[Code of Federal Regulations]

[Title 42, Volume 4]

[Revised as of October 1, 2006]

From the U.S. Government Printing Office via GPO Access

[CITE: 42CFR447.54]



[Page 315-316]

 

                         TITLE 42--PUBLIC HEALTH

 

  CHAPTER IV--CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF 

                  HEALTH AND HUMAN SERVICES (CONTINUED)

 

PART 447_PAYMENTS FOR SERVICES--Table of Contents

 

                 Subpart A_Payments: General Provisions

 

Sec.  447.54  Maximum allowable charges.



    (a) Non-institutional services. Except as specified in paragraph 

(b), for non-institutional services, the plan must provide that--

    (1) Any deductible it imposes does not exceed $2.00 per month per 

family for each period of Medicaid eligibility. For example, if Medicaid 

eligibility is certified for a 3-month period, the maximum deductible 

which may be imposed on a family for that period of eligibility is 

$6.00;

    (2) Any coinsurance rate it imposes does not exceed 5 percent of the 

payment the agency makes for the services; and

    (3) Any co-payments it imposes do not exceed the amounts shown in 

the following table:



------------------------------------------------------------------------

                                                                Maximum

                                                               copayment

               States payment for the service                 chargeable

                                                                  to

                                                               recipient

------------------------------------------------------------------------

$10 or less.................................................        $.50

$10.01 to $25...............................................        1.00

$25.01 to $50...............................................        2.00

$50.01 or more..............................................        3.00

------------------------------------------------------------------------



    (b) Waiver of the requirement that cost sharing amounts be nominal. 

Upon approval from CMS, the requirement that cost sharing charges must 

be nominal may be waived, in accordance with section 431.55(g) for 

nonemergency services furnished in a hospital emergency room.

    (c) Institutional services. For institutional services, the plan 

must provide that the maximum deductible, coinsurance or co-payment 

charge for each admission does not exceed 50 percent of the payment the 

agency makes for the first day of care in the institution.

    (d) Cumulative maximum. The plan may provide for a cumulative 

maximum amount for all deductible, coinsurance or co-payment charges 

that it



[[Page 316]]



imposes on any family during a specified period of time.



[48 FR 5736, Jan. 8, 1983]