicaid Premiums and Cost Sharing

Enforceability of Exemptions
The procedures for implementing and enforcing the exemptions from cost sharing contained in 42
CFR 447.56 are (check all that apply):
To identify that American Indians/Alaskan Natives (AI/AN) are currently receiving or have
ever received an item or service furnished by an Indian health care provider or through
referral under contract health services in accordance with 42 CFR 447.56(a)(1)(x), the state
uses the following procedures:
The state accepts self-attestation
The state runs periodic claims reviews
The state obtains an Active or Previous User Letter or other Indian Health Services
(IHS) document
The Eligibility and Enrollment and MMIS systems flag exempt recipients
Other procedure
If Other procedure is selected, display:

+ Description:

Additional description of procedures used is provided below (optional):

To identify all other individuals exempt from cost sharing, the state uses the following
procedures (check all that apply):
The MMIS system flags recipients who are exempt
The Eligibility and Enrollment System flags recipients who are exempt
The Medicaid card indicates if beneficiary is exempt
The Eligibility Verification System notifies providers when a beneficiary is exempt
Other procedure
If Other procedure is selected, display:

+ Description:

Additional description of procedures used is provided below (optional):

Medicaid Premiums and Cost Sharing
Payments to Providers
 The state reduces the payment it makes to a provider by the amount of a beneficiary's cost
sharing obligation, regardless of whether the provider has collected the payment or waived the
cost sharing, except as provided under 42 CFR 447.56(c ).

Payments to Managed Care Organizations
Y/N The state contracts with one or more managed care organizations to deliver services under
Medicaid.
If Yes, display:
 The state calculates its payments to managed care organizations to include cost sharing
established under the state plan for beneficiaries not exempt from cost sharing, regardless of
whether the organization imposes the cost sharing on its recipient members or the cost sharing is
collected.
Aggregate Limits
 Medicaid premiums and cost sharing incurred by all individuals in the Medicaid household do not
exceed an aggregate limit of 5 percent of the family's income applied on a quarterly or monthly
The percentage of family income used for the aggregate limit is:
●

5%

●

4%

●

3%

●

2%

●

1%

● Other:

%

The state calculates family income for the purpose of the aggregate limit on the following
basis:
● Quarterly
● Monthly
Y/N The state has a process to track each family's incurred premiums and cost sharing through a
mechanism that does not rely on beneficiary documentation.
If No, display:
Explain why the state's premium and cost sharing rules do not place beneficiaries at risk of
reaching the aggregate family limit:

If Yes, display:

Medicaid Premiums and Cost Sharing
Describe the mechanism by which the state tracks each family's incurred premiums and
cost sharing (check all that apply):
As claims are submitted for dates of services within the family's current monthly or
quarterly cap period, the state applies the incurred cost sharing for that service to
the family's aggregate limit. Once the family reaches the aggregate limit, based on
incurred cost sharing and any applicable premiums, the state notifies the family and
providers that the family has reached their aggregate limit for the current monthly or
quarterly cap period, and are no longer subject to premiums or cost sharing.
Managed care organization(s) track each family's incurred cost sharing, as follows:

Other process:

Describe how the state informs beneficiaries and providers of the beneficiaries'
aggregate family limit and notifies beneficiaries and providers when a beneficiary has
incurred premiums and cost sharing up to the aggregate family limit and individual
family members are no longer subject to premiums or cost sharing for the remainder of
the family's current monthly or quarterly cap period:

Y/N The state has a documented appeals process for families that believe they have incurred
premiums or cost sharing over the aggregate limit for the current monthly or quarterly cap
period.
If Yes, display:
Describe the appeals process used:

Describe the process used to reimburse beneficiaries and/or providers if the family is
identified as paying over the aggregate limit for the month/quarter:

Medicaid Premiums and Cost Sharing
Describe the process for beneficiaries to request a reassessment of their family aggregate
limit if they have a change in circumstances or if they are being terminated for failure to pay a
premium:

Y/N The state imposes additional aggregate limits, consistent with 42 CFR 447.56(f)(5).
If Yes, display:
Description of additional aggregate limits: