Special rules for certain expansion individuals

Beginning October 1, 2028 , 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.

(A) In general Subject to subparagraph (B) and subsection (j), in the case of a specified individual, 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.

(B) Limitations (i) Exclusion of certain services 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, or services provided by a Federally qualified health center (as defined in 1396d( l )(2) 1 1 So in original. Probably should be preceded by “section”. of this title), certified community behavioral health clinic (as defined in section 1396d(jj)(2) of this title ), or rural health clinic (as defined in 1396d( l )(1) 1 of this title), furnished to a specified individual. (ii) Item and service limitation (I) In general Except as provided in subclause (II), 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. (II) Special rules for prescription drugs In no case may a deduction, cost sharing, or similar charge imposed under the State plan with respect to a prescription drug furnished to a specified individual exceed the limit that would be applicable under paragraph (2)(A)(i) or (2)(B) of section 1396 o –1(c) of this title with respect to such drug and individual if such drug so furnished were subject to cost sharing under such section. (iii) Maximum limit on cost sharing The total aggregate amount of deductions, cost sharing, or similar charges imposed under the State plan 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).

(C) Cases of nonpayment Notwithstanding subsection (e), a State may permit a provider participating under the State plan to require, as a condition for the provision of care, items, or services to a specified individual entitled to medical assistance under this subchapter for such care, items, or services, the payment of any deductions, cost sharing, or similar charges authorized to be imposed with respect to such care, items, or services. Nothing in this subparagraph shall be construed as preventing a provider from reducing or waiving the application of such deductions, cost sharing, or similar charges on a case-by-case basis.

For purposes of this subsection, the term “specified individual” means an individual who has a family income (as determined in accordance with section 1396a(e)(14) of this title ) that exceeds the poverty line (as defined in section 1397jj(c)(5) of this title ) applicable to a family of the size involved and—

(A) is enrolled under section 1396a(a)(10)(A)(i)(VIII) of this title ; or

(B) is described in such subsection and otherwise enrolled under a waiver of the State plan that provides coverage that is equivalent to minimum essential coverage (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) to all individuals described in section 1396a(a)(10)(A)(i)(VIII) of this title .