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Notes

42 C.F.R. §§ 447.52–447.54

3 sections in range

§447.52. Cost sharing.

42 C.F.R. § 447.52

(a)
Applicability. Except as provided in § 447.56(a) (exemptions), the agency may impose cost sharing for any service under the state plan.
(b)
Maximum Allowable Cost Sharing.
(1)
At State option, cost sharing imposed for any service (other than for drugs and non-emergency services furnished in an emergency department, as described in §§ 447.53 and 447.54 respectively) may be established at or below the amounts shown in the following table (except that the maximum allowable cost sharing for individuals with family income at or below 100 percent of the FPL shall be increased each year, beginning October 1, 2015, by the percentage increase in the medical care component of the CPI-U for the period of September to September of the preceding calendar year, rounded to the next higher 5-cent increment):
(2)
States with cost sharing for an inpatient stay that exceeds $75, as of July 15, 2013, must submit a plan to CMS that provides for reducing inpatient cost sharing to $75 on or before July 1, 2017.
(3)
In states that do not have fee-for-service payment rates, any cost sharing imposed on individuals at any income level may not exceed the maximum amount established, for individuals with income at or below 100 percent of the FPL described in paragraph (b)(1) of this section.
(c)
Maximum cost sharing. In no case shall the maximum cost sharing established by the agency be equal to or exceed the amount the agency pays for the service.
(d)
Targeted cost sharing.
(1)
Except as provided in paragraph (d)(2) of this section, the agency may target cost sharing to specified groups of individuals with family income above 100 percent of the FPL.
(2)
For cost sharing imposed for non-preferred drugs under § 447.53 and for non-emergency services provided in a hospital emergency department under § 447.54, the agency may target cost sharing to specified groups of individuals regardless of income.
(e)
Denial of service for nonpayment.
(1)
The agency may permit a provider, including a pharmacy or hospital, to require an individual to pay cost sharing as a condition for receiving the item or service if—
(i)
The individual has family income above 100 percent of the FPL,
(ii)
The individual is not part of an exempted group under § 447.56(a), and
(iii)
For cost sharing imposed for non-emergency services furnished in an emergency department, the conditions under § 447.54(d) of this part have been satisfied.
(2)
Except as provided under paragraph (e)(1) of this section, the state plan must specify that no provider may deny services to an eligible individual on account of the individual's inability to pay the cost sharing.
(3)
Nothing in this section shall be construed as prohibiting a provider from choosing to reduce or waive such cost sharing on a case-by-case basis.
(f)
Prohibition against multiple charges. For any service, the agency may not impose more than one type of cost sharing.
(g)
Income-related charges. Subject to the maximum allowable charges specified in §§ 447.52(b), 447.53(b) and 447.54(b), the plan may establish different cost sharing charges for individuals at different income levels. If the agency imposes such income-related charges, it must ensure that lower income individuals are charged less than individuals with higher income.
(h)
Services furnished by a managed care organization (MCO). Contracts with MCOs must 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 §§ 447.50 through 447.57.
(i)
State Plan Specifications. For each cost sharing charge imposed under this part, the state plan must specify—
(1)
The service for which the charge is made;
(2)
The group or groups of individuals that may be subject to the charge;
(3)
The amount of the charge;
(4)
The process used by the state to—
(i)
Ensure individuals exempt from cost sharing are not charged,
(ii)
Identify for providers whether cost sharing for a specific item or service may be imposed on an individual and whether the provider may require the individual, as a condition for receiving the item or service, to pay the cost sharing charge; and
(5)
If the agency imposes cost sharing under § 447.54, the process by which hospital emergency room services are identified as non-emergency service.
Notes, amendments, and revision history

Source

Source: 78 FR 42307, July 15, 2013, unless otherwise noted.

Authority

Authority: 42 U.S.C. 1302, and 1396r-8, and Pub. L. 111-148.

Source

Source: 43 FR 45253, Sept. 29, 1978, unless otherwise noted.

§447.53. Cost sharing for drugs.

42 C.F.R. § 447.53

(a)
The agency may establish differential cost sharing for preferred and non-preferred drugs. The provisions in § 447.56(a) shall apply except as the agency exercises the option under paragraph (d) of this section. All drugs will be considered preferred drugs if so identified or if the agency does not differentiate between preferred and non-preferred drugs.
(b)
At state option, cost sharing for drugs may be established at or below the amounts shown in the following table (except that the maximum allowable cost sharing shall be increased each year, beginning October 1, 2015, by the percentage increase in the medical care component of the CPI-U for the period of September to September of the preceding calendar year, rounded to the next higher 5-cent increment. Such increase shall not be applied to any cost sharing that is based on the amount the agency pays for the service):
(c)
In states that do not have fee-for-service payment rates, cost sharing for prescription drugs imposed on individuals at any income level may not exceed the maximum amount established for individuals with income at or below 150 percent of the FPL in paragraph (b) of this section.
(d)
For individuals otherwise exempt from cost sharing under § 447.56(a), the agency may impose cost sharing for non-preferred drugs, not to exceed the maximum amount established in paragraph (b) of this section.
(e)
In the case of a drug that is identified by the agency as a non-preferred drug within a therapeutically equivalent or therapeutically similar class of drugs, the agency must have a timely process in place so that cost sharing is limited to the amount imposed for a preferred drug 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 the agency must ensure that reimbursement to the pharmacy is based on the appropriate cost sharing amount.
Notes, amendments, and revision history

Source

Source: 78 FR 42307, July 15, 2013, unless otherwise noted.

Authority

Authority: 42 U.S.C. 1302, and 1396r-8, and Pub. L. 111-148.

Source

Source: 43 FR 45253, Sept. 29, 1978, unless otherwise noted.

§447.54. Cost sharing for services furnished in a hospital emergency department.

42 C.F.R. § 447.54

(a)
The agency may impose cost sharing for non-emergency services provided in a hospital emergency department. The provisions in § 447.56(a) shall apply except as the agency exercises the option under paragraph (c) of this section.
(b)
At state option, cost sharing for non-emergency services provided in an emergency department may be established at or below the amounts shown in the following table (except that the maximum allowable cost sharing identified for individuals with family income at or below 150 percent of the FPL shall be increased each year, beginning October 1, 2015, by the percentage increase in the medical care component of the CPI-U for the period of September to September of the preceding calendar year, rounded to the next higher 5-cent increment):
(c)
For individuals otherwise exempt from cost sharing under § 447.56(a), the agency may impose cost sharing for non-emergency use of the emergency department, not to exceed the maximum amount established in paragraph (b) of this section for individuals with income at or below 150 percent of the FPL.
(d)
For the agency to impose cost sharing under paragraph (a) or (c) of this section for non-emergency use of the emergency department, the hospital providing the care must—
(1)
Conduct an appropriate medical screening under § 489.24 subpart G to determine that the individual does not need emergency services.
(2)
Before providing non-emergency services and imposing cost sharing for such services—
(i)
Inform the individual of the amount of his or her cost sharing obligation for non-emergency services provided in the emergency department;
(ii)
Provide the individual with the name and location of an available and accessible alternative non-emergency services provider;
(iii)
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
(iv)
Provide a referral to coordinate scheduling for treatment by the alternative provider.
(e)
Nothing in this section shall be construed to:
(1)
Limit a hospital's obligations for screening and stabilizing treatment of an emergency medical condition under section 1867 of the Act; or
(2)
Modify any obligations under either state or federal standards relating to the application of a prudent-layperson standard for payment or coverage of emergency medical services by any managed care organization.
Notes, amendments, and revision history

Source

Source: 78 FR 42307, July 15, 2013, unless otherwise noted.

Authority

Authority: 42 U.S.C. 1302, and 1396r-8, and Pub. L. 111-148.

Source

Source: 43 FR 45253, Sept. 29, 1978, unless otherwise noted.