|
U.S. Code as of:
01/19/04
Section 1396o. Use of enrollment fees, premiums, deductions, cost sharing, and similar charges
(a) Imposition of certain charges under plan in case of individuals
described in section 1396a(a)(10)(A) or (E)
Subject to subsection (g) of this section, the State plan shall
provide that in the case of individuals described in subparagraph
(A) or (E)(i) of section 1396a(a)(10) of this title who are
eligible under the plan -
(1) no enrollment fee, premium, or similar charge will be
imposed under the plan (except for a premium imposed under
subsection (c) of this section);
(2) no deduction, cost sharing or similar charge will be
imposed under the plan with respect to -
(A) 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),
(B) services furnished to pregnant women, if such services
relate to the pregnancy or to any other medical condition which
may complicate the pregnancy (or, at the option of the State,
any services furnished to pregnant women),
(C) 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 such
individual is required, as a condition of receiving services in
such institution under the State plan, to spend for costs of
medical care all but a minimal amount of his income required
for personal needs,
(D) emergency services (as defined by the Secretary), family
planning services and supplies described in section
1396d(a)(4)(C) of this title, or
(E) services furnished to an individual who is receiving
hospice care (as defined in section 1396d(o) of this title);
and
(3) any deduction, cost sharing, or similar charge imposed
under the plan with respect to other such individuals or other
care and services will be nominal in amount (as determined by the
Secretary in regulations which shall, if the definition of
"nominal" under the regulations in effect on July 1, 1982 is
changed, take into account the level of cash assistance provided
in such State and such other criteria as the Secretary determines
to be appropriate); except that a deduction, cost-sharing, or
similar charge of up to twice the nominal amount established for
outpatient services may be imposed by a State under a waiver
granted by the Secretary for services received at a hospital
emergency room if the services are not emergency services
(referred to in paragraph (2)(D)) and the State has established
to the satisfaction of the Secretary that individuals eligible
for services under the plan have actually available and
accessible to them alternative sources of nonemergency,
outpatient services.
(b) Imposition of certain charges under plan in case of individuals
other than those described in section 1396a(a)(10)(A) or (E)
The State plan shall provide that in the case of individuals
other than those described in subparagraph (A) or (E) of section
1396a(a)(10) of this title who are eligible under the plan -
(1) there may be imposed an enrollment fee, premium, or similar
charge, which (as determined in accordance with standards
prescribed by the Secretary) is related to the individual's
income,
(2) no deduction, cost sharing, or similar charge will be
imposed under the plan with respect to -
(A) 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),
(B) services furnished to pregnant women, if such services
relate to the pregnancy or to any other medical condition which
may complicate the pregnancy (or, at the option of the State,
any services furnished to pregnant women),
(C) 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 such
individual is required, as a condition of receiving services in
such institution under the State plan, to spend for costs of
medical care all but a minimal amount of his income required
for personal needs,
(D) emergency services (as defined by the Secretary), family
planning services and supplies described in section
1396d(a)(4)(C) of this title, or
(E) services furnished to an individual who is receiving
hospice care (as defined in section 1396d(o) of this title);
and
(3) any deduction, cost sharing, or similar charge imposed
under the plan with respect to other such individuals or other
care and services will be nominal in amount (as determined by the
Secretary in regulations which shall, if the definition of
"nominal" under the regulations in effect on July 1, 1982 is
changed, take into account the level of cash assistance provided
in such State and such other criteria as the Secretary determines
to be appropriate); except that a deduction, cost-sharing, or
similar charge of up to twice the nominal amount established for
outpatient services may be imposed by a State under a waiver
granted by the Secretary for services received at a hospital
emergency room if the services are not emergency services
(referred to in paragraph (2)(D)) and the State has established
to the satisfaction of the Secretary that individuals eligible
for services under the plan have actually available and
accessible to them alternative sources of nonemergency,
outpatient services.
(c) Imposition of monthly premium; persons affected; amount;
prepayment; failure to pay; use of funds from other programs
(1) The State plan of a State may at the option of the State
provide for imposing a monthly premium (in an amount that does not
exceed the limit established under paragraph (2)) with respect to
an individual described in subparagraph (A) or (B) of section
1396a(l)(1) of this title who is receiving medical assistance on
the basis of section 1396a(a)(10)(A)(ii)(IX) of this title and
whose family income (as determined in accordance with the
methodology specified in section 1396a(l)(3) of this title) equals
or exceeds 150 percent of the income official poverty line (as
defined by the Office of Management and Budget, and revised
annually in accordance with section 9902(2) of this title)
applicable to a family of the size involved.
(2) In no case may the amount of any premium imposed under
paragraph (1) exceed 10 percent of the amount by which the family
income (less expenses for the care of a dependent child) of an
individual exceeds 150 percent of the line described in paragraph
(1).
(3) A State shall not require prepayment of a premium imposed
pursuant to paragraph (1) and shall not terminate eligibility of an
individual for medical assistance under this subchapter on the
basis of failure to pay any such premium until such failure
continues for a period of not less than 60 days. The State may
waive payment of any such premium in any case where the State
determines that requiring such payment would create an undue
hardship.
(4) A State may permit State or local funds available under other
programs to be used for payment of a premium imposed under
paragraph (1). Payment of a premium with such funds shall not be
counted as income to the individual with respect to whom such
payment is made.
(d) Premiums for qualified disabled and working individuals
described in section 1396d(s)
With respect to a qualified disabled and working individual
described in section 1396d(s) of this title whose income (as
determined under paragraph (3) of that section) exceeds 150 percent
of the official poverty line referred to in that paragraph, the
State plan of a State may provide for the charging of a premium
(expressed as a percentage of the medicare cost-sharing described
in section 1396d(p)(3)(A)(i) of this title provided with respect to
the individual) according to a sliding scale under which such
percentage increases from 0 percent to 100 percent, in reasonable
increments (as determined by the Secretary), as the individual's
income increases from 150 percent of such poverty line to 200
percent of such poverty line.
(e) Prohibition of denial of services on basis of individual's
inability to pay certain charges
The State plan shall require that no provider participating under
the State plan may deny care or services to an individual eligible
for such care or services under the plan on account of such
individual's inability to pay a deduction, cost sharing, or similar
charge. The requirements of this subsection shall not extinguish
the liability of the individual to whom the care or services were
furnished for payment of the deduction, cost sharing, or similar
charge.
(f) Charges imposed under waiver authority of Secretary
No deduction, cost sharing, or similar charge may be imposed
under any waiver authority of the Secretary, except as provided in
subsections (a)(3) and (b)(3) of this section, unless such waiver
is for a demonstration project which the Secretary finds after
public notice and opportunity for comment -
(1) will test a unique and previously untested use of
copayments,
(2) is limited to a period of not more than two years,
(3) will provide benefits to recipients of medical assistance
which can reasonably be expected to be equivalent to the risks to
the recipients,
(4) is based on a reasonable hypothesis which the demonstration
is designed to test in a methodologically sound manner, including
the use of control groups of similar recipients of medical
assistance in the area, and
(5) is voluntary, or makes provision for assumption of
liability for preventable damage to the health of recipients of
medical assistance resulting from involuntary participation.
(g) Individuals provided medical assistance under section
1396a(a)(10)(A)(ii)(XV) or (XVI)
With respect to individuals provided medical assistance only
under subclause (XV) or (XVI) of section 1396a(a)(10)(A)(ii) of
this title -
(1) a State may (in a uniform manner for individuals described
in either such subclause) -
(A) require such individuals to pay premiums or other
cost-sharing charges set on a sliding scale based on income
that the State may determine; and
(B) require payment of 100 percent of such premiums for such
year in the case of such an individual who has income for a
year that exceeds 250 percent of the income official poverty
line (referred to in subsection (c)(1) of this section)
applicable to a family of the size involved, except that in the
case of such an individual who has income for a year that does
not exceed 450 percent of such poverty line, such requirement
may only apply to the extent such premiums do not exceed 7.5
percent of such income; and
(2) such State shall require payment of 100 percent of such
premiums for a year by such an individual whose adjusted gross
income (as defined in section 62 of the Internal Revenue Code of
1986) for such year exceeds $75,000, except that a State may
choose to subsidize such premiums by using State funds which may
not be federally matched under this subchapter.
In the case of any calendar year beginning after 2000, the dollar
amount specified in paragraph (2) shall be increased in accordance
with the provisions of section 415(i)(2)(A)(ii) of this title.
|
|