[Code of Federal Regulations]

[Title 42, Volume 4]

[Revised as of October 1, 2006]

From the U.S. Government Printing Office via GPO Access

[CITE: 42CFR447.53]



[Page 314-315]

 

                         TITLE 42--PUBLIC HEALTH

 

  CHAPTER IV--CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF 

                  HEALTH AND HUMAN SERVICES (CONTINUED)

 

PART 447_PAYMENTS FOR SERVICES--Table of Contents

 

                 Subpart A_Payments: General Provisions

 

Sec.  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



[[Page 315]]



care facility, or other medical institution if the individual is 

required (pursuant to Sec.  435.725, Sec.  435,733, Sec.  435.832, or 

Sec.  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]