Enforceability of alternative premiums and cost sharing.
(a) With respect to alternative premiums, a State may do the following:
(1) Require a group or groups of individuals to prepay.
(2) Terminate an individual from medical assistance on the basis of failure to pay for 60 days or more.
(3) Waive payment of a premium in any case where the State determines that requiring the payment would create an undue hardship for the individual.
(b) With respect to alternative cost sharing, a State may amend its Medicaid State plan to permit a provider, including a pharmacy or hospital, to require an individual, as a condition for receiving the item or service, to pay the cost sharing charge, except as specified in paragraphs (b)(1) through (3) of this section.
(1) A provider, including a pharmacy and a hospital, may not require an individual whose family income is at or below 100 percent of the FPL to pay the cost sharing charge as a condition of receiving the service.
(2) A hospital that has determined after an appropriate medical screening pursuant to § 489.24 of this chapter, that an individual does not need emergency services as defined at section 1932(b)(2) of the Act and § 438.114(a), before providing treatment and imposing alternative cost sharing on an individual in accordance with § 447.72(b)(2) and § 447.74(b) of this chapter for non-emergency services as defined in section 1916A(e)(4)(A) of the Act, must provide:
(i) The name and location of an available and accessible alternate non-emergency services provider, as defined in section 1916A(e)(4)(B) of the Act.
(ii) Information that the alternate provider can provide the services in a timely manner with the imposition of a lesser cost sharing amount or no cost sharing.
(iii) A referral to coordinate scheduling of treatment by this provider.
(3) The provider is not prohibited by this authority from choosing to reduce or waive cost sharing on a case-by-case basis.
(c) Nothing in paragraph (b)(2) of this section shall be construed to:
(1) Limit a hospital's obligations with respect to 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 with respect to payment or coverage of emergency medical services by any managed care organization.
[73 FR 71851, Nov. 25, 2008, as amended at 75 FR 30265, May 28, 2010]
Title 42 published on 2012-10-01
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