Medicaid Policy                                                                 

603 Cost Sharing Requirements

Effective Date: July 1, 2026

 

Previous Policy

 

A.   Co-Payments and Deductibles

Most Medicaid members are required to pay a co-payments and deductibles.  The amount of the co-payments and the maximum out-of-pocket costs for a Medicaid member vary depending on the program for which the recipient qualifies. 

•     Members can view co-payment information and the types of services that require a co-payment at:

     https://medicaid.utah.gov/medicaid-education-materials 

B.   Cost Sharing Exemptions

Some members are exempt from making any co-payments to receive Medicaid-covered services.  The eligibility agency will report to DHHS who qualifies for the exemption.  Exempt individuals include:

1. Members who qualify for EPSDT(Early and Periodic Screening, Diagnostic and Treatment) benefits.(See 600 for more information)
2. Pregnant women

• For current recipients, the exemption begins the month the pregnancy is reported.
• For applicants, the exemption begins the date eligibility begins, but no sooner than the month the pregnancy began.

3. American Indians/Alaska Natives

Verified American Indian/Alaska Native individuals are not required to pay co-payments. The tribe must be recognized by the Federal government. The definition of who is an American Indian/Alaska Native is defined by the tribe.

• See Table VIII for acceptable verification of American Indian/Alaska Native Status and how to verify if the tribe is recognized by the United States Bureau of Indian Affairs.

3. 1. Applicants: Allow the exemption when an individual declares to be an American Indian/Alaska Native or a descendent of a tribal member, and there is no evidence that contradicts their claim.
      • Give the member reasonable time to provide documentation of their status upon approval. “Reasonable time” is at least 95 days. A member may request more time if needed.
      • If the member has been given reasonable time and does not provide the documentation or proof that they are working on obtaining it, remove the exemption with proper 10-day notice.
   2. Recipients: Allow the exemption when a member makes a new declaration to be an American Indian/Alaskan Native, a descendent of a tribal member or have federal Indian status.
   3. If verification of a person's American Indian/Alaska Native status is received at any time, allow the exemption starting the month verification is received.

Example:  At application the individual declares to be Native Hawaiian or Other Pacific Islander and was approved for Adult Expansion. The member then contacts the Eligibility Agency and declares to be an American Indian/ Alaska Native. The member is given reasonable time to provide required documentation.    

• Give the member reasonable time to provide documentation of their status. “Reasonable time” is at least 95 days. A member may request more time if needed.
• If the member fails to provide the verification or proof that they are working on obtaining it, remove the exemption with proper 10 day notice.

4. Residents of nursing homes whose income is limited to a small personal needs allowance
5. Individuals whose household's gross income is less than the FEP payment level for a household of the same size. ALL income is counted for this gross income test including FEP payments and SSI benefits.
6. Qualified Medicare Beneficiaries

• Medicaid recipients who are eligible for the Qualified Medicare Beneficiaries (QMB -- not SLMB or QI) do not have to pay co-payments for services or the inpatient hospital co-payment. They must pay co-payments for prescriptions and for non-emergency use of an emergency room.