42 C.F.R. Subpart A—Payments: General Provisions
Title 42 - Public Health
This subpart prescribes State plan requirements, FFP limitations and procedures concerning payments made by State Medicaid agencies for Medicaid services. (a) Basis and purpose. This section implements section 1902(a)(32) of the Act which prohibits State payments for Medicaid services to anyone other than a provider or recipient, except in specified circumstances. (b) Definitions. For purposes of this section: Facility means an institution that furnishes health care services to inpatients. Factor means an individual or an organization, such as a collection agency or service bureau, that advances money to a provider for accounts receivable that the provider has assigned, sold or transferred to the individual organization for an added fee or a deduction of a portion of the accounts receivable. Factor does not include a business representative as described in paragraph (f) of this section. Organized health care delivery system means a public or private organization for delivering health services. It includes, but is not limited to, a clinic, a group practice prepaid capitation plan, and a health maintenance organization. (c) State plan requirements. A State plan must provide that the requirements of paragraphs (d) through (h) of this section are met. (d) Who may receive payment. Payment may be made only— (1) To the provider; or (2) To the recipient if he is a noncash recipient eligible to receive the payment under §447.25; or (3) In accordance with paragraphs (e), (f), and (g) of this section. (e) Reassignments. Payment may be made in accordance with a reassignment from the provider to a government agency or reassignment by a court order. (f) Business agents. Payment may be made to a business agent, such as a billing service or an accounting firm, that furnishes statements and receives payments in the name of the provider, if the agent's compensation for this service is— (1) Related to the cost of processing the billing; (2) Not related on a percentage or other basis to the amount that is billed or collected; and (3) Not dependent upon the collection of the payment. (g) Individual practitioners. Payment may be made to— (1) The employer of the practitioner, if the practitioner is required as a condition of employment to turn over his fees to the employer; (2) The facility in which the service is provided, if the practitioner has a contract under which the facility submits the claim; or (3) A foundation, plan, or similar organization operating an organized health care delivery system, if the practitioner has a contract under which the organization submits the claim. (h) Prohibition of payment to factors. Payment for any service furnished to a recipient by a provider may not be made to or through a factor, either directly or by power of attorney. [43 FR 45253, Sept. 29, 1978, as amended at 46 FR 42672, Aug. 24, 1981; 61 FR 38398, July 24, 1996] A State plan must provide that the Medicaid agency must limit participation in the Medicaid program to providers who accept, as payment in full, the amounts paid by the agency plus any deductible, coinsurance or copayment required by the plan to be paid by the individual. However, the provider may not deny services to any eligible individual on account of the individual's inability to pay the cost sharing amount imposed by the plan in accordance with §431.55(g) or §447.53. The previous sentence does not apply to an individual who is able to pay. An individual's inability to pay does not eliminate his or her liability for the cost sharing charge. [50 FR 23013, May 30, 1985] A State plan must provide for the following: (a) In the case of an individual who is eligible for medical assistance under the plan for service(s) for which a third party or parties is liable for payment, if the total amount of the established liability of the third party or parties for the service is— (1) Equal to or greater than the amount payable under the State plan (which includes, when applicable, cost-sharing payments provided for in §§447.53 through 447.56), the provider furnishing the service to the individual may not seek to collect from the individual (or any financially responsible relative or representative of that individual) any payment amount for that service; or (2) Less than the amount payable under the State plan (including cost sharing payments set forth in §§447.53 through 447.56), the provider furnishing the service to that individual may collect from the individual (or any financially responsible relative or representative of the individual) an amount which is the lesser of— (i) Any cost-sharing payment amount imposed upon the individual under §§447.53 through 447.56; or (ii) An amount which represents the difference between the amount payable under the State plan (which includes, where applicable, cost-sharing payments provided for in §§447.53 through 447.56) and the total of the established third party liability for the services. (b) A provider may not refuse to furnish services covered under the plan to an individual who is eligible for medical assistance under the plan on account of a third party's potential liability for the service(s). [55 FR 1433, Jan. 16, 1990] If a provider seeks to collect from an individual (or any financially responsible relative or representative of that individual) an amount that exceeds an amount specified under §447.20(a)— (a) The Medicaid agency may provide for a reduction of any payment amount otherwise due to the provider in addition to any other sanction available to the agency; and (b) The reduction may be equal to up to three times the amount that the provider sought to collect in violation of §447.20(a). [55 FR 1433, Jan. 16, 1990] (a) Basis and purpose. This section implements section 1905(a) of the Act by prescribing requirements applicable to States making direct payments to certain recipients for physicians' or dentists' services. (b) State plan requirements. Except for groups specified in paragraph (c) of this section, a State may make direct payments to recipients for physicians' or dentists' services. If it does so, the State plan must— (1) Provide for direct payments; and (2) Specify the conditions under which payments are made. (c) Federal financial participation. No FFP is available in expenditures for direct payment for physicians' or dentists' services to any recipient— (1) Who is receiving assistance under the State's approved plan under title I, IV-A, X, XIV or XVI (AABD) of the Act; or (2) To whom supplemental security benefits are being paid under title XVI of the Act; or (3) Who is receiving or eligible for a State supplementary payment or would be eligible if he were not in a medical institution, and who is eligible for Medicaid as a categorically needy recipient. (d) Federal requirements. (1) Direct payments to recipients under this section are an alternative to payments directly to providers and are subject to the same conditions; for example, the State's reasonable charge schedules are applicable. (2) Direct payments must be supported by providers' bills for services. (a) Basis and purpose. This section implements section 1914 of the Act, which provides for withholding the Federal share of Medicaid payments to a provider if the provider has not arranged to repay Medicare overpayments or has failed to provide information to determine the amount of the overpayments. The intent of the statute and regulations is to facilitate the recovery of Medicare overpayments. The provision enables recovery of overpayments when institutions have reduced participation in Medicare or when physicians and suppliers have submitted few or no claims under Medicare, thus not receiving enough in Medicare reimbursement to permit offset of the overpayment. (b) When withholding occurs. The Federal share of Medicaid payments may be withheld from any provider specified in paragraph (c) of this section to recover Medicare overpayments that CMS has been unable to collect if the provider participates in Medicaid and— (1) The provider has not made arrangements satisfactory to CMS to repay the Medicare overpayment; or (2) CMS has been unable to collect information from the provider to determine the existence or amount of Medicare overpayment. (c) The Federal share of Medicaid payments may be withheld with respect to the following providers: (1) An institutional provider that has or previously had in effect a Medicare provider agreement under section 1866 of the Act; and (2) A Medicaid provider who has previously accepted Medicare payment on the basis of an assignment under section 1842(b)(3)(B)(ii) of the Act; and during the 12 month period preceding the quarter in which the Federal share is to be withheld for a Medicare overpayment, submitted no claims under Medicare or submitted claims which total less than the amount of overpayment. (d) Order to reduce State payment. (1) CMS may, at its discretion, issue an order to the Medicaid agency of any State that is using the provider's services, to reduce its payment to the provider by the amount specified in paragraph (f) of this section. (2) The order to reduce payment to the provider will remain in effect until— (i) The Medicaid agency determines that the overpayment has been completely recovered; or (ii) CMS terminates the order. (3) CMS may withhold FFP from any State that does not comply with the order specified in paragraph (d)(1) of this section to reduce payment to the provider and claims FFP for the expenditure on its quarterly expenditure report. (e) Notice of withholding. (1) Before the Federal share of payments may be withheld under this section, CMS will notify the provider and the Medicaid agency of each State that CMS believes may use the overpaid provider's services under Medicaid. (2) The notice will include the instruction to reduce State payments, as provided under paragraph (d) of this section. (3) CMS will send the notice referred to in paragraph (e)(1) by certified mail, return receipt requested. (4) Each Medicaid agency must identify the amount of payment due the provider under Medicaid and give that information to CMS in the next quarterly expenditure report. (5) The Medicaid agency may appeal any disallowance of FFP resulting from the withholding decision to the Grant Appeals Board, in accordance with 45 CFR part 16. (f) Amount to be withheld. CMS may require the Medicaid agency to reduce the Federal share of its payment to the provider by the lesser of the following amounts. (1) The Federal matching share of payments to the provider, or (2) The total Medicare overpayment to the provider. (g) Effective date of withholding. Withholding of payment will become effective no less than 60 days after the day on which the agency receives notice of withholding. (h) Duration of withholding. No Federal funds are available in expenditures for services that are furnished by a provider specified in paragraph (c) of this section from the date on which the withholding becomes effective until the termination of withholding under paragraph (i) of this section. (i) Termination of withholding. (1) CMS will terminate the order to reduce State payment if it determines that any of the following has occurred: (i) The Medicare overpayment is completely recovered: (ii) The institution or person makes an agreement satisfactory to CMS to repay the overpayment; or (iii) CMS determines that there is no overpayment based on newly acquired evidence or a subsequent audit. (2) CMS will notify each State that previously received a notice ordering the withholding that the withholding has been terminated. (j) Procedures for restoring excess withholding. If an amount ultimately determined to be in excess of the Medicare overpayment is withheld, CMS will restore any excess funds withheld. (k) Recovery of funds from Medicaid agency. A provider is not entitled to recover from the Medicaid agency the amount of payment withheld by the agency in accordance with a CMS order issued under paragraph (d) of this section. [50 FR 19688, May 10, 1985; 50 FR 23307, June 3, 1985] (a) Basis and purpose. Section 1885 of the Act provides authority for CMS to withhold Medicare payments to a Medicaid provider in order to recover Medicaid overpayments to the provider. Section 405.377 of this chapter sets forth the Medicare rules implementing section 1885, and specifies under what circumstances withholding will occur and the providers that are subject to withholding. This section establishes the procedures that the Medicaid agency must follow when requesting that CMS withhold Medicare payments. (b) Agency notice to providers. (1) Before the agency requests recovery of a Medicaid overpayment through Medicare, the agency must send either or both of the following notices, in addition to that required under paragraph (b)(2) of this section, to the provider. (i) Notice that— (A) There has been an overpayment; (B) Repayment is required; and (C) The overpayment determination is subject to agency appeal procedures, but we may withhold Medicare payments while an appeal is in progress. (ii) Notice that— (A) Information is needed to determine the amount of overpayment if any; and (B) The provider has at least 30 days in which to supply the information to the agency. (2) Notice that, 30 days or later from the date of the notice, the agency intends to refer the case to CMS for withholding of Medicare payments. (3) The agency must send all notices to providers by certified mail, return receipt requested. (c) Documentation to be submitted to CMS. The agency must submit the following information or documentation to CMS (unless otherwise specified) with the request for withholding of Medicare payments. (1) A statement of the reason that withholding is requested. (2) The amount of overpayment, type of overpayment, date the overpayment was determined, and the closing date of the pertinent cost reporting period (if applicable). (3) The quarter in which the overpayment was reported on the quarterly expenditure report (Form CMS 64). (4) As needed, and upon request from CMS, the names and addresses of the provider's officers and owners for each period that there is an outstanding overpayment. (5) A statement of assurance that the State agency has met the notice requirements under paragraph (b) of this section. (6) As needed, and upon request for CMS, copies of notices (under paragraph (b) of this section), and reports of contact or attempted contact with the provider concerning the overpayment, including any reduction or suspension of Medicaid payments made with respect to that overpayment. (7) A copy of the provider's agreement with the agency under §431.107 of this chapter. (d) Notification to terminate withholding. (1) If an agency has requested withholding under this section, it must notify CMS if any of the following occurs: (i) The Medicaid provider makes an agreement satisfactory to the agency to repay the overpayment; (ii) The Medicaid overpayment is completely recovered; or (iii) The agency determines that there is no overpayment, based on newly acquired evidence or subsequent audit. (2) Upon receipt of notification from the State agency, CMS will terminate withholding. (e) Accounting for returned overpayment. The agency must treat as a recovered overpayment the amounts received from CMS to offset Medicaid overpayments. (f) Procedures for restoring excess withholding. The agency must establish procedures satisfactory to CMS to assure the return to the provider of amounts withheld under this section that are ultimately determined to be in excess of overpayments. Those procedures are subject to CMS review. [50 FR 19689, May 10, 1985, as amended at 61 FR 63749, Dec. 2, 1996] (a) The Medicaid agency may make payments to reserve a bed during a recipient's temporary absence from an inpatient facility, if— (1) The State plan provides for such payments and specifies any limitations on the policy; and (2) Absences for purposes other than required hospitalization (which cannot be anticipated and planned) are included in the patient's plan of care. (b) An agency that pays for reserved beds in an inpatient facility may pay less for a reserved bed than an occupied bed if there is a cost differential between the two beds. (Section 1102 of the Act.) [43 FR 45253, Sept. 29, 1978, as amended at 51 FR 24491, July 3, 1986] (a) Basis and purpose. This section implements section 1902(a)(37) of the Act by specifying— (1) State plan requirements for— (i) Timely processing of claims for payment; (ii) Prepayment and postpayment claims reviews; and (2) Conditions under which the Administrator may grant waivers of the time requirements. (b) Definitions. Claim means (1) a bill for services, (2) a line item of service, or (3) all services for one recipient within a bill. Clean claim means one that can be processed without obtaining additional information from the provider of the service or from a third party. It includes a claim with errors originating in a State's claims system. It does not include a claim from a provider who is under investigation for fraud or abuse, or a claim under review for medical necessity. A shared health facility means any arrangement in which— (1) Two or more health care practitioners practice their professions at a common physical location; (2) The practitioners share common waiting areas, examining rooms, treatment rooms, or other space, the services of supporting staff, or equipment; (3) The practitioners have a person (who may himself be a practitioner)— (i) Who is in charge of, controls, manages, or supervises substantial aspects of the arrangement or operation for the delivery of health or medical services at the common physical location other than the direct furnishing of professional health care services by the practitioners to their patients; or (ii) Who makes available to the practitioners the services of supporting staff who are not employees of the practitioners; and (iii) Who is compensated in whole or in part, for the use of the common physical location or related support services, on a basis related to amounts charged or collected for the services rendered or ordered at the location or on any basis clearly unrelated to the value of the services provided by the person; and (4) At least one of the practitioners received payments on a fee-for-service basis under titles V, XVIII, and XIX in an amount exceeding $5,000 for any one month during the preceding 12 months or in an aggregate amount exceeding $40,000 during the preceding 12 months. The term does not include a provider of services (as specified in §489.2(b) of this chapter), a health maintenance organization (as defined in section 1301(a) of the Public Health Service Act), a hospital cooperative shared services organization meeting the requirements of section 501(e) of the Internal Revenue Code of 1954, or any public entity. Third party is defined in §433.135 of this chapter. (c) State plan requirements. A State plan must (1) provide that the requirements of paragraphs (d), (e)(2), (f) and (g) of this section are met; and (2) Specify the definition of a claim, as provided in paragraph (b) of this section, to be used in meeting the requirements for timely claims payment. The definition may vary by type of service (e.g., physician service, hospital service). (d) Timely processing of claims. (1) The Medicaid agency must require providers to submit all claims no later than 12 months from the date of service. (2) The agency must pay 90 percent of all clean claims from practitioners, who are in individual or group practice or who practice in shared health facilities, within 30 days of the date of receipt. (3) The agency must pay 99 percent of all clean claims from practitioners, who are in individual or group practice or who practice in shared health facilities, within 90 days of the date of receipt. (4) The agency must pay all other claims within 12 months of the date of receipt, except in the following circumstances: (i) This time limitation does not apply to retroactive adjustments paid to providers who are reimbursed under a retrospective payment system, as defined in §447.272 of this part. (ii) If a claim for payment under Medicare has been filed in a timely manner, the agency may pay a Medicaid claim relating to the same services within 6 months after the agency or the provider receives notice of the disposition of the Medicare claim. (iii) The time limitation does not apply to claims from providers under investigation for fraud or abuse. (iv) The agency may make payments at any time in accordance with a court order, to carry out hearing decisions or agency corrective actions taken to resolve a dispute, or to extend the benefits of a hearing decision, corrective action, or court order to others in the same situation as those directly affected by it. (5) The date of receipt is the date the agency receives the claim, as indicated by its date stamp on the claim. (6) The date of payment is the date of the check or other form of payment. (e) Waivers. (1) The Administrator may waive the requirements of paragraphs (d) (2) and (3) of this section upon request by an agency if he finds that the agency has shown good faith in trying to meet them. In deciding whether the agency has shown good faith, the Administrator will consider whether the agency has received an unusually high volume of claims which are not clean claims, and whether the agency is making diligent efforts to implement an automated claims processing and information retrieval system. (2) The agency's request for a waiver must contain a written plan of correction specifying all steps it will take to meet the requirements of this section. (3) The Administrator will review each case and if he approves a waiver, will specify its expiration date, based on the State's capability and efforts to meet the requirements of this section. (f) Prepayment and postpayment claims review. (1) For all claims, the agency must conduct prepayment claims review consisting of— (i) Verification that the recipient was included in the eligibility file and that the provider was authorized to furnish the service at the time the service was furnished; (ii) Checks that the number of visits and services delivered are logically consistent with the recipient's characteristics and circumstances, such as type of illness, age, sex, service location; (iii) Verification that the claim does not duplicate or conflict with one reviewed previously or currently being reviewed; (iv) Verification that a payment does not exceed any reimbursement rates or limits in the State plan; and (v) Checks for third party liability within the requirements of §433.137 of this chapter. (2) The agency must conduct post-payment claims review that meets the requirements of parts 455 and 456 of this chapter, dealing with fraud and utilization control. (g) Reports. The agency must provide any reports and documentation on compliance with this section that the Administrator may require. (Secs. 1102 and 1902(a)(37) of the Social Security Act (42 U.S.C. 1302, 1396a(a)(37))) [44 FR 30344, May 25, 1979, as amended at 55 FR 1434, Jan. 16, 1990] (a) Basis and scope. This section implements section 1932(f) of the Act by specifying the rules and exceptions for prompt payment of claims by MCOs. (b) Definitions. “Claim” and “clean claim” have the meaning given those terms in §447.45. (c) Contract requirements—(1) Basic rule. A contract with an MCO must provide that the organization will meet the requirements of §§447.45(d)(2) and (d)(3), and abide by the specifications of §§447.45(d)(5) and (d)(6). (2) Exception. The MCO and its providers may, by mutual agreement, establish an alternative payment schedule. (3) Alternative schedule. Any alternative schedule must be stipulated in the contract. [67 FR 41115, June 14, 2002] (a) Section 1902(a)(14) of the Act permits States to require certain recipients to share some of the costs of Medicaid by imposing upon them such payments as enrollment fees, premiums, deductibles, coinsurance, co-payments, or similar cost sharing charges. For States that impose cost sharing payments, §§447.51 through 447.59 prescribe State plan requirements and options for cost sharing, specify the standards and conditions under which States may impose cost sharing, set forth minimum amounts and the methods for determining maximum amounts, and prescribe conditions for FFP that relate to cost sharing requirements.
Title 42: Public Health
PART 447—PAYMENTS FOR SERVICES
Subpart A—Payments: General Provisions
§ 447.1 Purpose.
§ 447.10 Prohibition against reassignment of provider claims.
§ 447.15 Acceptance of State payment as payment in full.
§ 447.20 Provider restrictions: State plan requirements.
§ 447.21 Reduction of payments to providers.
§ 447.25 Direct payments to certain recipients for physicians' or dentists' services.
§ 447.30 Withholding the Federal share of payments to Medicaid providers to recover Medicare overpayments.
§ 447.31 Withholding Medicare payments to recover Medicaid overpayments.
§ 447.40 Payments for reserving beds in institutions.
§ 447.45 Timely claims payment.
§ 447.46 Timely claims payment by MCOs.
Cost Sharing
§ 447.50 Cost sharing: Basis and purpose.
enrollment fee, premium or similar cost sharing charge
§ 447.51 Requirements and options.
(a) The plan must provide that the Medicaid agency does not impose any enrollment fee, premium, or similar charge upon categorically needy individuals, as defined in §§435.4 and 436.3 of this subchapter, for any services available under the plan.
(b) The plan may impose an enrollment fee, premium, or similar charge on medically needy individuals, as defined in §§435.4 and 436.3 of this subchapter, for any services available under the plan.
(c) For each charge imposed under paragraph (b) of this section, the plan must specify—
(1) The amount of the charge;
(2) The period of liability for the charge; and
(3) The consequences for an individual who does not pay.
(d) The plan must provide that any charge imposed under paragraph (b) of this section is related to total gross family income as set forth under §447.52.
§ 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------------------------------------------------------------------------ Family size ----------------------- Gross family income (per month) 5 or 1 or 2 3 or 4 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 14More than $1,000................................ 19 16 15------------------------------------------------------------------------
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(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] deductible, coinsurance, co-payment or similar cost-sharing charge§ 447.53 Applicability; specification; multiple charges.(a) Basic requirements. Except as specified in paragraph (b) of this section, the plan may impose a nominal deductible, coinsurance, copayment, or similar charge upon categorically and medically needy individuals for any service under the plan. (b) Exclusions from cost sharing. The plan may not provide for impositions of a deductible, coinsurance, copayment, or similar charge upon categorically or medically needy individuals for the following: (1) Children. Services furnished to individuals under 18 years of age (and, at the option of the State, individuals under 21, 20, or 19 years of age, or any reasonable category of individuals 18 years of age or over but under 21) are excluded from cost sharing. (2) Pregnant women. Services furnished to pregnant women if such services related to the pregnancy, or to any other medical condition which may complicate the pregnancy are excluded from cost sharing obligations. These services include routine prenatal care, labor and delivery, routine post-partum care, family planning services, complications of pregnancy or delivery likely to affect the pregnancy, such as hypertension, diabetes, urinary tract infection, and services furnished during the postpartum period for conditions or complications related to the pregnancy. The postpartum period is the immediate postpartum period which begins on the last day of pregnancy and extends through the end of the month in which the 60-day period following termination of pregnancy ends. States may further exclude from cost sharing all services furnished to pregnant women if they desire. (3) Institutionalized individuals. 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 (pursuant to §435.725, §435,733, §435.832, or §436.832), as a condition of receiving services in the institution, to spend all but a minimal amount of his income required for personal needs, for medical care costs are excluded from cost sharing. (4) Emergency services. Services provided in a hospital, clinic, office, or other facility that is equipped to furnish the required care, after the sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that the absence of immediate medical attention could reasonably be expected to result in— (i) Placing the patient's health in serious jeopardy; (ii) Serious impairment to bodily functions; or (iii) Serious dysfunction of any bodily organ or part. (5) Family planning. Family planning services and supplies furnished to individuals of child-bearing age are excluded from cost sharing. (c) Prohibition against multiple charges. For any service, the plan may not impose more than one type of charge referred to in paragraph (a) of this section. (d) State plan specifications. For each charge imposed under this section, the plan must specify— (1) The service for which the charge is made; (2) The amount of the charge; (3) The basis for determining the charge; (4) The basis for determining whether an individual is unable to pay the charge and the means by which such an individual will be identified to providers; and (5) The procedures for implementing and enforcing the exclusions from cost sharing found in paragraph (b) of this section. (e) No provider may deny services, to an individual who is eligible for the services, on account of the individual's inability to pay the cost sharing. [43 FR 45253, Sept. 29, 1978, as amended at 47 FR 21051, May 17, 1982; 48 FR 5736, Jan. 8, 1983; 50 FR 23013, May 30, 1985; 55 FR 48611, Nov. 21, 1990; 55 FR 52130, Dec. 19, 1990; 67 FR 41116, June 14, 2002] § 447.54 Maximum allowable charges.(a) Non-institutional services. Except as specified in paragraph (b), for non-institutional services, the plan must provide that— (1) Any deductible it imposes does not exceed $2.00 per month per family for each period of Medicaid eligibility. For example, if Medicaid eligibility is certified for a 3-month period, the maximum deductible which may be imposed on a family for that period of eligibility is $6.00; (2) Any coinsurance rate it imposes does not exceed 5 percent of the payment the agency makes for the services; and (3) Any co-payments it imposes do not exceed the amounts shown in the following table: |
------------------------------------------------------------------------ Maximum copayment States payment for the service chargeable to recipient------------------------------------------------------------------------$10 or less................................................. $.50$10.01 to $25............................................... 1.00$25.01 to $50............................................... 2.00$50.01 or more.............................................. 3.00------------------------------------------------------------------------
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(b) Waiver of the requirement that cost sharing amounts be nominal. Upon approval from CMS, the requirement that cost sharing charges must be nominal may be waived, in accordance with section 431.55(g) for nonemergency services furnished in a hospital emergency room. (c) Institutional services. For institutional services, the plan must provide that the maximum deductible, coinsurance or co-payment charge for each admission does not exceed 50 percent of the payment the agency makes for the first day of care in the institution. (d) Cumulative maximum. The plan may provide for a cumulative maximum amount for all deductible, coinsurance or co-payment charges that it imposes on any family during a specified period of time. [48 FR 5736, Jan. 8, 1983] § 447.55 Standard co-payment.(a) The plan may provide for a standard, or fixed, co-payment amount for any service. (b) This standard copayment amount for any service may be determined by applying the maximum co-payment amounts specified in §447.54 (a) and (b) to the agency's average or typical payment for that service. For example, if the agency's typical payment for prescribed drugs is $4 to $5 per prescription, the agency might set a standard copayment of $0.50 per prescription. § 447.56 Income-related charges.Subject to the maximum allowable charges specified in §447.54 (a) and (b), the plan may provide for income-related deductible, coinsurance or co-payment charges. For example, an agency may impose a higher charge on medically needy recipients than it imposes upon categorically needy recipients. § 447.57 Restrictions on payments to providers.(a) The plan must provide that the agency does not increase the payment it makes to any provider to offset uncollected amounts for deductibles, coinsurance, copayments or similar charges that the provider has waived or are uncollectable, except as permitted under paragraph (b) of this section. (b) For those providers that the agency reimburses under Medicare reasonable cost reimbursement principles, in accordance with subpart B of this part, an agency may increase its payment to offset uncollected deductible, coinsurance, copayment, or similar charges that are bad debts of providers. § 447.58 Payments to prepaid capitation organizations.If the agency contracts with a prepaid capitation organization that does not impose the agency's deductibles, coinsurance, co-payments or similar charges on its recipient members, the plan must provide that the agency calculates its payments to the organization as if those cost sharing charges were collected. [48 FR 5736, Jan. 8, 1983, as amended at 67 FR 41116, June 14, 2002] federal financial participation§ 447.59 FFP: Conditions relating to cost sharing.No FFP in the State's expenditures for services is available for— (a) Any cost sharing amounts that recipients should have paid as enrollment fees, premiums, deductibles, coinsurance, copayments, or similar charges under §§447.50 through 447.58 (except for amounts that the agency pays as bad debts of providers under §447.57); and (b) Any amounts paid by the agency on behalf of ineligible individuals, whether or not the individual had paid any required premium or enrollment fee. § 447.60 Cost-sharing requirements for services furnished by MCOs.Contracts with MCOs must provide that any cost-sharing charges the MCO imposes on Medicaid enrollees are in accordance with the requirements set forth in §§447.50 and 447.53 through 447.58 for cost-sharing charges imposed by the State agency. [67 FR 41116, June 14, 2002] § 447.88 Options for claiming FFP payment for section 1920A presumptive eligibility medical assistance payments.(a) The FMAP rate for medical assistance payments made available to a child during a presumptive eligibility period under section 1920A of the Act is the regular FMAP under title XIX, based on the category of medical assistance; that is, the enhanced FMAP is not available for section 1920A presumptive eligibility expenditures. (b) States have the following 3 options for identifying Medicaid section 1920A presumptive eligibility expenditures and the application of payments for those expenditures: (1) A State may identify Medicaid section 1920A presumptive eligibility expenditures in the quarter expended with no further adjustment based on the results of a subsequent actual eligibility determination (if any). (2) A State may identify Medicaid section 1920A presumptive eligibility expenditures in the quarter expended but may adjust reported expenditures based on results of the actual eligibility determination (if any) to reflect the actual eligibility status of the individual, if other than presumptively eligible. (3) A State may elect to delay submission of claims for payments of section 1920A presumptive eligibility expenditures until after the actual eligibility determination (if any) is made and, at that time identify such expenditures based on the actual eligibility status of individuals if other than presumptively eligible. At that time, the State would, as appropriate, recategorize the medical assistance expenditures made during the section 1920A presumptive eligibility period based on the results of the actual eligibility determination, and claim them appropriately. [65 FR 33622, May 24, 2000] Browse Next
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