Obsolete 0726 - 603 Cost Sharing Requirements

Effective Date: April 1, 2019 - June 30, 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. 

o    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

O For current recipients, the exemption begins the month the pregnancy is reported.

O 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.

O 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. 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. “Reasonable time” is at least 30 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.
4. Recipients: Request proof of American Indian/Alaska Native status at review if their status was self-declared at application and tribal verification has not yet been provided.
   • Give the member reasonable time to provide documentation of their status. “Reasonable time” is at least 30 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.
5. 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.
6. Residents of nursing homes whose income is limited to a small personal needs allowance
7. 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.
8. Qualified Medicare Beneficiaries

O 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.