GenIC #10 (Extension w/o change): Section 1115 Demonstration and Waiver Application

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