Modifying Cost Sharing Requirements for Certain Expansion Individuals under the Medicaid Program
Section 71120 · Sec. 71120 ·
What this chapter is about
This part makes states charge some Medicaid adults toward their care. It starts October 1, 2028 and covers people above the poverty line. No charge may top $35 for an item or service. Primary, mental health and addiction care are free of charge.
“the State plan shall provide that in the case of a specified individual (as defined in paragraph (3)) who is eligible under the plan, no enrollment fee, premium, or similar charge will be imposed under the plan.”
The section adds a new subsection (k) to section 1916 of the Social Security Act (42 U.S.C. 1396o) barring, from October 1, 2028, any enrollment fee, premium or similar charge on a specified individual eligible under the plan.
What the document actually says
“the State plan shall provide that in the case of a specified individual (as defined in paragraph (3)) who is eligible under the plan, no enrollment fee, premium, or similar charge will be imposed under the plan.”
That sentence, in plain words
The state plan must say one thing. No signup fee or premium may be charged. That covers the group named below.
What this is about
The bar starts on October 1, 2028. It reaches premiums and like charges. Charges at the point of care are dealt with next.
No action is recorded against this proposal. That is not evidence that none has been taken, and nobody has yet read it against the record. See what the tracker does not yet cover.
“the State plan shall, beginning October 1, 2028, provide for the imposition of such deductions, cost sharing, or similar charges determined appropriate by the State (in an amount greater than $0) with respect to certain care, items, or services furnished to such an individual, as determined by the State.”
The section requires the State plan, from October 1, 2028, to charge more than zero in deductions, cost sharing or similar charges on certain care, items or services given to a specified individual, as the State decides.
What the document actually says
“the State plan shall, beginning October 1, 2028, provide for the imposition of such deductions, cost sharing, or similar charges determined appropriate by the State (in an amount greater than $0) with respect to certain care, items, or services furnished to such an individual, as determined by the State.”
That sentence, in plain words
The state must charge something. It must be more than zero. It picks which care it applies to.
What this is about
That starts on October 1, 2028. The next rules set limits on it. Some care may not be charged for at all.
No action is recorded against this proposal. That is not evidence that none has been taken, and nobody has yet read it against the record. See what the tracker does not yet cover.
The document says “may not”Who acts: State agenciesHow: statuteSec. 71120 in the PDF
What the document says
“In no case may a deduction, cost sharing, or similar charge be imposed under the State plan with respect to care, items, or services described in any of subparagraphs (B) through (J) of subsection (a)(2), or any primary care services, mental health care services, substance use disorder services”
The section bars any charge on care described in subparagraphs (B) through (J) of section 1916(a)(2) of the Social Security Act, on primary care, mental health care or substance use disorder services, or on services from a Federally qualified health center, a certified community behavioral health clinic or a rural health clinic.
What the document actually says
“In no case may a deduction, cost sharing, or similar charge be imposed under the State plan with respect to care, items, or services described in any of subparagraphs (B) through (J) of subsection (a)(2), or any primary care services, mental health care services, substance use disorder services”
That sentence, in plain words
No charge may be laid on the care named here. That covers care already free under an older list.
What this is about
It also covers primary care and mental health care. It covers care for addiction. Care at named community clinics is free of charge too.
No action is recorded against this proposal. That is not evidence that none has been taken, and nobody has yet read it against the record. See what the tracker does not yet cover.
The document says “may not”Who acts: State agenciesHow: statuteSec. 71120 in the PDF
What the document says
“in no case may a deduction, cost sharing, or similar charge imposed under the State plan with respect to care or an item or service furnished to a specified individual exceed $35.”
The section caps a charge for care, an item or a service at $35, with prescription drugs capped instead by the limits that would apply under section 1916A(c), and caps the total charges for everyone in a family at 5 percent of family income, applied quarterly or monthly as the State specifies. A State may let a provider require payment as a condition of care, and a provider may still reduce or waive it case by case.
What the document actually says
“in no case may a deduction, cost sharing, or similar charge imposed under the State plan with respect to care or an item or service furnished to a specified individual exceed $35.”
That sentence, in plain words
No single charge may top $35. That covers care, an item or a service.
What this is about
Prescription drugs follow a different cap. The family total may not top 5 percent of income. A provider may still waive a charge.
No action is recorded against this proposal. That is not evidence that none has been taken, and nobody has yet read it against the record. See what the tracker does not yet cover.
“the term `specified individual' means an individual who has a family income (as determined in accordance with section 1902(e)(14)) that exceeds the poverty line (as defined in section 2110(c)(5)) applicable to a family of the size involved and--”
The section defines a specified individual as someone whose family income exceeds the poverty line for a family of that size and who is enrolled under the expansion group in section 1902(a)(10)(A)(i)(VIII) or is described there and enrolled under a waiver giving coverage equivalent to minimum essential coverage. State means one of the 50 States or the District of Columbia.
What the document actually says
“the term `specified individual' means an individual who has a family income (as determined in accordance with section 1902(e)(14)) that exceeds the poverty line (as defined in section 2110(c)(5)) applicable to a family of the size involved and--”
That sentence, in plain words
The person's family income must top the poverty line. That line is set for a family of that size. The tests that follow narrow it further.
What this is about
The person must be in the Medicaid expansion group. A waiver with like cover also counts. Only the 50 states and the capital are covered.
No action is recorded against this proposal. That is not evidence that none has been taken, and nobody has yet read it against the record. See what the tracker does not yet cover.
Each distinct thing the section does: bar premiums for the named group, require cost sharing on some care, exclude named kinds of care from any charge, cap a charge at $35 with a separate drug rule, cap the family total at 5 percent of income, allow a provider to require payment, and define a specified individual and a State.
The conforming amendments carrying the requirement into other provisions.
The section works by amending sections 1902 and 1916 of the Social Security Act and points to sections 1905, 1916A and 2110 of that Act and the Internal Revenue Code of 1986, none of which is indexed here.
