42 C.F.R. Subpart E—State Plan Requirements: Enrollee Financial Responsibilities
Title 42 - Public Health
Source: 66 FR 2681, Jan. 11, 2001, unless otherwise noted.
(a) Statutory basis. This subpart implements— (1) Section 2101(a) of the Act, which provides that the purpose of title XXI is to provide funds to States to enable them to initiate and expand the provision of child health assistance to uninsured, low-income children in an effective and efficient manner; and (2) Section 2103(e) of the Act, which sets forth provisions regarding State plan requirements and options for cost sharing. (b) Scope. This subpart consists of provisions relating to the imposition under a separate child health program of cost-sharing charges including enrollment fees, premiums, deductibles, coinsurance, copayments, and similar cost-sharing charges. (c) Applicability. The requirements of this subpart apply to separate child health programs. The State plan must include a description of— (a) The amount of premiums, deductibles, coinsurance, copayments, and other cost sharing imposed; (b) The methods, including the public schedule, the State uses to inform enrollees, applicants, providers and the general public of the cost-sharing charges, the cumulative cost-sharing maximum, and any changes to these amounts; (c) The disenrollment protections as required under §457.570; (d) In the case of coverage obtained through premium assistance for group health plans— (1) The procedures the State uses to ensure that eligible children are not charged copayments, coinsurance, deductibles or similar fees on well-baby and well-child care services described at §457.520, and that any cost sharing complies with the requirements of this subpart; (2) The procedures to ensure that American Indian and Alaska Native children are not charged premiums, copayments, coinsurance, deductibles, or similar fees in accordance with §457.535; (3) The procedures to ensure that eligible children are not charged cost sharing in excess of the cumulative cost-sharing maximum specified in §457.560. (e) Procedures that do not primarily rely on a refund given by the State for overpayment on behalf of an eligible child to ensure compliance with this subpart. [66 FR 2681, Jan. 11, 2001, as amended at 66 FR 33824, June 25, 2001] When a State imposes premiums, enrollment fees, or similar fees on enrollees, the State plan must describe— (a) The amount of the premium, enrollment fee or similar fee imposed on enrollees; (b) The time period for which the charge is imposed; (c) The group or groups that are subject to the premiums, enrollment fees, or similar charges; (d) The consequences for an enrollee or applicant who does not pay a charge, and the disenrollment protections adopted by the State in accordance with §457.570; and (e) The methodology used to ensure that total cost-sharing liability for a family does not exceed the cumulative cost-sharing maximum specified in §457.560. To impose copayments, coinsurance, deductibles or similar charges on enrollees, the State plan must describe— (a) The service for which the charge is imposed; (b) The amount of the charge; (c) The group or groups of enrollees that may be subject to the cost-sharing charge; (d) The consequences for an enrollee who does not pay a charge, and the disenrollment protections adopted by the State in accordance with §457.570; (e) The methodology used to ensure that total cost-sharing liability for a family does not exceed the cumulative cost-sharing maximum specified in §457.560; and (f) An assurance that enrollees will not be held liable for cost-sharing amounts for emergency services that are provided at a facility that does not participate in the enrollee's managed care network beyond the copayment amounts specified in the State plan for emergency services as defined in §457.10. (a) A State may not impose copayments, deductibles, coinsurance or other cost sharing with respect to the well-baby and well-child care services covered under the State plan in either the managed care delivery setting or the fee-for-service delivery setting. (b) For the purposes of this subpart, at a minimum, any of the following services covered under the State plan will be considered well-baby and well-child care services: (1) All healthy newborn physician visits, including routine screening, whether provided on an inpatient or outpatient basis. (2) Routine physical examinations as recommended and updated by the American Academy of Pediatrics (AAP) “Guidelines for Health Supervision III” and described in “Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents.” (3) Laboratory tests associated with the well-baby and well-child routine physical examinations as described in paragraph (b)(2) of this section. (4) Immunizations and related office visits as recommended and updated by the Advisory Committee on Immunization Practices (ACIP). (5) Routine preventive and diagnostic dental services (such as oral examinations, prophylaxis and topical fluoride applications, sealants, and x-rays) as described in the most recent guidelines issued by the American Academy of Pediatric Dentistry (AAPD). (a) The State must make available to the groups in paragraph (b) of this section a public schedule that contains the following information: (1) Current cost-sharing charges. (2) Enrollee groups subject to the charges. (3) Cumulative cost-sharing maximums. (4) Mechanisms for making payments for required charges. (5) The consequences for an applicant or an enrollee who does not pay a charge, including the disenrollment protections required by §457.570. (b) The State must make the public schedule available to the following groups: (1) Enrollees, at the time of enrollment and reenrollment after a redetermination of eligibility, and when cost-sharing charges and cumulative cost-sharing maximums are revised. (2) Applicants, at the time of application. (3) All participating providers. (4) The general public. The State may vary premiums, deductibles, coinsurance, copayments or any other cost sharing based on family income only in a manner that does not favor children from families with higher income over children from families with lower income. States may not impose premiums, deductibles, coinsurance, copayments or any other cost-sharing charges on children who are American Indians or Alaska Natives, as defined in §457.10. The State may impose premiums, enrollment fees, deductibles, copayments, coinsurance, cost sharing and other similar charges for children whose family income is at or below 150 percent of the FPL as long as— (a) Aggregate monthly enrollment fees, premiums, or similar charges imposed on a family are less than or equal to the maximum amounts permitted under §447.52 of this chapter for a Medicaid eligible family of the same size and income; (b) Any copayments, coinsurance, deductibles or similar charges for children whose family income is at or below 100 percent of the FPL are equal to or less than the amounts permitted under §447.54 of this chapter; (c) For children whose family income is from 101 percent to 150 percent of the FPL, any copayments, coinsurance, deductibles or similar charges are equal to or less than the maximum amounts permitted under §457.555; (d) The State does not impose more than one type of cost-sharing charge (deductible, copayment, or coinsurance) on a service; (e) The State only imposes one copayment based on the total cost of services furnished during one office visit; and (f) Aggregate annual cost sharing of all types, with respect to all targeted low-income children in a family, does not exceed the maximum permitted under §457.560(a). [66 FR 2681, Jan. 11, 2001, as amended at 66 FR 33824, June 25, 2001] (a) Non-institutional services. For targeted low-income children whose family income is from 101 to 150 percent of the FPL, the State plan must provide that for non-institutional services, including emergency services— (1) Any copayment or similar charge the State imposes under a fee-for-service delivery system does not exceed the following amounts: (2) Any copayment that the State imposes for services provided by a managed care organization may not exceed $5.00 per visit; (3) Any coinsurance rate the State imposes may not exceed 5 percent of the payment the State directly or through contract makes for the service; and (4) Any deductible the State imposes may not exceed $3.00 per month, per family for each period of eligibility. (b) Institutional services. For targeted low-income children whose family income is from 101 to 150 percent of the FPL, the maximum deductible, coinsurance or copayment charge for each institutional admission may not exceed 50 percent of the payment the State would make under the Medicaid fee-for-service system for the first day of care in the institution. (c) Institutional emergency services. Any copayment that the State imposes on emergency services provided by an institution may not exceed $5.00. (d) Nonemergency use of the emergency room. 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 $10.00, for services furnished in a hospital emergency room if those services are not emergency services as defined in §457.10. (e) Standard copayment amount. For targeted low-income children whose family income is from 101 to 150 percent of the FPL, a standard copayment amount for any service may be determined by applying the maximum copayment amounts specified in paragraphs (a), (b), and (c) of this section to the State's average or typical payment for that service. (a) A State may not impose premiums, enrollment fees, copayments, coinsurance, deductibles, or similar cost-sharing charges that, in the aggregate, exceed 5 percent of a family's total income for the length of a child's eligibility period in the State. (b) The State must inform the enrollee's family in writing and orally if appropriate of their individual cumulative cost-sharing maximum amount at the time of enrollment and reenrollment. [66 FR 2681, Jan. 11, 2001, as amended at 66 FR 33824, June 25, 2001] (a) The State must give enrollees reasonable notice of and an opportunity to pay past due premiums, copayments, coinsurance, deductibles or similar fees prior to disenrollment. (b) The disenrollment process must afford the enrollee an opportunity to show that the enrollee's family income has declined prior to disenrollment for non payment of cost-sharing charges, and in the event that such a showing indicates that the enrollee may have become eligible for Medicaid or for a lower level of cost sharing, the State must facilitate enrolling the child in Medicaid or adjust the child's cost-sharing category as appropriate. (c) The State must provide the enrollee with an opportunity for an impartial review to address disenrollment from the program in accordance with §457.1130(a)(3).
Title 42: Public Health
PART 457—ALLOTMENTS AND GRANTS TO STATES
Subpart E—State Plan Requirements: Enrollee Financial Responsibilities
§ 457.500 Basis, scope, and applicability.
§ 457.505 General State plan requirements.
§ 457.510 Premiums, enrollment fees, or similar fees: State plan requirements.
§ 457.515 Co-payments, coinsurance, deductibles, or similar cost-sharing charges: State plan requirements.
§ 457.520 Cost sharing for well-baby and well-child care services.
§ 457.525 Public schedule.
§ 457.530 General cost-sharing protection for lower income children.
§ 457.535 Cost-sharing protection to ensure enrollment of American Indians and Alaska Natives.
§ 457.540 Cost-sharing charges for children in families with incomes at or below 150 percent of the FPL.
§ 457.555 Maximum allowable cost-sharing charges on targeted low-income children in families with income from 101 to 150 percent of the FPL.
------------------------------------------------------------------------ Maximum amount Total cost of services provided during a visit chargeable to enrollee------------------------------------------------------------------------$15.00 or less............................................. $1.00$15.01 to $40.............................................. 2.00$40.01 to $80.............................................. 3.00$80.01 or more............................................. 5.00------------------------------------------------------------------------
§ 457.560 Cumulative cost-sharing maximum.
§ 457.570 Disenrollment protections.
