Section 570. Recipient cost sharing and similar charges

A. Unless a waiver under 42 CFR 431.55(g) applies, deductibles, coinsurance rates, and copayments do not exceed the maximum allowable charges under 42 CFR 447.54.

B. With respect to individuals covered as categorically needy or as qualified Medicare beneficiaries (as defined in § 1905(p)(1) of the Act) under the plan:

1. No enrollment fee, premium, or similar charge is imposed under the plan.

2. No deductible, coinsurance, copayment, or similar charge is imposed under the plan for the following:

a. Services to individuals under age 21. Reasonable categories of individuals who are age 18 or older, but under age 21, to whom charges apply are listed below, if applicable.

b. Services to pregnant women related to the pregnancy or any other medical condition that may complicate the pregnancy.

c. Charges apply for services to pregnant women unrelated to the pregnancy.

d. Services furnished to any individual who is an inpatient in a hospital, long-term care facility, or other medical institution, if the individual is required, as a condition of receiving medical services in the institution, to spend for medical care costs all but a minimal amount of his or her income required for personal needs.

e. Emergency services if the services meet the requirements in 42 CFR 447.53(b)(4).

f. Family planning services and supplies furnished to individuals of childbearing age.

g. Services furnished by a health maintenance organization in which the individual is enrolled.

h. Services furnished to an individual receiving hospice care, as defined in § 1905(o) of the Act.

3. Unless a waiver under 42 CFR 431.55(g) applies, nominal deductible, coinsurance, copayment, or similar charges are imposed for services that are not excluded from such charges under item B 2 above:

a. For any service, no more than one type of charge is imposed.

b. Charges apply to services furnished to persons 21 or older.

c. For the categorically needy and qualified Medicare beneficiaries, 12VAC30-20-150 specifies the:

(1) Service(s) for which a charge is applied;

(2) Nature of the charge imposed on each service;

(3) Amount(s) of and basis for determining the charge(s);

(4) Method used to collect the charge(s);

(5) Basis for determining whether an individual is unable to pay the charge and the means by which such an individual is identified to providers; and

(6) Procedures for implementing and enforcing the exclusions from cost sharing contained in 42 CFR 447.53(b).

No cumulative maximum applies to deductible, coinsurance, or copayment charges imposed on a specified time period.

C. Individuals are covered as medically needy under the plan.

1. No enrollment fee, premium, or similar charge is imposed.

2. No deductible, coinsurance, copayment, or similar charge is imposed under the plan for:

a. Services to individuals under 21; reasonable categories of individuals who are age 18, but under age 21, to whom charges apply are listed below, if applicable.

b. Services to pregnant women related to the pregnancy or any other medical condition that may complicate the pregnancy.

c. Charges apply for services to pregnant women unrelated to the pregnancy.

d. Services furnished to any individual who is an inpatient in a hospital, long-term care facility, or other medical institution, if the individual is required, as a condition of receiving services in the institution, to spend for medical care costs all but a minimal amount of his income required for personal needs.

e. Emergency services if the services meet the requirements in 42 CFR 447.53(b)(4).

f. Family planning services and supplies furnished to individuals of childbearing age.

g. Services furnished to an individual receiving hospice care, as defined in § 1905(o) of the Act.

h. Services provided by a health maintenance organization (HMO) to enrolled individuals.

Unless a waiver under 42 CFR 431.55(g) applies, nominal deductible, coinsurance, copayment, or similar charges are imposed on services that are not excluded from such charges under item B 2 above.

(1) For any service, no more than one type of charge is imposed.

(2) Charges apply to services furnished to persons 21 or older.

Reasonable categories of individuals who are 18 years of age, but under 21, to whom charges apply are listed below, if applicable.

(3) For the medically needy, and other optional groups, 12VAC30-20-160 specifies the:

(a) Service(s) for which charge(s) is applied;

(b) Nature of the charge imposed on each service;

(c) Amount(s) of and basis for determining the charge(s);

(d) Method used to collect the charge(s);

(e) Basis for determining whether an individual is unable to pay the charge(s) and the means by which such an individual is identified to providers;

(f) Procedures for implementing and enforcing the exclusions from cost sharing contained in 42 CFR 447.53(b); and

(g) No cumulative maximum applies to deductible, coinsurance, or copayment charges imposed on a family during a specified time period.

Historical Notes

Subsections A and B 1 through B 2 b derived from VR460-01-54, eff. June 6, 1993; subsections B 2 c through h derived from VR460-01-55, eff. June 16, 1993; subsections B 3 a and b, derived from VR460-01-56, eff. June 16, 1993; subsection B 3 c derived from VR460-01-56.1, eff. June 16, 1993; subsection C 1 and 2 a derived from VR460-01-56.3, eff. June 16, 1993; subsections C 2 b through h derived from VR460-01-56.4, eff. June 16, 1993; subsections C 3 a and b derived from VR460-01-56.5, eff. June 16, 1993; subsection C 3 c derived from VR460-01-56.6, eff. June 16, 1993.

Statutory Authority

Social Security Act Title XIX; 42 CFR 430 to end; all other applicable statutory and regulatory sections.