---
kind: "section"
citation: "42 U.S.C. § 1396o"
title: "42"
title_heading: "The Public Health and Welfare"
number: "1396o"
heading: "Use of enrollment fees, premiums, deductions, cost sharing, and similar charges"
release: "119-102"
date: "2026-07-12"
url: "https://uscodex.org/usc/42/1396o"
units:
  - "Chapter 7 — Social Security"
  - "Subchapter XIX — Grants to States for Medical Assistance Programs"
---

# §1396o. Use of enrollment fees, premiums, deductions, cost sharing, and similar charges

- (a) **Imposition of certain charges under plan in case of individuals described in section 1396a(a)(10)(A) or (E)—** Subject to subsections [(g)](#g), [(i)](#i), and [(j)](#j), the [State](/usc/42/619.md?p=5) plan shall provide that in the case of individuals (other than, beginning October 1, 2028, specified individuals (as defined in [subsection (k)(3)](#k-3))) described in subparagraph (A) or (E)(i) of [section 1396a(a)(10) of this title](/usc/42/1396a.md?p=a-10) who are eligible under the plan—
  - (1) no enrollment fee, premium, or similar charge will be imposed under the plan (except for a premium imposed under [subsection (c)](#c));
  - (2) no deduction, cost sharing or similar charge will be imposed under the plan with respect to—
    - (A) services furnished to individuals under 18 years of age (and, at the option of the [State](/usc/42/619.md?p=5), individuals under 21, 20, or 19 years of age, or any reasonable category of individuals 18 years of age or over),
    - (B) services furnished to pregnant women, if such services relate to the pregnancy or to any other medical condition which may complicate the pregnancy, and [counseling and pharmacotherapy for cessation of tobacco use by pregnant women](/usc/42/1396d.md?p=bb-1) (as defined in [section 1396d(bb) of this title](/usc/42/1396d.md?p=bb)) and covered outpatient [drugs](/usc/42/11851.md?p=4) (as defined in subsection (k)(2) of [section 1396r–8 of this title](/usc/42/1396r–8.md) and [including](/usc/42/1301.md?p=b) nonprescription [drugs](/usc/42/11851.md?p=4) described in [subsection (d)(2)](/usc/42/1396r–8.md?p=d-2) of such section) that are prescribed for purposes of promoting, and when used to promote, tobacco cessation by pregnant women in accordance with the Guideline referred to in [section 1396d(bb)(2)(A) of this title](/usc/42/1396d.md?p=bb-2-A) (or, at the option of the [State](/usc/42/619.md?p=5), any services furnished to pregnant women),
    - (C) services furnished to any individual who is an inpatient in a [hospital](/usc/42/300s–3.md?p=1), [nursing facility](/usc/42/1396d.md?p=c), [intermediate care facility for the mentally retarded](/usc/42/1396d.md?p=d), or other medical institution, if such individual is required, as a condition of receiving services in such institution under the [State](/usc/42/619.md?p=5) plan, to spend for costs of [medical care](/usc/42/1301.md?p=a-7) all but a minimal amount of his income required for personal needs,
    - (D) emergency services (as defined by the [Secretary](/usc/42/1301.md?p=a-6)), family planning services and supplies described in [section 1396d(a)(4)(C) of this title](/usc/42/1396d.md),
    - (E) services furnished to an individual who is receiving [hospice care](/usc/42/1396d.md?p=o-1-A) (as defined in [section 1396d(o)](/usc/42/1396d.md?p=o) of this title),
    - (F) any in vitro diagnostic product described in [section 1396d(a)(3)(B) of this title](/usc/42/1396d.md?p=a-3-B) that is administered during any portion of the emergency period described in such section beginning on or after March 18, 2020 (and the [administration](/usc/42/1301.md?p=a-10) of such product),
    - (G) COVID–19 testing-related services for which payment may be made under the [State](/usc/42/619.md?p=5) plan,
    - (H) during the period beginning on March 11, 2021, and ending on the last day of the first calendar quarter that begins one year after the last day of the emergency period described in [section 1320b–5(g)(1)(B) of this title](/usc/42/1320b–5.md?p=g-1-B), a COVID–19 vaccine and the [administration](/usc/42/1301.md?p=a-10) of such vaccine (for any individual eligible for [medical assistance](/usc/42/1396d.md?p=a) for such vaccine (and [administration](/usc/42/1301.md?p=a-10))),
    - (I) during the period beginning on March 11, 2021, and ending on the last day of the first calendar quarter that begins one year after the last day of the emergency period described in [section 1320b–5(g)(1)(B) of this title](/usc/42/1320b–5.md?p=g-1-B), testing and [treatments](/usc/42/11851.md?p=11) for COVID–19, [including](/usc/42/1301.md?p=b) specialized equipment and therapies ([including](/usc/42/1301.md?p=b) preventive therapies), and, in the case of an individual who is diagnosed with or presumed to have COVID–19, during the period during which such individual has (or is presumed to have) COVID–19, the [treatment](/usc/42/11851.md?p=11) of a condition that may seriously complicate the [treatment](/usc/42/11851.md?p=11) of COVID–19, if otherwise covered under the [State](/usc/42/619.md?p=5) plan (or waiver of such plan), or
    - (J) vaccines described in [section 1396d(a)(13)(B) of this title](/usc/42/1396d.md?p=a-13-B) and the [administration](/usc/42/1301.md?p=a-10) of such vaccines; and
  - (3) any deduction, cost sharing, or similar charge imposed under the plan with respect to other such individuals or other care and services will be nominal in amount (as determined by the [Secretary](/usc/42/1301.md?p=a-6) in regulations which shall, if the definition of “nominal” under the regulations in effect on July 1, 1982 is changed, take into account the level of cash assistance provided in such [State](/usc/42/619.md?p=5) and such other criteria as the [Secretary](/usc/42/1301.md?p=a-6) determines to be appropriate); except that a deduction, cost-sharing, or similar charge of up to twice the nominal amount established for outpatient services may be imposed by a [State](/usc/42/619.md?p=5) under a waiver granted by the [Secretary](/usc/42/1301.md?p=a-6) for services received at a [hospital](/usc/42/300s–3.md?p=1) emergency room if the services are not emergency services (referred to in [paragraph (2)(D)](#a-2-D)) and the [State](/usc/42/619.md?p=5) has established to the satisfaction of the [Secretary](/usc/42/1301.md?p=a-6) that individuals eligible for services under the plan have actually available and accessible to them alternative sources of nonemergency, outpatient services.
- (b) **Imposition of certain charges under plan in case of individuals other than those described in section 1396a(a)(10)(A) or (E)—** The [State](/usc/42/619.md?p=5) plan shall provide that in the case of individuals other than those described in subparagraph (A) or (E) of [section 1396a(a)(10) of this title](/usc/42/1396a.md?p=a-10) who are eligible under the plan—
  - (1) there may be imposed an enrollment fee, premium, or similar charge, which (as determined in accordance with [standards](/usc/42/1320d.md?p=7) prescribed by the [Secretary](/usc/42/1301.md?p=a-6)) is related to the individual’s income,
  - (2) no deduction, cost sharing, or similar charge will be imposed under the plan with respect to—
    - (A) services furnished to individuals under 18 years of age (and, at the option of the [State](/usc/42/619.md?p=5), individuals under 21, 20, or 19 years of age, or any reasonable category of individuals 18 years of age or over),
    - (B) services furnished to pregnant women, if such services relate to the pregnancy or to any other medical condition which may complicate the pregnancy, and [counseling and pharmacotherapy for cessation of tobacco use by pregnant women](/usc/42/1396d.md?p=bb-1) (as defined in [section 1396d(bb) of this title](/usc/42/1396d.md?p=bb)) and covered outpatient [drugs](/usc/42/11851.md?p=4) (as defined in subsection (k)(2) of [section 1396r–8 of this title](/usc/42/1396r–8.md) and [including](/usc/42/1301.md?p=b) nonprescription [drugs](/usc/42/11851.md?p=4) described in [subsection (d)(2)](/usc/42/1396r–8.md?p=d-2) of such section) that are prescribed for purposes of promoting, and when used to promote, tobacco cessation by pregnant women in accordance with the Guideline referred to in [section 1396d(bb)(2)(A) of this title](/usc/42/1396d.md?p=bb-2-A) (or, at the option of the [State](/usc/42/619.md?p=5), any services furnished to pregnant women),
    - (C) services furnished to any individual who is an inpatient in a [hospital](/usc/42/300s–3.md?p=1), [nursing facility](/usc/42/1396d.md?p=c), [intermediate care facility for the mentally retarded](/usc/42/1396d.md?p=d), or other medical institution, if such individual is required, as a condition of receiving services in such institution under the [State](/usc/42/619.md?p=5) plan, to spend for costs of [medical care](/usc/42/1301.md?p=a-7) all but a minimal amount of his income required for personal needs,
    - (D) emergency services (as defined by the [Secretary](/usc/42/1301.md?p=a-6)), family planning services and supplies described in [section 1396d(a)(4)(C) of this title](/usc/42/1396d.md),
    - (E) services furnished to an individual who is receiving [hospice care](/usc/42/1396d.md?p=o-1-A) (as defined in [section 1396d(o)](/usc/42/1396d.md?p=o) of this title),
    - (F) any in vitro diagnostic product described in [section 1396d(a)(3)(B) of this title](/usc/42/1396d.md?p=a-3-B) that is administered during any portion of the emergency period described in such section beginning on or after March 18, 2020 (and the [administration](/usc/42/1301.md?p=a-10) of such product),
    - (G) COVID–19 testing-related services for which payment may be made under the [State](/usc/42/619.md?p=5) plan,
    - (H) during the period beginning on March 11, 2021, and ending on the last day of the first calendar quarter that begins one year after the last day of the emergency period described in [section 1320b–5(g)(1)(B) of this title](/usc/42/1320b–5.md?p=g-1-B), a COVID–19 vaccine and the [administration](/usc/42/1301.md?p=a-10) of such vaccine (for any individual eligible for [medical assistance](/usc/42/1396d.md?p=a) for such vaccine (and [administration](/usc/42/1301.md?p=a-10))),
    - (I) during the period beginning on March 11, 2021, and ending on the last day of the first calendar quarter that begins one year after the last day of the emergency period described in [section 1320b–5(g)(1)(B) of this title](/usc/42/1320b–5.md?p=g-1-B), testing and [treatments](/usc/42/11851.md?p=11) for COVID–19, [including](/usc/42/1301.md?p=b) specialized equipment and therapies ([including](/usc/42/1301.md?p=b) preventive therapies), and, in the case of an individual who is diagnosed with or presumed to have COVID–19, during the period during which such individual has (or is presumed to have) COVID–19, the [treatment](/usc/42/11851.md?p=11) of a condition that may seriously complicate the [treatment](/usc/42/11851.md?p=11) of COVID–19, if otherwise covered under the [State](/usc/42/619.md?p=5) plan (or waiver of such plan), or
    - (J) vaccines described in [section 1396d(a)(13)(B) of this title](/usc/42/1396d.md?p=a-13-B) and the [administration](/usc/42/1301.md?p=a-10) of such vaccines; and
  - (3) any deduction, cost sharing, or similar charge imposed under the plan with respect to other such individuals or other care and services will be nominal in amount (as determined by the [Secretary](/usc/42/1301.md?p=a-6) in regulations which shall, if the definition of “nominal” under the regulations in effect on July 1, 1982 is changed, take into account the level of cash assistance provided in such [State](/usc/42/619.md?p=5) and such other criteria as the [Secretary](/usc/42/1301.md?p=a-6) determines to be appropriate); except that a deduction, cost-sharing, or similar charge of up to twice the nominal amount established for outpatient services may be imposed by a [State](/usc/42/619.md?p=5) under a waiver granted by the [Secretary](/usc/42/1301.md?p=a-6) for services received at a [hospital](/usc/42/300s–3.md?p=1) emergency room if the services are not emergency services (referred to in [paragraph (2)(D)](#b-2-D)) and the [State](/usc/42/619.md?p=5) has established to the satisfaction of the [Secretary](/usc/42/1301.md?p=a-6) that individuals eligible for services under the plan have actually available and accessible to them alternative sources of nonemergency, outpatient services.
- (c) **Imposition of monthly premium; persons affected; amount; prepayment; failure to pay; use of funds from other programs—**
  - (1) The [State](/usc/42/619.md?p=5) plan of a [State](/usc/42/619.md?p=5) may at the option of the [State](/usc/42/619.md?p=5) provide for imposing a monthly premium (in an amount that does not exceed the limit established under [paragraph (2)](#c-2)) with respect to an individual described in subparagraph [(A)](/usc/42/1396a.md?p=l-1-A) or [(B)](/usc/42/1396a.md?p=l-1-B) of section 1396a(l)(1) of this title who is receiving [medical assistance](/usc/42/1396d.md?p=a) on the basis of [section 1396a(a)(10)(A)(ii)(IX) of this title](/usc/42/1396a.md?p=a-10-A-ii-IX) and whose family income (as determined in accordance with the methodology specified in [section 1396a(l)(3)](/usc/42/1396a.md?p=l-3) of this title) equals or exceeds 150 percent of the income [official poverty line](/usc/42/254c–12.md?p=1) (as defined by the Office of Management and Budget, and revised annually in accordance with [section 9902(2) of this title](/usc/42/9902.md?p=2)) applicable to a family of the size involved.
  - (2) In no case may the amount of any premium imposed under [paragraph (1)](#c-1) exceed 10 percent of the amount by which the family income (less expenses for the care of a dependent [child](/usc/42/1382c.md?p=c)) of an individual exceeds 150 percent of the line described in [paragraph (1)](#c-1).
  - (3) A [State](/usc/42/619.md?p=5) shall not require prepayment of a premium imposed pursuant to [paragraph (1)](#c-1) and shall not terminate eligibility of an individual for [medical assistance](/usc/42/1396d.md?p=a) under this subchapter on the basis of failure to pay any such premium until such failure continues for a period of not less than 60 days. The [State](/usc/42/619.md?p=5) may waive payment of any such premium in any case where the [State](/usc/42/619.md?p=5) determines that requiring such payment would create an undue hardship.
  - (4) A [State](/usc/42/619.md?p=5) may permit [State](/usc/42/619.md?p=5) or local funds available under other programs to be used for payment of a premium imposed under [paragraph (1)](#c-1). Payment of a premium with such funds shall not be counted as income to the individual with respect to whom such payment is made.
- (d) **Premiums for qualified disabled and working individuals described in section 1396d(s)—** With respect to a [qualified disabled and working individual](/usc/42/1396d.md?p=s) described in [section 1396d(s) of this title](/usc/42/1396d.md?p=s) whose income (as determined under [paragraph (3)](/usc/42/1396d.md?p=s-3) of that section) exceeds 150 percent of the [official poverty line](/usc/42/254c–12.md?p=1) referred to in that paragraph, the [State](/usc/42/619.md?p=5) plan of a [State](/usc/42/619.md?p=5) may provide for the charging of a premium (expressed as a percentage of the [medicare cost-sharing](/usc/42/1396d.md?p=p-3) described in [section 1396d(p)(3)(A)(i) of this title](/usc/42/1396d.md?p=p-3-A-i) provided with respect to the individual) according to a sliding scale under which such percentage increases from 0 percent to 100 percent, in reasonable increments (as determined by the [Secretary](/usc/42/1301.md?p=a-6)), as the individual’s income increases from 150 percent of such [poverty line](/usc/42/1397jj.md?p=c-5) to 200 percent of such [poverty line](/usc/42/1397jj.md?p=c-5).
- (e) **Prohibition of denial of services on basis of individual’s inability to pay certain charges—** The [State](/usc/42/619.md?p=5) plan shall require that no provider participating under the [State](/usc/42/619.md?p=5) plan may deny care or services to an individual eligible for such care or services under the plan on account of such individual’s inability to pay a deduction, cost sharing, or similar charge. The requirements of this subsection shall not extinguish the liability of the individual to whom the care or services were furnished for payment of the deduction, cost sharing, or similar charge.
- (f) **Charges imposed under waiver authority of Secretary—** No deduction, cost sharing, or similar charge may be imposed under any waiver authority of the [Secretary](/usc/42/1301.md?p=a-6), except as provided in subsections [(a)(3)](#a-3) and [(b)(3)](#b-3) and [section 1396o–1](/usc/42/1396o–1.md) of this title, unless such waiver is for a demonstration [project](/usc/42/13641.md?p=2) which the [Secretary](/usc/42/1301.md?p=a-6) finds after public notice and opportunity for comment—
  - (1) will test a unique and previously untested use of copayments,
  - (2) is limited to a period of not more than two years,
  - (3) will provide benefits to recipients of [medical assistance](/usc/42/1396d.md?p=a) which can reasonably be expected to be equivalent to the risks to the recipients,
  - (4) is based on a reasonable hypothesis which the demonstration is designed to test in a methodologically sound manner, [including](/usc/42/1301.md?p=b) the use of control groups of similar recipients of [medical assistance](/usc/42/1396d.md?p=a) in the area, and
  - (5) is voluntary, or makes provision for assumption of liability for preventable damage to the health of recipients of [medical assistance](/usc/42/1396d.md?p=a) resulting from involuntary participation.
- (g) **Individuals provided medical assistance under section 1396a(a)(10)(A)(ii)(XV) or (XVI)—** With respect to individuals provided [medical assistance](/usc/42/1396d.md?p=a) only under subclause (XV) or (XVI) of [section 1396a(a)(10)(A)(ii) of this title](/usc/42/1396a.md?p=a-10-A-ii)—
  - (1) a [State](/usc/42/619.md?p=5) may (in a uniform manner for individuals described in either such subclause)—
    - (A) require such individuals to pay premiums or other cost-sharing charges set on a sliding scale based on income that the [State](/usc/42/619.md?p=5) may determine; and
    - (B) require payment of 100 percent of such premiums for such year in the case of such an individual who has income for a year that exceeds 250 percent of the income [official poverty line](/usc/42/254c–12.md?p=1) (referred to in [subsection (c)(1)](#c-1)) applicable to a family of the size involved, except that in the case of such an individual who has income for a year that does not exceed 450 percent of such [poverty line](/usc/42/1397jj.md?p=c-5), such requirement may only apply to the extent such premiums do not exceed 7.5 percent of such income; and
  - (2) such [State](/usc/42/619.md?p=5) shall require payment of 100 percent of such premiums for a year by such an individual whose adjusted gross income (as defined in section 62 of the Internal Revenue Code of 1986) for such year exceeds $75,000, except that a [State](/usc/42/619.md?p=5) may choose to subsidize such premiums by using [State](/usc/42/619.md?p=5) funds which may not be federally matched under this subchapter.

  In the case of any calendar year beginning after 2000, the dollar amount specified in [paragraph (2)](#g-2) shall be increased in accordance with the provisions of [section 415(i)(2)(A)(ii) of this title](/usc/42/415.md?p=i-2-A-ii).

- (h) **Indexing nominal cost sharing—** In applying this section and subsections [(c)](/usc/42/1396o–1.md?p=c) and [(e)](/usc/42/1396o–1.md?p=e) of section 1396o–1 of this title, with respect to cost sharing that is “nominal” in amount, the [Secretary](/usc/42/1301.md?p=a-6) shall increase such “nominal” amounts for each year (beginning with 2006) by the annual percentage increase in the [medical care](/usc/42/1301.md?p=a-7) component of the consumer price index for all urban consumers (U.S. city average) as rounded up in an appropriate manner.
- (i) **State option to impose income-related premiums for families of disabled children—**
  - (1) With respect to disabled children provided [medical assistance](/usc/42/1396d.md?p=a) under [section 1396a(a)(10)(A)(ii)(XIX) of this title](/usc/42/1396a.md?p=a-10-A-ii-XIX), subject to [paragraph (2)](#i-2), a [State](/usc/42/619.md?p=5) may (in a uniform manner for such children) require the families of such children to pay monthly premiums set on a sliding scale based on family income.
  - (2) A premium requirement imposed under [paragraph (1)](#i-1) may only apply to the extent that—
    - (A) in the case of a disabled [child](/usc/42/1382c.md?p=c) described in that paragraph whose family income—
      - (i) does not exceed 200 percent of the [poverty line](/usc/42/1397jj.md?p=c-5), the aggregate amount of such premium and any premium that the parent is required to pay for family coverage under [section 1396a(cc)(2)(A)(i) of this title](/usc/42/1396a.md?p=cc-2-A-i) and other cost-sharing charges do not exceed 5 percent of the family’s income; and
      - (ii) exceeds 200, but does not exceed 300, percent of the [poverty line](/usc/42/1397jj.md?p=c-5), the aggregate amount of such premium and any premium that the parent is required to pay for family coverage under [section 1396a(cc)(2)(A)(i) of this title](/usc/42/1396a.md?p=cc-2-A-i) and other cost-sharing charges do not exceed 7.5 percent of the family’s income; and
    - (B) the requirement is imposed consistent with [section 1396a(cc)(2)(A)(ii)(I) of this title](/usc/42/1396a.md?p=cc-2-A-ii-I).
  - (3) A [State](/usc/42/619.md?p=5) shall not require prepayment of a premium imposed pursuant to [paragraph (1)](#i-1) and shall not terminate eligibility of a [child](/usc/42/1382c.md?p=c) under [section 1396a(a)(10)(A)(ii)(XIX) of this title](/usc/42/1396a.md?p=a-10-A-ii-XIX) for [medical assistance](/usc/42/1396d.md?p=a) under this subchapter on the basis of failure to pay any such premium until such failure continues for a period of at least 60 days from the date on which the premium became past due. The [State](/usc/42/619.md?p=5) may waive payment of any such premium in any case where the [State](/usc/42/619.md?p=5) determines that requiring such payment would create an undue hardship.
- (j) **No premiums or cost sharing for Indians furnished items or services directly by Indian health programs or through referral under contract health services—**
  - (1) **No cost sharing for items or services furnished to Indians through Indian health programs—**
    - (A) **In general—** No enrollment fee, premium, or similar charge, and no deduction, copayment, cost sharing, or similar charge shall be imposed against an [Indian](/usc/42/619.md?p=4-A) who is furnished an item or service directly by the [Indian](/usc/42/619.md?p=4-A) Health Service, an [Indian Tribe](/usc/42/619.md?p=4-A), [Tribal Organization](/usc/42/619.md?p=4-A), or Urban [Indian](/usc/42/619.md?p=4-A) Organization or through referral under contract health services for which payment may be made under this subchapter.
    - (B) **No reduction in amount of payment to Indian health providers—** Payment due under this subchapter to the [Indian](/usc/42/619.md?p=4-A) Health Service, an [Indian Tribe](/usc/42/619.md?p=4-A), [Tribal Organization](/usc/42/619.md?p=4-A), or Urban [Indian](/usc/42/619.md?p=4-A) Organization, or a [health care provider](/usc/42/1320d.md?p=3) through referral under contract health services for the furnishing of an item or service to an [Indian](/usc/42/619.md?p=4-A) who is eligible for assistance under such subchapter, may not be reduced by the amount of any enrollment fee, premium, or similar charge, or any deduction, copayment, cost sharing, or similar charge that would be due from the [Indian](/usc/42/619.md?p=4-A) but for the operation of [subparagraph (A)](#j-1-A).
  - (2) **Rule of construction—** Nothing in this subsection shall be construed as restricting the application of any other limitations on the imposition of premiums or cost sharing that may apply to an individual receiving [medical assistance](/usc/42/1396d.md?p=a) under this subchapter who is an [Indian](/usc/42/619.md?p=4-A).
- (k) **Special rules for certain expansion individuals—**
  - (1) **Premiums—** Beginning October 1, 2028, the [State](/usc/42/619.md?p=5) plan shall provide that in the case of a specified individual (as defined in [paragraph (3)](#k-3)) who is eligible under the plan, no enrollment fee, premium, or similar charge will be imposed under the plan.
  - (2) **Required imposition of cost sharing—**
    - (A) **In general—** Subject to [subparagraph (B)](#k-2-B) and [subsection (j)](#j), in the case of a specified individual, the [State](/usc/42/619.md?p=5) plan shall, beginning October 1, 2028, provide for the imposition of such deductions, cost sharing, or similar charges determined appropriate by the [State](/usc/42/619.md?p=5) (in an amount greater than $0) with respect to certain care, items, or services furnished to such an individual, as determined by the [State](/usc/42/619.md?p=5).
    - (B) **Limitations—**
      - (i) **Exclusion of certain services—** In no case may a deduction, cost sharing, or similar charge be imposed under the [State](/usc/42/619.md?p=5) plan with respect to care, items, or services described in any of subparagraphs [(B)](#a-2-B) through [(J)](#a-2-J) of subsection (a)(2), or any [primary care](/usc/42/1396d.md?p=t-4) services, mental health care services, substance use disorder services, or services provided by a Federally qualified health center (as defined in 1396d(l)(2)[^1] of this title), [certified community behavioral health clinic](/usc/42/1396d.md?p=jj-2) (as defined in [section 1396d(jj)(2) of this title](/usc/42/1396d.md?p=jj-2)), or [rural health clinic](/usc/42/1396d.md?p=l-1) (as defined in 1396d(l)(1)[^1] of this title), furnished to a specified individual.
      - (ii) **Item and service limitation—**
        - (I) **In general—** Except as provided in [subclause (II)](#k-2-B-ii-II), in no case may a deduction, cost sharing, or similar charge imposed under the [State](/usc/42/619.md?p=5) plan with respect to care or an item or service furnished to a specified individual exceed $35.
        - (II) **Special rules for prescription drugs—** In no case may a deduction, cost sharing, or similar charge imposed under the [State](/usc/42/619.md?p=5) plan with respect to a prescription [drug](/usc/42/11851.md?p=4) furnished to a specified individual exceed the limit that would be applicable under paragraph [(2)(A)(i)](/usc/42/1396o–1.md?p=c-2-A-i) or [(2)(B)](/usc/42/1396o–1.md?p=c-2-B) of section 1396o–1(c) of this title with respect to such [drug](/usc/42/11851.md?p=4) and individual if such [drug](/usc/42/11851.md?p=4) so furnished were subject to cost sharing under such section.
      - (iii) **Maximum limit on cost sharing—** The total aggregate amount of deductions, cost sharing, or similar charges imposed under the [State](/usc/42/619.md?p=5) plan for all individuals in the family may not exceed 5 percent of the family income of the family involved, as applied on a quarterly or monthly basis (as specified by the [State](/usc/42/619.md?p=5)).
    - (C) **Cases of nonpayment—** Notwithstanding [subsection (e)](#e), a [State](/usc/42/619.md?p=5) may permit a provider participating under the [State](/usc/42/619.md?p=5) plan to require, as a condition for the provision of care, items, or services to a specified individual entitled to [medical assistance](/usc/42/1396d.md?p=a) under this subchapter for such care, items, or services, the payment of any deductions, cost sharing, or similar charges authorized to be imposed with respect to such care, items, or services. Nothing in this subparagraph shall be construed as preventing a provider from reducing or waiving the application of such deductions, cost sharing, or similar charges on a case-by-case basis.
  - (3) **Specified individual defined—** For purposes of this subsection, the term “specified individual” means an individual who has a family income (as determined in accordance with [section 1396a(e)(14) of this title](/usc/42/1396a.md?p=e-14)) that exceeds the [poverty line](/usc/42/1397jj.md?p=c-5) (as defined in [section 1397jj(c)(5) of this title](/usc/42/1397jj.md?p=c-5)) applicable to a family of the size involved and—
    - (A) is enrolled under [section 1396a(a)(10)(A)(i)(VIII) of this title](/usc/42/1396a.md?p=a-10-A-i-VIII); or
    - (B) is described in such subsection and otherwise enrolled under a waiver of the [State](/usc/42/619.md?p=5) plan that provides coverage that is equivalent to minimum essential coverage (as described in section 5000A(f)(1)(A) of the Internal Revenue Code of 1986 and determined in accordance with [standards](/usc/42/1320d.md?p=7) prescribed by the [Secretary](/usc/42/1301.md?p=a-6) in regulations) to all individuals described in [section 1396a(a)(10)(A)(i)(VIII) of this title](/usc/42/1396a.md?p=a-10-A-i-VIII).
  - (4) **State defined—** For purposes of this subsection, the term “[State](/usc/42/619.md?p=5)” means 1 of the 50 [States](/usc/42/619.md?p=5) or the District of Columbia.

## Footnotes

[^1]: So in original. Probably should be preceded by “section”.

## Source credit

(Aug. 14, 1935, ch. 531, title XIX, § 1916, as added Pub. L. 97–248, title I, § 131(b), Sept. 3, 1982, 96 Stat. 367; amended Pub. L. 97–448, title III, § 309(b)(18)–(20), Jan. 12, 1983, 96 Stat. 2409, 2410; Pub. L. 99–272, title IX, § 9505(c)(2), Apr. 7, 1986, 100 Stat. 209; Pub. L. 99–509, title IX, § 9403(g)(4)(B), Oct. 21, 1986, 100 Stat. 2056; Pub. L. 100–203, title IV, §§ 4101(d)(1), 4211(h)(11), Dec. 22, 1987, 101 Stat. 1330–142, 1330–207; Pub. L. 100–360, title IV, § 411(k)(2), July 1, 1988, 102 Stat. 791; Pub. L. 101–239, title VI, § 6408(d)(3), Dec. 19, 1989, 103 Stat. 2269; Pub. L. 105–33, title IV, § 4708(b), Aug. 5, 1997, 111 Stat. 506; Pub. L. 106–170, title II, § 201(a)(3), Dec. 17, 1999, 113 Stat. 1893; Pub. L. 109–171, title VI, §§ 6041(b), 6062(b), Feb. 8, 2006, 120 Stat. 84, 98; Pub. L. 111–5, div. B, title V, § 5006(a)(1), Feb. 17, 2009, 123 Stat. 505; Pub. L. 111–148, title IV, § 4107(c)(1), Mar. 23, 2010, 124 Stat. 561; Pub. L. 116–127, div. F, § 6004(a)(2)(A), Mar. 18, 2020, 134 Stat. 204; Pub. L. 117–2, title IX, § 9811(a)(3)(A), Mar. 11, 2021, 135 Stat. 209; Pub. L. 117–169, title I, § 11405(a)(2)(A), Aug. 16, 2022, 136 Stat. 1900; Pub. L. 119–21, title VII, § 71120(a), July 4, 2025, 139 Stat. 315.)

## Notes

### Editorial Notes

### References in Text

The Internal Revenue Code of 1986, referred to in subsecs. (g)(2) and (k)(3)(B), is classified generally to Title 26, Internal Revenue Code.

### Amendments

2025—Subsec. (a). Pub. L. 119–21, § 71120(a)(1), inserted “(other than, beginning October 1, 2028, specified individuals (as defined in subsection (k)(3)))” after “individuals” in introductory provisions.

Subsec. (k). Pub. L. 119–21, § 71120(a)(2), added subsec. (k).

2022—Subsec. (a)(2)(G). Pub. L. 117–169, § 11405(a)(2)(A)(i)(I), inserted a comma after “State plan”.

Subsec. (a)(2)(J). Pub. L. 117–169, § 11405(a)(2)(A)(i)(II)–(IV), added subpar. (J).

Subsec. (b)(2)(G). Pub. L. 117–169, § 11405(a)(2)(A)(ii)(I), inserted a comma after “State plan”.

Subsec. (b)(2)(J). Pub. L. 117–169, § 11405(a)(2)(A)(ii)(II)–(IV), added subpar. (J).

2021—Subsecs. (a)(2)(H), (I), (b)(2)(H), (I). Pub. L. 117–2 added subpars. (H) and (I).

2020—Subsecs. (a)(2)(F), (G), (b)(2)(F), (G). Pub. L. 116–127 added subpars. (F) and (G).

2010—Subsecs. (a)(2)(B), (b)(2)(B). Pub. L. 111–148 inserted “, and counseling and pharmacotherapy for cessation of tobacco use by pregnant women (as defined in section 1396d(bb) of this title) and covered outpatient drugs (as defined in subsection (k)(2) of section 1396r–8 of this title and including nonprescription drugs described in subsection (d)(2) of such section) that are prescribed for purposes of promoting, and when used to promote, tobacco cessation by pregnant women in accordance with the Guideline referred to in section 1396d(bb)(2)(A) of this title” after “complicate the pregnancy”.

2009—Subsec. (a). Pub. L. 111–5, § 5006(a)(1)(A), substituted “, (i), and (j)” for “and (i)” in introductory provisions.

Subsec. (j). Pub. L. 111–5, § 5006(a)(1)(B), added subsec. (j).

2006—Subsec. (a). Pub. L. 109–171, § 6062(b)(1), substituted “subsections (g) and (i)” for “subsection (g)” in introductory provisions.

Subsec. (f). Pub. L. 109–171, § 6041(b)(1), inserted “and section 1396o–1 of this title” after “(b)(3)”.

Subsec. (h). Pub. L. 109–171, § 6041(b)(2), added subsec. (h).

Subsec. (i). Pub. L. 109–171, § 6062(b)(2), added subsec. (i).

1999—Subsec. (a). Pub. L. 106–170, § 201(a)(3)(A), substituted “Subject to subsection (g), the State plan” for “The State plan” in introductory provisions.

Subsec. (g). Pub. L. 106–170, § 201(a)(3)(B), added subsec. (g).

1997—Subsec. (a)(2)(D). Pub. L. 105–33, § 4708(b)(1), struck out “or services furnished to such an individual by a health maintenance organization (as defined in section 1396b(m) of this title) in which he is enrolled,” after “section 1396d(a)(4)(C) of this title,”.

Subsec. (b)(2)(D). Pub. L. 105–33, § 4708(b)(2), struck out “or (at the option of the State) services furnished to such an individual by a health maintenance organization (as defined in section 1396b(m) of this title) in which he is enrolled,” after “section 1396d(a)(4)(C) of this title,”.

1989—Subsec. (a). Pub. L. 101–239, § 6408(d)(3)(A), substituted “subparagraph (A) or (E)(i)” for “subparagraph (A) or (E)” in introductory provisions.

Subsecs. (d) to (f). Pub. L. 101–239, § 6408(d)(3)(B), (C), added subsec. (d) and redesignated former subsecs. (d) and (e) as (e) and (f), respectively.

1988—Subsec. (c)(1). Pub. L. 100–360 struck out “nonfarm” after “150 percent of the”.

1987—Subsec. (a)(1). Pub. L. 100–203, § 4101(d)(1)(A), inserted “(except for a premium imposed under subsection (c))” after “plan”.

Subsecs. (a)(2)(C), (b)(2)(C). Pub. L. 100–203, § 4211(h)(11), substituted “nursing facility, intermediate care facility for the mentally retarded” for “skilled nursing facility, intermediate care facility”.

Subsecs. (c) to (e). Pub. L. 100–203, § 4101(d)(1)(B), (C), added subsec. (c) and redesignated former subsecs. (c) and (d) as (d) and (e), respectively.

1986—Subsec. (a). Pub. L. 99–509 substituted “subparagraph (A) or (E) of section 1396a(a)(10) of this title” for “section 1396a(a)(10)(A) of this title”.

Subsec. (a)(2)(E). Pub. L. 99–272 added subpar. (E).

Subsec. (b). Pub. L. 99–509 substituted “subparagraph (A) or (E) of section 1396a(a)(10) of this title” for “section 1396a(a)(10)(A) of this title”.

Subsec. (b)(2)(E). Pub. L. 99–272 added subpar. (E).

1983—Subsec. (c). Pub. L. 97–448, § 309(b)(18), substituted “subsection” for “subparagraph”.

Subsec. (d). Pub. L. 97–448, § 309(b)(19), (20), substituted in introductory text “, except as provided in subsections (a)(3) and (b)(3)” for “unless authorized under this section”, and in cl. (5) substituted “is voluntary, or makes provision” for “in which participation is voluntary, or in which provision is made”.

### Statutory Notes and Related Subsidiaries

### Effective Date of 2022 Amendment

Amendment by Pub. L. 117–169 effective on the 1st day of the 1st fiscal quarter that begins on or after the date that is 1 year after Aug. 16, 2022, and applicable to expenditures made under a State plan or waiver of such plan under title XIX of the Social Security Act or under a State child health plan or waiver of such plan under title XXI of such Act on or after such effective date, see section 11405(c) of Pub. L. 117–169, set out as a note under section 1396a of this title.

### Effective Date of 2010 Amendment

Amendment by Pub. L. 111–148 effective Oct. 1, 2010, see section 4107(d) of Pub. L. 111–148, set out as a note under section 1396d of this title.

### Effective Date of 2009 Amendment

Amendment by Pub. L. 111–5 effective July 1, 2009, see section 5006(f) of Pub. L. 111–5, set out as a note under section 1396a of this title.

### Effective Date of 2006 Amendment

Pub. L. 109–171, title VI, § 6041(c), Feb. 8, 2006, 120 Stat. 85, provided that: “The amendments made by this section [enacting section 1396o–1 of this title and amending this section] shall apply to cost sharing imposed for items and services furnished on or after March 31, 2006.”

Amendment by section 6062(b) of Pub. L. 109–171 applicable to medical assistance for items and services furnished on or after Jan. 1, 2007, see section 6062(d) of Pub. L. 109–171, set out as a note under section 1396a of this title.

### Effective Date of 1999 Amendment

Amendment by Pub. L. 106–170 applicable to medical assistance for items and services furnished on or after Oct. 1, 2000, see section 201(d) of Pub. L. 106–170, set out as a note under section 1396a of this title.

### Effective Date of 1997 Amendment

Amendment by Pub. L. 105–33 effective Aug. 5, 1997, and applicable to contracts entered into or renewed on or after Oct. 1, 1997, see section 4710 of Pub. L. 105–33, set out as a note under section 1396b of this title.

### Effective Date of 1989 Amendment

Amendment by Pub. L. 101–239 applicable, except as otherwise provided, to payments under this subchapter for calendar quarters beginning on or after July 1, 1990, without regard to whether or not final regulations have been promulgated by such date, see section 6408(d)(5) of Pub. L. 101–239, set out as a note under section 1396a of this title.

### Effective Date of 1988 Amendment

Except as specifically provided in section 411 of Pub. L. 100–360, amendment by Pub. L. 100–360, as it relates to a provision in the Omnibus Budget Reconciliation Act of 1987, Pub. L. 100–203, effective as if included in the enactment of that provision in Pub. L. 100–203, see section 411(a) of Pub. L. 100–360, set out as a Reference to OBRA; Effective Date note under section 106 of Title 1, General Provisions.

### Effective Date of 1987 Amendment

Pub. L. 100–203, title IV, § 4101(d)(2), Dec. 22, 1987, 101 Stat. 1330–142, provided that: “The amendments made by paragraph (1) [amending this section] shall become effective on July 1, 1988.”

Amendment by section 4211(h)(11) of Pub. L. 100–203 applicable to nursing facility services furnished on or after Oct. 1, 1990, without regard to whether regulations implementing such amendment are promulgated by such date, except as otherwise specifically provided in section 1396r of this title, with transitional rule, see section 4214(a), (b)(2) of Pub. L. 100–203, as amended, set out as an Effective Date note under section 1396r of this title.

### Effective Date of 1986 Amendment

Amendment by Pub. L. 99–509 applicable to payments under this subchapter for calendar quarters beginning on or after July 1, 1987, without regard to whether or not final regulations to carry out such amendments have been promulgated by such date, see section 9403(h) of Pub. L. 99–509, set out as a note under section 1396a of this title.

Amendment by Pub. L. 99–272 applicable to medical assistance provided for hospice care furnished on or after Apr. 7, 1986, see section 9505(e) of Pub. L. 99–272, set out as a note under section 1396a of this title.

### Effective Date of 1983 Amendment

Amendment by Pub. L. 97–448 effective as if originally included as a part of this section as this section was added by the Tax Equity and Fiscal Responsibility Act of 1982, Pub. L. 97–248, see section 309(c)(2) of Pub. L. 97–448, set out as a note under section 426–1 of this title.

### Effective Date

Pub. L. 97–248, title I, § 131(d), formerly § 131(c), Sept. 3, 1982, 96 Stat. 370, redesignated by Pub. L. 97–448, title III, § 309(a)(8), Jan. 12, 1983, 96 Stat. 2408, provided that: Except as provided in paragraph (2), the amendments made by this section [enacting this section and amending section 1396a of this title] shall become effective on October 1, 1982. In the case of a State plan for medical assistance under title XIX of the Social Security Act [42 U.S.C. 1396 et seq.] which the Secretary of Health and Human Services determines requires State legislation in order for the plan to meet the additional requirements imposed by the amendments made by this section, the State plan shall not be regarded as failing to comply with the requirements of such title solely on the basis of its failure to meet these additional requirements before the first day of the first calendar quarter beginning after the close of the first regular session of the State legislature that begins after the date of the enactment of this Act [Sept. 3, 1982].”

### Applicability of 2020 Amendment to Territories

Pub. L. 116–127, div. F, § 6004(a)(2)(C), Mar. 18, 2020, 134 Stat. 205, provided that: “The amendments made [by] this paragraph [amending this section and section 1396o–1 of this title] shall apply with respect to a State plan of a territory in the same manner as a State plan of one of the 50 States.”