42 U.S.C. § 1396o — Use of enrollment fees, premiums, deductions, cost sharing, and similar charges

(a) For people covered under section 1396a(a)(10)(A) or (E), the State plan must follow these rules, subject to subsections (g), (i), and (j). Beginning October 1, 2028, this subsection does not cover a “specified individual” defined in subsection (k)(3). (1) The plan may not charge an enrollment fee, premium, or similar charge, except for a premium allowed by subsection (c). (2) It may not charge a deduction, cost sharing, or similar charge for: (A) services for people under 18 (or, if the State chooses, under 21, 20, or 19, or a reasonable category of people 18 or older); (B) services for a pregnant woman that concern the pregnancy or a condition that could complicate it; counseling and medicines to stop tobacco use by a pregnant woman; and covered outpatient drugs, including specified nonprescription drugs, prescribed and used to help a pregnant woman stop tobacco use according to the Guideline named in the statute (the State may instead exempt all services for pregnant women); (C) services for an inpatient in a hospital, nursing facility, intermediate care facility for people with intellectual disabilities, or another medical institution, when the person must spend all but a minimal amount of income needed for personal needs on medical care; (D) emergency services, as the Secretary defines them, and the listed family-planning services and supplies; (E) services for a person receiving “hospice care,” which this section does not define; (F) the specified in-vitro diagnostic product given during any part of the emergency period beginning on or after March 18, 2020, and its administration; (G) COVID-19 testing-related services payable under the plan; (H) from March 11, 2021, through the last day of the first calendar quarter beginning one year after the COVID-19 emergency period ends, a COVID-19 vaccine and its administration for a person eligible for assistance for them; (I) during that same period, COVID-19 testing and treatment, including special equipment and therapies, including preventive therapies, and, while a person has or is presumed to have COVID-19, treatment of a condition that could seriously complicate COVID-19 treatment, if the plan or a waiver covers it; and (J) the vaccines listed in section 1396d(a)(13)(B) and their administration. (3) Charges for other people, care, and services must be “nominal,” as the Secretary determines by regulation. If the regulations’ definition of “nominal” changes from the definition in effect July 1, 1982, the Secretary must consider the State’s cash assistance level and other appropriate criteria. A State may, under a Secretary-approved waiver, charge up to twice the nominal outpatient amount for nonemergency services in a hospital emergency room only if it has shown that eligible people have actually available and accessible alternative nonemergency outpatient sources. (b) For other eligible people—those not described in section 1396a(a)(10)(A) or (E)—the State plan must provide: (1) an enrollment fee, premium, or similar charge may be imposed if it is related to the person’s income under the Secretary’s standards; (2) no deduction, cost sharing, or similar charge for the same categories of services and items listed in subsection (a)(2)(A) through (J), with the same age choices, pregnancy rules, institutional-income rule, definitions, dates, and coverage conditions; and (3) nominal charges for other people, care, and services under the same Secretary rules. The same waiver may permit up to twice the nominal outpatient amount for nonemergency emergency-room services if the State proves that accessible alternatives exist. (c) (1) A State may choose to charge a monthly premium to a person described in section 1396a(l)(1)(A) or (B) who receives assistance under section 1396a(a)(10)(A)(ii)(IX), if the person’s family income is at least 150 percent of the official poverty line for a family of that size. Income is measured under section 1396a(l)(3); the poverty line is the Office of Management and Budget line, revised yearly under section 9902(2). (2) The premium may not exceed 10 percent of the amount by which the person’s family income, after subtracting dependent-child-care expenses, exceeds 150 percent of that line. (3) The State may not require advance payment and may not end eligibility for nonpayment until the failure lasts at least 60 days. It may waive payment if requiring it would cause undue hardship. (4) State or local money from other programs may pay the premium, and that payment is not income to the person. (d) For a qualified disabled and working individual defined in section 1396d(s) whose income is above 150 percent of the official poverty line, the State may charge a premium stated as a percentage of that person’s Medicare cost sharing. The percentage must rise in reasonable Secretary-determined steps from 0 to 100 as income rises from 150 to 200 percent of the line. (e) The State plan must require participating providers not to deny covered care or services because a person cannot pay a deduction, cost sharing, or similar charge. The person still owes the charge. (f) The Secretary may not impose such a charge through waiver authority except as allowed by (a)(3), (b)(3), or section 1396o-1, unless the waiver is a demonstration project announced publicly with an opportunity for comment and the Secretary finds that it: (1) tests a unique, previously untested use of copayments; (2) lasts no more than two years; (3) gives recipients benefits reasonably expected to equal the risks; (4) tests a reasonable hypothesis in a methodologically sound way, including similar control groups in the area; and (5) is voluntary or provides liability for preventable health damage caused by involuntary participation. (g) For people receiving assistance only under section 1396a(a)(10)(A)(ii)(XV) or (XVI), a State may uniformly: (1)(A) require income-based sliding-scale premiums or other cost sharing; and (B) require payment of all premiums for a year by a person whose income exceeds 250 percent of the poverty line, but for a person at or below 450 percent, only to the extent premiums do not exceed 7.5 percent of that income; and (2) require all premiums from a person whose adjusted gross income, as defined in section 62 of the Internal Revenue Code, exceeds $75,000. The State may subsidize those premiums with State money that cannot receive Federal matching. After 2000, the $75,000 amount rises under section 415(i)(2)(A)(ii). (h) For cost sharing that is “nominal,” the Secretary must raise the amount each year beginning in 2006 by the yearly percentage increase in the medical-care component of the Consumer Price Index for all urban consumers, U.S. city average, rounded up appropriately. This rule also applies to the listed provisions of section 1396o-1. (i) (1) For disabled children receiving assistance under section 1396a(a)(10)(A)(ii)(XIX), a State may uniformly require families to pay monthly premiums based on family income. (2) This may apply only if: (A) for family income at or below 200 percent of the poverty line, the premium plus the parent’s required family-coverage premium and other cost sharing is no more than 5 percent of family income; for income above 200 but no more than 300 percent, it is no more than 7.5 percent; and (B) the requirement follows section 1396a(cc)(2)(A)(ii)(I). (3) The State may not require advance payment or end the child’s eligibility for nonpayment until the failure lasts at least 60 days after the premium became overdue. It may waive payment for undue hardship. (j) (1)(A) No enrollment fee, premium, deduction, copayment, cost sharing, or similar charge may be imposed on an Indian who receives an item or service directly from the Indian Health Service, an Indian Tribe, Tribal Organization, or Urban Indian Organization, or through a contract-health-services referral, when payment may be made under this subchapter. (B) Payment due under this subchapter to those Indian health entities or to a referred provider may not be reduced by a charge that would have been owed by the Indian without subparagraph (A). (2) This subsection does not limit any other premium or cost-sharing protection that applies to an Indian receiving assistance. (k) Beginning October 1, 2028: (1) the State plan may not charge an eligible “specified individual” an enrollment fee, premium, or similar charge; (2)(A) subject to (B) and (j), it must impose State-selected deductions, cost sharing, or similar charges greater than zero for selected care, items, or services for a specified individual; (B)(i) it may not charge for care, items, or services listed in subsection (a)(2)(B) through (J), or for primary care, mental-health, substance-use-disorder services, or services from a Federally qualified health center, certified community behavioral health clinic, or rural health clinic. This section does not define those quoted terms. (ii)(I) A charge for care, an item, or a service may not exceed $35. (II) A prescription-drug charge may not exceed the limit that would apply under the specified provisions of section 1396o-1(c) if that drug were subject to those provisions. (iii) Total charges for everyone in the family may not exceed 5 percent of family income, applied quarterly or monthly as the State specifies. (C) Despite subsection (e), a participating provider may require payment of an authorized charge before furnishing covered care, items, or services. The provider may reduce or waive it case by case. (3) “Specified individual” means a person whose family income under section 1396a(e)(14) exceeds the poverty line under section 1397jj(c)(5), for a family of that size, and who either (A) is enrolled under section 1396a(a)(10)(A)(i)(VIII), or (B) is described there and enrolled under a waiver providing equivalent minimum essential coverage to everyone described there under Secretary-set standards. This section does not define “minimum essential coverage.” (4) “State” means one of the 50 States or the District of Columbia.