However, some states have obtained waivers to impose charges in Medicaid that are not otherwise allowed. . legal research should verify their results against an official edition of Beginning October 1, 2015, maximum allowable amounts increase annually by the percentage increase in the medical care component of the Consumer Price Index for All Urban Consumers (CPI-U). Centers for Medicare & Medicaid Services (CMS), HHS. Cost sharing cannot be charged for emergency, family planning . (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. Under section Start Printed Page 97291916A(c), States may amend their State plans to require increased cost sharing by certain groups of individuals for non-preferred drugs and to waive or reduce the otherwise applicable cost sharing for preferred drugs. We expect that this rule would promote the modernization of the Medicaid program. Section 1102 of the Social Security Act (, II. electronic version on GPOs govinfo.gov. Further, the research suggests that state savings from premiums and cost sharing in Medicaid and CHIP are limited and that increases in premiums and cost sharing in Medicaid and CHIP can increase pressures on safety-net providers. Start Printed Page 9730. This analysis must conform to the provisions of section 603 of the RFA. Olivia Pham , and Figure 19: Premiums or Enrollment Fees for Children in Medicaid and CHIP, January 2019. This document has been published in the Federal Register. The accuracy of our estimate of the information collection burden. Thereafter, any deductible may not exceed this amount as updated each October 1 by the percentage increase in the medical care component of the CPI-U for the period of September to September ending in the preceding calendar year and then rounded to the next higher 10-cent increment. This table of contents is a navigational tool, processed from the Section 1916A(b)(3)(C) of the Act clarifies that a State may exempt additional individuals or services from cost sharing. Section 6041 of the DRA established new subsections 1916A(a) and (b), of the Act, which allow States to amend their State plans to impose alternative premiums and cost sharing on certain groups of individuals, for items and services other than drugs (which are subject to a separate provision discussed below), and to enforce payment of the premiums and cost sharing. (b) The State must make the public schedule available to the following: (1) Recipients, at the time of their enrollment and reenrollment after a redetermination of eligibility, and when premiums, cost sharing charges, and the aggregate limits are revised. We believe 56 States will be affected by this requirement for an annual burden of 18.67 hours. a. Republishing paragraph (a) introductory text. This proposal would provide greater flexibility to State Medicaid programs consistent with that provided to State SCHIP programs. Section 6041(b)(2) of the DRA requires the Secretary to increase the nominal cost sharing amounts under section 1916 of the Act for each year (beginning with 2006) by the annual percentage increase in the medical care component of the consumer price index for all urban consumers (U.S. city average) as rounded up in an appropriate manner. At 151% FPL, 18 states charge cost sharing for non-preventive physician visits, 14 states charge for an inpatient hospital visit, and 14 charge for generic drugs. Sections 6041, 6042, and 6043 of the DRA established a new section 1916A of the Social Security Act (the Act). Under these rules, states may. (b) The schedule of the premiums, enrollment fees, or similar fees imposed. Under this option, if the hospital determines that an individual does not have an emergency medical condition, before providing the non-emergency services and imposing cost sharing, it must inform the individual that an available and accessible alternate non-emergency services provider can provide the services without the imposition of the same cost sharing and that the hospital can coordinate a referral to that provider. As of January 2019, five states (Arkansas, Indiana, Iowa, Michigan, and Montana) have implemented premiums or monthly contributions for expansion adults, and, in Indiana, the charges also apply to parents. We propose to round to the next higher 10-cent increment because it will simplify calculation and collection of the amounts involved. 2 Most of these charges are limited to children in CHIP since . L. 109-432, enacted on December 20, 2006) modified section 1916A of the Act. corresponding official PDF file on govinfo.gov. recall it. for better understanding how a document is structured but Under these rules, states may not charge premiums in Medicaid for enrollees with incomes less than 150% FPL. The republication, revisions, and additions read as follows: (a) Non-institutional services. This prototype edition of the (vi) Emergency services as defined at 447.53(b)(4), except charges for services furnished after the hospital has determined, based on the screening and any other services required under 489.24 of this chapter, that the individual does not have an emergency medical condition consistent with the requirements of paragraph (a)(2) of this section and 447.80(b)(1). (d) The methods, such as the use of integrated automated systems, for tracking cost sharing charges, informing recipients and providers of their liability, and notifying recipients and providers when individual recipients have paid the maximum cost sharing charges permitted for the period of time. The Effects of Premiums and Cost Sharing on Low-Income Populations: Updated Review of. It draws on findings from 65 papers published between 2000 and March 2017, including peer-reviewed studies and freestanding reports, government reports, and white papers by research and policy organizations. In accordance with the statute, at 447.72(a), we propose that the State plan exclude these individuals from the imposition of premiums. Children under age 18 (or under age 19, 20, or 21 at the state's option) - states may impose alternative out of pocket costs on children under age 18 who are not covered under a mandatory categorically needy eligibility group or the Family Opportunity Act. Billing Protections for QMBs Samantha Artiga Section 1916A(b)(1)(B)(i) of the Act provides that, in the case of individuals whose family income exceeds 100 percent, but does not exceed 150 percent of the FPL applicable to a family of the size involved, cost sharing imposed under the State plan may not exceed 10 percent of the cost of such item or service. Section 405(a)(1) of the TRHCA modified subsections 1916A(a) and (b) of the Act. (a) States may not impose alternative premiums upon the following individuals: (1) Individuals under 18 years of age that are required to be provided medical assistance under section 1902(a)(10)(A)(i) of the Act, and including individuals with respect to whom child welfare services are made available under Part B of title IV on the basis of being a child in foster care and individuals with respect to whom adoption or foster care assistance is made available under Part E of that title, without regard to age. We would implement this section at proposed 447.70(b). Premium & Cost-Sharing Requirements Medicaid & CHIP This category provides information about Medicaid and the Children's Health Insurance Program (CHIP), states' health coverage programs. For example, States may impose cost sharing for non-exempt items and services to individuals in the section 1931 eligibility group with family incomes between 100 and 200 percent of the FPL. Section 6043 of the DRA created section 1916A(e) of the Act, which permits States to amend their State plans to allow hospitals, after an appropriate medical screening examination under section 1867 (EMTALA) of the Act, to impose higher cost sharing upon certain groups of individuals for non-emergency care or services furnished in a hospital emergency department. Section 1916A(b)(2)(A) of the Act provides that the total aggregate amount of cost sharing imposed under section 1916 and 1916A of the Act 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. Section 1916A sets forth options for alternative premiums and cost sharing, including options for higher cost sharing for non-preferred prescription drugs and for non-emergency use of a hospital emergency room. These two indicators will be used in multiple areas within HPMS and are essential to the proper display of benefits in Medicare Plan Finder. Comments mailed to the addresses indicated as appropriate for hand or courier delivery may be delayed and received after the comment period. The exemption from cost-sharing and premiums applies to children under 18 in "mandatory" Medicaid coverage groups. You may submit comments on this document's paperwork requirements by mailing your comments to the addresses provided at the end of the Collection of Information Requirements section in this document. It is not an official legal edition of the Federal Individuals under 18 years of age who are required to be provided medical assistance under section 1902(a)(10)(A)(i) of the Act, and including individuals with respect to whom child welfare services are made available under Part B of title IV on the basis of being a child in foster care and individuals with respect to whom adoption or foster care assistance is made available under part E of that title, without regard to age; Any terminally ill individual receiving hospice care, as defined in section 1905(o) of the Act; Any individual who is an inpatient in a hospital, nursing facility, intermediate care facility, or other medical institution, if the individual is required, as a condition of receiving services in that institution under the State plan, to spend for costs of medical care all but a minimal amount of the individual's income required for personal needs; Women who are receiving Medicaid on the basis of the breast or cervical cancer eligibility group under sections 1902(a)(10)(A)(ii)(XVIII) and 1902(aa) of the Act; and. , (b) The methodology used to determine family income, for purposes of the limitations on cost sharing related to family income that are described below, including the period and periodicity of those determinations. The total number of states charging premiums or enrollment fees for children has decreased from 34 in 2009, just prior to the ACA. (v) Services furnished to any individual who is an inpatient in a hospital, nursing facility, intermediate care facility for the mentally retarded, or other medical institution, if the individual is required, as a condition of receiving services in that institution under the State plan, to spend for costs of medical care all but a minimal amount of the individual's income required for personal needs. We have determined, and the Secretary certifies, that this rule would not have a significant impact on the operations of a substantial number of small rural hospitals. 2. Research shows that premiums serve as a barrier to enrollment for low-income families and copayments can limit utilization of needed health care.1 Federal regulations establish parameters for premiums and cost sharing for Medicaid and CHIP enrollees that reflect their limited ability to pay out-of-pocket health care costs due to their modest incomes. We added language encouraging states and D-SNPs to finalize D-SNP eligibility criteria in their State Medicaid Agency Contracts in advance of bid submission. For purposes of section 1102(b) of the Act, we define a small rural hospital as a hospital that is located outside of a Core-Based Statistical Area and has fewer than 100 beds. the Federal Register. While every effort has been made to ensure that (b) Cost sharing may not exceed 10 percent of the payment the agency makes for the item or service, with the following exceptions: (1) Cost sharing for non-preferred drugs cannot exceed the nominal amount as defined in 447.54. Each document posted on the site includes a link to the In accordance with these provisions, at 447.78(a), we propose that for individuals with family income above 100 percent of the FPL the aggregate amount of premiums (when applicable) and cost sharing under section 1916 and 1916A of the Act not exceed 5 percent of a family's income for the monthly or quarterly period, as specified by the State in the State plan. As such, increases in premiums and cost sharing result in increased barriers to coverage and care, greater unmet health needs, and increased financial burdens for families. Wisconsin also suspended copayments but plans to reinstate them in July 2020. The OFR/GPO partnership is committed to presenting accurate and reliable A total of 39 states charge copayments for parents eligible for Medicaid under traditional pathways that existed before the ACA (Figure 21). Under section 1916A(b)(3)(A) of the Act, the State plan may not impose premiums upon the following: In accordance with the statute, at 447.66(a), we propose that the State exclude these classes of individuals from the imposition of premiums. In accordance with the statute, we propose at 447.74(c) that aggregate cost sharing for individuals whose family income exceeds 150 percent of the FPL applicable to a family of the size involved, not exceed the maximum permitted under 447.78(a). Aggregate limits on alternative premiums and cost sharing. As of January 2020, 14 states have lockout periods in CHIP, with 12 of those states imposing the maximum 90 days. Section 1916A(b)(2)(B) of the Act provides that, in the case of individuals whose family income exceeds 150 percent of the FPL applicable to a family of the size involved, cost sharing imposed under the State plan may not exceed 20 percent of the cost of that item (including a non-preferred drug) or service. (2) Cost sharing for non-emergency services furnished in the hospital emergency department cannot exceed twice the nominal amount as defined in 447.54. The effects on individuals, providers, and state costs reflect varied implementation of premiums and cost sharing across states as well as differing premium and cost sharing amounts. Medicaid: Program Eligibility, Coverage & Costs - Debt.org PDF Dually Eligible Beneficiaries Under Medicare and Medicaid - HHS.gov We believe the Congress intended to provide additional flexibilities to States in issuing the DRA. and services, go to As such, these individuals face increased cost burdens associated with accessing care because of copayment increases.110,111 Other research finds that even relatively small copayments can reduce utilization among individuals with significant health needs.112,113,114, Numerous studies find that cost sharing has negative effects on individuals ability to access needed care and health outcomes and increases financial burdens for families.115,116,117,118,119,120,121,122 For example, studies have found that increases in cost sharing are associated with increased rates of uncontrolled hypertension and hypercholesterolemia123 and reduced treatment for children with asthma.124 Increases in cost sharing also increase financial burdens for families, causing some to cut back on necessities or borrow money to pay for care. A stamp-in clock is available for persons wishing to retain a proof of filing by stamping in and retaining an extra copy of the comments being filed.) The share of costs covered by your insurance that you pay out of your own pocket. Under the Paperwork Reduction Act of 1995, we are required to provide 60-Start Printed Page 9734day notice in the Federal Register and solicit public comment before a collection of information requirement is submitted to the Office of Management and Budget (OMB) for review and approval. 1302). Premium and Cost Sharing Exemptions and Protections for Individuals Whose Family Income is Above 100 Percent but Does Not Exceed 150 Percent of the FPL (447.72), 9. Section 1916A(d)(2) of the Act permits a State to allow a provider to require that an individual, as a condition of receiving an item or service, pay the cost sharing charge imposed under section 1916A of the Act. For Federal Fiscal Year 2007, for targeted low-income children whose family income is from 101 to 150 percent of the FPL, the State may charge up to twice the charge for non-institutional services, up to a maximum amount of $10.40, for services furnished in a hospital emergency room if those services are not emergency services as defined in 457.10. (c) Family income shall be determined in a manner and for that period as specified by the State in the State plan. Figure 20: Income at Which Cost Sharing for Children in Medicaid and/or CHIP Begins, January 2019. Figure 4.3 - Distribution of Medicare Persons Served and Amount of Cost-Sharing Liability: Calendar Year 2005. The documents posted on this site are XML renditions of published Federal Through alternative cost sharing, States would help recipients become more educated and efficient health care consumers. 93.778, Medical Assistance Program). Office of Information and Regulatory Affairs, Office of Management and Budget, Room 10235, New Executive Office Building, Washington, DC 20503. To determine whether Medicaid cost savings can be achieved by modifying the reimbursement methodology for Medicare Part C cost-sharing claims in accordance with federal requirements. The audit covered the period from July 1, 2016 through December 31, 2020. States can use the same methods that SCHIP programs use to track cost sharing. Section 1916A of the Act allows States to impose alternative premiums and cost sharing that are not subject to the limitations on premiums and cost sharing under section 1916 of the Act. Recently, there has been increased interest at the federal and state levels to expand the use of premiums and cost sharing in Medicaid as a way to promote personal responsibility, prepare beneficiaries to transition to commercial and private insurance, and support consumers in making value-conscious health decisions. However, 15 of the 22 states charging monthly or quarterly premiums in CHIP provide at least a 60-day grace period. This brief, which updates an earlier brief Premiums and Cost-Sharing in Medicaid: A Review of Research Findings, reviews research on the effects of premiums and cost sharing on low-income populations in Medicaid and CHIP. To compile data from multiple indicators for one or more states, build a Custom State Report. In the case of States that do not have fee-for-service payment rates, we propose that any copayment that the State imposes for services provided by an MCO may not exceed $5.20 for FY 2007. By express or overnight mail. publication in the future. This decrease, in part, reflects some states transitioning their separate CHIP programs to Medicaid expansions. We also propose that the State plan describe the methodology the State will use to ensure that the aggregate amount of premiums and cost sharing imposed for all individuals in the family does not exceed 5 percent of family income as applied during the monthly or quarterly period specified by the State. 1800 M Street NW Suite 650 South Washington, DC 20036. Most hospitals and most other providers and suppliers are small entities, either by nonprofit status or by having revenues of $6.5 million to $31.5 million in any 1 year. Cost-Sharing and Premiums in Medicaid: What Rules Apply? (3) Waive payment of a premium in any case where it determines that requiring the payment would create an undue hardship. L. 96-354), section 1102(b) of the Social Security Act, the Unfunded Mandates Reform Act of 1995 (Pub. In order to fairly evaluate whether an information collection should be approved by OMB, section 3506(c)(2)(A) of the Paperwork Reduction Act of 1995 requires that we solicit comment on the following issues: We are soliciting public comment on each of these issues for the following sections of this document that contain information collection requirements: Section 447.64 requires a State imposing premiums, enrollment fees, or similar fees on individuals to describe in the State plan: (a) The group or groups of individuals that may be subject to the premiums, enrollment fees, or similar charges.