Alternative Premiums & Cost-Sharing

Sections 6041 and 6042 of the DRA allow States to vary the premiums and cost-sharing that they charge to certain Medicaid recipients.  No premiums are permitted for families with income above 100 percent and at/or below 150 percent of the Federal Poverty Limit (FPL).  Cost-sharing up to 10 percent of the cost of services is permitted within this group. Above 150 percent of the FPL, premiums are permitted and cost-sharing up to 20 percent of the cost of services is allowed.  No premiums or cost-sharing are permitted for families with incomes below 100 percent of the FPL.  The DRA contains special rules on cost-sharing for prescription drugs and non-emergency care provided in emergency rooms (ER).

In addition, States have the option to require payment of alternative premiums as a condition of eligibility and alternative cost-sharing as a condition of receipt of the service or drug, or cost-sharing for non-emergency services in the ER.  The DRA provides that the aggregate premium and/or cost-sharing amounts must not exceed 5 percent of the family's income for all family members for the month or quarter period.  As part of the ER provision, the DRA sets up a grant program that provides $50 million in funding for States to establish non-emergency alternative providers.

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Page Last Modified: 07/28/2008 5:43:17 PM
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