In July 2013, the Centers for Medicare and Medicaid Services (CMS) issued new regulations for Medicaid premiums and cost-sharing. Higher beneficiary cost-sharing is allowed in certain circumstances, and federal regulations modified some of these provisions. States can use either Medicaid state plan amendments (SPAs) or Section 1115 waiver authority in the Social Security Act to establish both premiums and point-of-service cost-sharing. Table 2 provides information about optional premiums that states can choose to apply to specific Medicaid subgroups with income that exceeds 150% FPL. Other caveats apply to specific subgroups, also identified in this table. A co - payment is a specified dollar amount for each item or service delivered. Federal statute and regulations prohibit states from requiring out-of-pocket costs for the following exempted services:
emergency services (e.g., both inpatient and outpatient services furnished by a qualified provider) that are needed to evaluate or stabilize an emergency medical condition; family planning services and supplies for individuals of childbearing age including contraceptives and pharmaceuticals for which the state claims or could claim a 90% federal share of the total cost; preventive services, including well-baby and well-child care services in either the managed care or fee-for-service delivery systems; pregnancy-related services; provider-preventable services (e.g., health care acquired conditions).
The federal Medicaid statute and accompanying regulations include provisions that states can apply to certain program beneficiaries with respect to out-of-pocket cost-sharing, including premiums that may be required on a monthly or quarterly basis, enrollment fees that may be applied on an annual or semiannual basis, and point-of-service cost-sharing (e.g., a co-payment to a Medicaid participating provider for a specific covered service received). To implement these options, states must submit Medicaid state plan amendments (SPAs) detailing these provisions to the federal Centers for Medicare and Medicaid Services (CMS) for approval. This report provides an overview of these federal authorities and includes some state-specific examples.