42 CFR 447.52 - Minimum and maximum income-related charges.

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§ 447.52 Minimum and maximum income-related charges.
For the purpose of relating the amount of an enrollment fee, premium, or similar charge to total gross family income, as required under § 447.51(d), the following rules apply:
(a) Minimum charge. A charge of at least $1.00 per month is imposed on each—
(1) One- or two-person family with monthly gross income of $150 or less;
(2) Three- or four-person family with monthly gross income of $300 or less; and
(3) Five- or more-person family with monthly gross income of $350 or less.
(b) Maximum charge. Any charge related to gross family income that is above the minimum listed in paragraph (a) of this section may not exceed the standards shown in the following table:
Maximum Monthly Charge
Gross family income (per month) Family size
1 or 2 3 or 4 5 or more
$150 or less $1 $1 $1
$151 or $200 2 1 1
$201 to $250 3 1 1
$251 to $300 4 1 1
$301 to $350 5 2 1
$351 to $400 6 3 2
$401 to $450 7 4 3
$451 to $500 8 5 4
$501 to $550 9 6 5
$551 to $600 10 7 6
$601 to $650 11 8 7
$651 to $700 12 9 8
$701 to $750 13 10 9
$751 to $800 14 11 10
$801 to $850 15 12 11
$851 to $900 16 13 12
$901 to $950 17 14 13
$951 to $1,000 18 15 14
More than $1,000 19 16 15
(c) Income-related charges. The agency must impose an appropriately higher charge for each higher level of family income, within the maximum amounts specified in paragraph (b) of this section.
[43 FR 45253, Sept. 29, 1978, as amended at 45 FR 24889, Apr. 11, 1980]
Beta! The text on the eCFR tab represents the unofficial eCFR text at ecfr.gov.
§ 447.52 Cost sharing.

(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):

Services Maximum allowable cost sharing
Individuals with family income
≤100% of the FPL
Individuals with family income
101-150% of the FPL
Individuals with family income
>150% of the FPL
Outpatient Services (physician visit, physical therapy, etc.) $4 10% of cost the agency pays 20% of cost the agency pays.
Inpatient Stay 75 10% of total cost the agency pays for the entire stay 20% of total cost the agency pays for the entire stay.

(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.

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United States Code

Title 42 published on 2015-10-01

The following are ALL rules, proposed rules, and notices (chronologically) published in the Federal Register relating to 42 CFR Part 447 after this date.

  • 2015-11-02; vol. 80 # 211 - Monday, November 2, 2015
    1. 80 FR 67377 - Medicaid Program; Request for Information (RFI)—Data Metrics and Alternative Processes for Access to Care in the Medicaid Program
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      DEPARTMENT OF HEALTH AND HUMAN SERVICES, Centers for Medicare & Medicaid Services
      Request for information.
      Comment Date: To be assured consideration, comments must be received at one of the addresses provided below, no later than 5 p.m. on January 4, 2016.
      42 CFR Part 447