Sec. 301. Strengthened cost sharing protections under Medicaid and CHIP

1,877 words·~9 min read·/bill/113/s/2461/is/section-301

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Section 1916 ( 42 U.S.C. 1396o ) is amended— in subsection (a)— in subparagraph

(E)of paragraph (2), by striking and at the end; in paragraph (3)— by inserting subject to paragraph (4), before any deduction ; and by striking the period at the end and inserting ; and ; and by adding at the end the following new paragraph: the total annual aggregate amount of any premium, enrollment fee, deduction, cost sharing, or similar charge imposed under the plan with respect to such individuals and their families shall not exceed 5 percent of the family income of the individual involved, as applied on a quarterly or monthly basis (as specified by the State). ; in subsection (b)— in subparagraph

(E)of paragraph (2), by striking and at the end; in paragraph (3)— by inserting subject to paragraph

(4)before any deduction ; and by striking the period at the end and inserting ; and ; and by adding at the end the following new paragraph: the total annual aggregate amount of any premium, enrollment fee, deduction, cost sharing, or similar charge imposed under the plan with respect to such individuals and their families shall not exceed 5 percent of the family income of the individual involved, as applied on a quarterly or monthly basis (as specified by the State). ; in subsection (d), by inserting , and provided that the total annual aggregate amount of any such premium, and any enrollment fee, deduction, cost sharing, or similar charge imposed under the plan with respect to such individuals and their families shall not exceed 5 percent of the family income of the individual involved, as applied on a quarterly or monthly basis (as specified by the State) before the period; and by adding at the end the following new subsection: If the State plan imposes premiums, enrollment fees, deductions, cost sharing, or similar charges under this section that, together with any such charges imposed under section 1916A, could cause families to have out-of-pocket expenses that exceed a total aggregate cost sharing limit imposed under subsection (a)(4) or (b)(4) for the month or quarter (as specified by the State), the State shall establish a process for tracking and aggregating such expenses (including expenses incurred for separately administered benefits) that— does not rely on documentation provided by the individual or the family; is communicated in a manner designed to ensure the privacy of patient-related information; and allows for coordination with managed care entities (as defined in section 1932(a)(1)(B)) that are under contract with the State. When a family reaches any limit for a period imposed on premiums, deductions, cost sharing, or similar charges under this section, no further premiums, deductions, cost sharing, or similar charges (or any portions thereof) shall be imposed on any individual in the family who is eligible for and receiving medical assistance under the plan for the remainder of the period. With respect to a limit imposed on premiums, deductions, cost sharing, or similar charges under this section the State plan shall provide for the notification of providers and each family to which such a limit applies— of any such limit applicable to the family; when the family has incurred out-of-pocket expenses up to any such limit; and when a family reaches any such limit for a period, that the limit has been reached and that no further premiums, deductions, cost sharing, or similar charges (or portions thereof) shall be imposed on any individual in the family who is eligible for and receiving medical assistance under the plan for the remainder of such month or quarter. The State shall establish a process for families that include an individual who is eligible for and receiving medical assistance under the plan to request a reassessment of the family’s aggregate limit on premiums, deductions, cost sharing, or similar charges if the family has a change in circumstances, in accordance with criteria specified by the Secretary. The requirements of this subsection shall apply in the same manner to limits imposed under subsections (c), (d), (g), and (i). . Section 1916A(b) ( 42 U.S.C. 1396o–1(b) ) is amended— in paragraphs (1)(B)(ii) and (2)(A), by inserting or section 1916 after subsection

(c)or

(e)in each place it appears; and by adding at the end the following new paragraph: If the State plan imposes premiums or cost sharing under this section that, together with cost sharing imposed under section 1916, could cause families to have out-of-pocket expenses that exceed the total aggregate limit imposed under paragraph

(1)or

(2)of this subsection for a month or quarter (as specified by the State), the State shall establish a process for tracking and aggregating such expenses (including expenses for separately administered benefits) that— does not rely on documentation provided by the individual or the family; is communicated in a manner designed to ensure the privacy of patient-related information; and allows for coordination with managed care entities (as defined in section 1932(a)(1)(B)) that are under contract with the State. When a family reaches any limit for a period imposed on premiums or cost sharing under this section, no further premiums or cost sharing (or any portions thereof) shall be imposed on any individual in the family who is eligible for and receiving medical assistance under the plan for the remainder of the period. With respect to a limit imposed on premiums or cost sharing under paragraph

(1)or

(2)of this subsection the State plan shall provide for the notification of providers and each family to which such a limit applies— of any such limit applicable to the family; when the family has incurred out-of-pocket expenses up to any such limit; and when a family reaches such a limit for a period, that the limit has been reached and that no further premiums or cost sharing (or portions thereof) shall be imposed on any individual in the family who is eligible for and receiving medical assistance under the plan for the remainder of such month or quarter. The State shall establish a process for families that include an individual who is eligible for and receiving medical assistance under the plan to request a reassessment of the family’s aggregate limit on premiums, deductions, cost sharing, or similar charges if the family has a change in circumstances, in accordance with criteria specified by the Secretary. . Section 1932(a)(5) ( 42 U.S.C. 1396u–2(a)(5) ) is amended by adding at the end the following new subparagraph: The State shall require that a managed care entity with a contract with the State, as a condition of such contract, comply with the requirements of sections 1916 and 1916A (as applicable), for such individuals who are enrolled with the organization or entity and coordinate with the State with respect to tracking and aggregating an enrollee's family's out-of-pocket expenses for premiums, deductions, cost sharing, or similar charges. . Section 1916A(a)(2)(B) ( 42 U.S.C. 1396o–1(a)(2)(B) ) is amended— by inserting and the tracking, suspension, and notification requirements under subsection (b)(7) before shall apply ; and by inserting and requirements after limitations . Section 2103(e) ( 42 U.S.C. 1397cc(e) ) is amended— by striking paragraphs

(2)and (4); by redesignating paragraph

(3)as paragraph (2); in paragraph

(2)(as so redesignated)— by striking subparagraph (B); by redesignating subparagraph

(C)as subparagraph (D); and by inserting after subparagraph

(A)the following new subparagraphs: The State child health plan may not impose deductions, cost sharing, or similar charges with respect to pregnancy-related assistance. Subject to subparagraphs

(A)and

(B)and paragraph (3), the State child health plan may only impose deductions, cost sharing, or similar charges to the extent that such charges do not exceed the nominal limits set under section 1916(a)(3). ; and by adding at the end the following new paragraph: Subject to paragraph (2)(A), any premiums, deductions, cost sharing, or similar charges imposed under the State child health plan for medical or dental benefits may be imposed on a sliding scale related to income, except that the total annual aggregate cost sharing imposed for such benefits with respect to all individuals in a family that includes a targeted low-income child or a targeted low-income pregnant woman under this title shall not exceed 5 percent of such family's income for the year involved. With respect to dental-only supplemental coverage offered under section 2110(b)(5), the total annual aggregate cost sharing imposed for such coverage shall not exceed 5 percent of a family's income for the year involved, minus the amount the family is required to pay during such year in premiums, deductions, cost sharing, or similar charges for health care services for children in the family enrolled in a group health plan or health insurance coverage offered through an employer. If the State child health plan imposes premiums, deductions, cost sharing, or similar charges that could cause families that include a targeted low-income child or a targeted low-income pregnant woman to have out-of-pocket expenses that exceed the aggregate cost sharing limit imposed under subparagraph

(A)for the year, the State shall— establish a process for tracking and aggregating such expenses (including expenses incurred for separately administered benefits) that— does not rely on documentation provided by the targeted low-income child, the targeted low-income pregnant woman, or the family; is communicated in a manner designed to ensure the privacy of patient-related information; and allows for coordination with managed care entities and managed care organizations that are under contract with the State; when a family reaches the aggregate cost-sharing limit for a year imposed under subparagraph (A), not impose any further premiums or cost sharing (or any portions thereof) on any targeted low-income child or targeted low-income pregnant woman in the family for the remainder of the year; notify providers and each family that includes a targeted low-income child or a targeted low-income pregnant woman— of the annual aggregate limits on out-of-pocket expenses applicable to the family; when the family has incurred out-of-pocket expenses up to the annual aggregate family limit imposed under subparagraph (A); and when a family reaches the aggregate out-of-pocket expenses limit for a year, that the limit has been reached and that no further premiums, deductions, cost sharing, or similar charges (or portions thereof) shall be imposed on any targeted low-income child or targeted low-income pregnant woman in the family for the remainder of such year; and establish a process for families that include a targeted low-income child or a targeted low-income pregnant woman to request a reassessment of the family's annual aggregate limit on premiums, deductions, cost sharing, or similar charges if the family has a change in circumstances, in accordance with criteria specified by the Secretary. . Section 2103(f) ( 42 U.S.C. 1397cc(f) ) is amended by adding at the end following new paragraph: The State shall require that a managed care entity or a managed care organization with a contract with the State, as a condition of such contract, comply with the requirements of 2103(e) and coordinate with the State with respect to in tracking and aggregating an enrollee's family's out-of-pocket expenses for cost sharing as required under subsection (e)(3)(C). . Section 2105(c)(10)(C)(i) ( 42 U.S.C. 1397ee(c)(10)(C)(i) ) is amended by striking paragraph (3)(B) of . Section 2112(b)(6) ( 42 U.S.C. 1397ll(b)(6) ) is amended by striking paragraph (3)(B) of .

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