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Page 21 – CMCS Informational Bulletin family income exceeds 100 percent of the FPL, who are described in section 1902(a)(10)(A)(i)(VIII) of the Act, and who are enrolled in coverage under a waiver of the state plan (including a section 1115 demonstration) that provides coverage that is equivalent to MEC49 to all individuals described in section 1902(a)(10)(A)(i)(VIII) of the Act. Under new section 1916(k) of the Act, states must impose such cost sharing beginning October 1, 2028. Cost sharing imposed under this section cannot exceed $35 for any care, item, or service. Cost sharing amounts for prescription drugs remain subject to cost sharing rules and limitations established by section 1916A of the Act. The provision also prohibits states from imposing premiums or enrollment fees on this population. The new section 1916(k) exempts primary care, behavioral health, federally qualified heath center (FQHC), rural health clinic, and certified community behavioral health clinic (CCBHC) services from cost sharing for this population, in addition to the previously existing exemptions.50 Existing cost sharing exemptions for American Indians and Alaska Natives are not changed by this section and still apply.51 Aggregate out-of-pocket costs for all individuals in the family cannot exceed 5 percent of the income of the family. Section 1916(k) of the Act, as added by section 71120, is applicable to all states and the District of Columbia that provide coverage to the individuals noted above; it does not apply to the territories. Subchapter E – Expanding Access to Care Section 71121. Making Certain Adjustments to Coverage of Home or Community-Based Services under Medicaid Section 1915(c) of the Act authorizes home and community-based services (HCBS) waivers. These waivers permit states to waive certain Medicaid state plan requirements, such as statewideness and comparability requirements, and to limit the number of individuals who may receive HCBS under the waiver. Under Section 1915(c)(1) of the Act, eligible individuals must meet an institutional level of care (ILOC) requirement (e.g., in the absence of HCBS, they would require hospital, nursing facility, or intermediate care facility care). States with approved 1915(c) waivers must meet numerous requirements, including cost neutrality and health and welfare protections.52 Section 71121 amends section 1915(c) of the Act to create a new waiver option for states that will be available beginning on July 1, 2028. Under this new waiver option, states may cover 49 MEC is defined in the statute as follows: “as described in section 5000A(f)(1)(A) of the Internal Revenue Code of 1986 and determined in accordance with standards prescribed by the Secretary in regulations.” 50 Sections 1916(a)(2), (b)(2) and Section 1916A(b)(3)(B) of the Act. 51 Section 1916(j) of the Act. 52 Section 1915(c)(2)(A) and Section 1915(c)(2)(D) & (E) of the Act.