Limitations on exercise of authority
(1) Individuals with family income between 100 and 150 percent of the poverty line
(1)Individuals with family income between 100 and 150 percent of the poverty line#
In the case of an individual whose family income exceeds 100 percent, but does not exceed 150 percent, of the poverty line applicable to a family of the size involved—
(A) no premium may be imposed under the plan; and
(B) with respect to cost sharing— (i) the cost sharing imposed under subsection (a) with respect to any item or service may not exceed 10 percent of the cost of such item or service; and (ii) the total aggregate amount of cost sharing imposed under this section (including any cost sharing imposed under subsection (c) or (e)) for all individuals in the family may not exceed 5 percent of the family income of the family involved, as applied on a quarterly or monthly basis (as specified by the State).
(1)(A)#
no premium may be imposed under the plan; and
(1)(B)#
with respect to cost sharing—
(i) the cost sharing imposed under subsection (a) with respect to any item or service may not exceed 10 percent of the cost of such item or service; and
(ii) the total aggregate amount of cost sharing imposed under this section (including any cost sharing imposed under subsection (c) or (e)) for all individuals in the family may not exceed 5 percent of the family income of the family involved, as applied on a quarterly or monthly basis (as specified by the State).
(2)Individuals with family income above 150 percent of the poverty line#
In the case of an individual whose family income exceeds 150 percent of the poverty line applicable to a family of the size involved—
(A) the total aggregate amount of premiums and cost sharing imposed under this section (including any cost sharing imposed under subsection (c) or (e)) for all individuals in the family may not exceed 5 percent of the family income of the family involved, as applied on a quarterly or monthly basis (as specified by the State); and
(B) with respect to cost sharing, the cost sharing imposed with respect to any item or service under subsection (a) may not exceed 20 percent of the cost of such item or service.
(2)(A)#
the total aggregate amount of premiums and cost sharing imposed under this section (including any cost sharing imposed under subsection (c) or (e)) for all individuals in the family may not exceed 5 percent of the family income of the family involved, as applied on a quarterly or monthly basis (as specified by the State); and
(2)(B)#
with respect to cost sharing, the cost sharing imposed with respect to any item or service under subsection (a) may not exceed 20 percent of the cost of such item or service.
(3)Additional limitations#
(A) Premiums No premiums shall be imposed under this section with respect to the following: (i) Individuals under 18 years of age that are required to be provided medical assistance under section 1396a(a)(10)(A)(i) of this title , and including individuals with respect to whom child welfare services are made available under part B of subchapter IV on the basis of being a child in foster care and individuals with respect to whom adoption or foster care assistance is made available under part E of such subchapter, without regard to age. (ii) Pregnant women. (iii) Any terminally ill individual who is receiving hospice care (as defined in section 1396d( o ) of this title). (iv) Any individual who is an inpatient in a hospital, nursing facility, intermediate care facility for the mentally retarded, or other medical institution, if such individual is required, as a condition of receiving services in such institution under the State plan, to spend for costs of medical care all but a minimal amount of the individual’s income required for personal needs. (v) Women who are receiving medical assistance by virtue of the application of sections 1396a(a)(10)(A)(ii)(XVIII) and 1396a(aa) of this title. (vi) Disabled children who are receiving medical assistance by virtue of the application of sections 1396a(a)(10)(A)(ii)(XIX) and 1396a(cc) of this title. (vii) An Indian who is furnished an item or service directly by the Indian Health Service, an Indian Tribe, Tribal Organization or Urban Indian Organization or through referral under contract health services.
(B) Cost sharing Subject to the succeeding provisions of this section, no cost sharing shall be imposed under subsection (a) with respect to the following: (i) Services furnished to individuals under 18 years of age that are required to be provided medical assistance under section 1396a(a)(10)(A)(i) of this title , and including services furnished to individuals with respect to whom child welfare services are made available under part B of subchapter IV on the basis of being a child in foster care or and 1 1 So in original. individuals with respect to whom adoption or foster care assistance is made available under part E of such subchapter, without regard to age. (ii) Preventive services (such as well baby and well child care and immunizations) provided to children under 18 years of age regardless of family income. (iii) Services furnished to pregnant women, if such services relate to the pregnancy or to any other medical condition which may complicate the pregnancy, and counseling and pharmacotherapy for cessation of tobacco use by pregnant women (as defined in section 1396d(bb) of this title ). (iv) Services furnished to a terminally ill individual who is receiving hospice care (as defined in section 1396d( o ) of this title). (v) Services furnished to any individual who is an inpatient in a hospital, nursing facility, intermediate care facility for the mentally retarded, or other medical institution, if such individual is required, as a condition of receiving services in such institution under the State plan, to spend for costs of medical care all but a minimal amount of the individual’s income required for personal needs. (vi) Emergency services (as defined by the Secretary for purposes of section 1396 o (a)(2)(D) of this title). (vii) Family planning services and supplies described in section 1396d(a)(4)(C) of this title . (viii) Services furnished to women who are receiving medical assistance by virtue of the application of sections 1396a(a)(10)(A)(ii)(XVIII) and 1396a(aa) of this title. (ix) Services furnished to disabled children who are receiving medical assistance by virtue of the application of sections 1396a(a)(10)(A)(ii)(XIX) and 1396a(cc) of this title. (x) Items and services furnished to an Indian directly by the Indian Health Service, an Indian Tribe, Tribal Organization or Urban Indian Organization or through referral under contract health services. (xi) Any in vitro diagnostic product described in section 1396d(a)(3)(B) of this title that is administered during any portion of the emergency period described in such section beginning on or after March 18, 2020 (and the administration of such product), and any service described in section 1396 o (a)(2)(G) of this title that is furnished during any such portion. (xii) During the period beginning on March 11, 2021 , and ending on the last day of the first calendar quarter that begins one year after the last day of the emergency period described in section 1320b–5(g)(1)(B) of this title , a COVID–19 vaccine and the administration of such vaccine (for any individual eligible for medical assistance for such vaccine (and administration)). (xiii) During the period beginning on March 11, 2021 , and ending on the last day of the first calendar quarter that begins one year after the last day of the emergency period described in section 1320b–5(g)(1)(B) of this title , testing and treatments for COVID–19, including specialized equipment and therapies (including preventive therapies), and, in the case of an individual who is diagnosed with or presumed to have COVID–19, during the period during which such individual has (or is presumed to have) COVID–19, the treatment of a condition that may seriously complicate the treatment of COVID–19, if otherwise covered under the State plan (or waiver of such plan). (xiv) Vaccines described in section 1396d(a)(13)(B) of this title and the administration of such vaccines.
(C) Construction Nothing in this paragraph shall be construed as preventing a State from exempting additional classes of individuals from premiums under this section or from exempting additional individuals or services from cost sharing under subsection (a).
(4)Determinations of family income#
In applying this subsection, family income shall be determined in a manner specified by the State for purposes of this subsection, including the use of such disregards as the State may provide. Family income shall be determined for such period and at such periodicity as the State may provide under this subchapter.
(5)Poverty line defined#
For purposes of this section, the term “poverty line” has the meaning given such term in section 9902(2) of this title , including any revision required by such section.
(6)Construction#
Nothing in this section shall be construed—
(A) as preventing a State from further limiting the premiums and cost sharing imposed under this section beyond the limitations provided under this section;
(B) as affecting the authority of the Secretary through waiver to modify limitations on premiums and cost sharing under this section; or
(C) as affecting any such waiver of requirements in effect under this subchapter before February 8, 2006 , with regard to the imposition of premiums and cost sharing.
(6)(A)#
as preventing a State from further limiting the premiums and cost sharing imposed under this section beyond the limitations provided under this section;
(6)(B)#
as affecting the authority of the Secretary through waiver to modify limitations on premiums and cost sharing under this section; or
(6)(C)#
as affecting any such waiver of requirements in effect under this subchapter before February 8, 2006 , with regard to the imposition of premiums and cost sharing.