(a) The agency may impose cost sharing for non-emergency services provided in a hospital emergency department. The provisions in § 447.56(a) shall apply except as the agency exercises the option under paragraph (c) of this section.
(b) At state option, cost sharing for non-emergency services provided in an emergency department may be established at or below the amounts shown in the following table (except that the maximum allowable cost sharing identified for individuals with family income at or below 150 percent of the FPL shall be increased each year, beginning October 1, 2015, by the percentage increase in the medical care component of the CPI-U for the period of September to September of the preceding calendar year, rounded to the next higher 5-cent increment):
| Services | Maximum allowable cost sharing |
|---|
| Individuals with family income ≤150% of the FPL | Individuals with family income >150% of the FPL |
|---|
| Non-emergency Use of the Emergency Department | $8 | No Limit. |
(c) For individuals otherwise exempt from cost sharing under § 447.56(a), the agency may impose cost sharing for non-emergency use of the emergency department, not to exceed the maximum amount established in paragraph (b) of this section for individuals with income at or below 150 percent of the FPL.
(d) For the agency to impose cost sharing under paragraph (a) or (c) of this section for non-emergency use of the emergency department, the hospital providing the care must—
(1) Conduct an appropriate medical screening under § 489.24 subpart G to determine that the individual does not need emergency services.
(2) Before providing non-emergency services and imposing cost sharing for such services:
(i) Inform the individual of the amount of his or her cost sharing obligation for non-emergency services provided in the emergency department;
(ii) Provide the individual with the name and location of an available and accessible alternative non-emergency services provider;
(iii) Determine that the alternative provider can provide services to the individual in a timely manner with the imposition of a lesser cost sharing amount or no cost sharing if the individual is otherwise exempt from cost sharing; and
(iv) Provide a referral to coordinate scheduling for treatment by the alternative provider.
(e) Nothing in this section shall be construed to:
(1) Limit a hospital's obligations for screening and stabilizing treatment of an emergency medical condition under section 1867 of the Act; or
(2) Modify any obligations under either state or federal standards relating to the application of a prudent-layperson standard for payment or coverage of emergency medical services by any managed care organization.
Notes of Decisions
Cited in
14
cases, 1992–2004 · leading case:
Conlan v. Bonta', 125 Cal. Rptr. 2d 788 (Cal. Ct. App. 2002).
Conlan v. Bonta', 125 Cal. Rptr. 2d 788 (Cal. Ct. App. 2002).
“§ 1396o(b)(3); 42 C.F.R. § 447.54 (a)(3) (2001).) These sections are designed to limit the amount a state Medicaid program can charge for cost-sharing, and by their terms are not applicable to retroactive payments.”
Nebraska Pharmacists Ass'n v. Nebraska Dep't of Soc. Servs., 863 F. Supp. 1037 (D. Neb. 1994).
· cites it 3× “42 C.F.R. § 447.54 (a)(3). Alternatively, the state could adopt a so-called “standard” copayment in which the state determined its “average or typical payment for that service” and then applied the maximum copayment limitations set forth in the sliding scale found in 42 C.”
Kansas Hosp. Ass'n v. Whiteman, 835 F. Supp. 1556 (D. Kan. 1993).
· cites it 2× “It appears to this court that the maximum amount the state can charge for inpatient hospital services is controlled by 42 C.F.R. § 447.54 (c). Under that regulation, the maximum amount a beneficiary may be charged as a copay may not exceed half of the amount the defendant pays…”
Greenstein, Ex Rel. Horowitz v. Bane, 833 F. Supp. 1054 (S.D.N.Y. 1993).
“§ 1396o(b)(3) (emphasis added); see also 42 C.F.R. § 447.54 (a)(3) (supplying chart setting maximum co-payment rates for recipients).”
Rozema v. Marshfield Clinic, 174 F.R.D. 425 (W.D. Wis. 1997).
“Apparently, the federal regulations at 42 C.F.R. § 447.54 set minimum and maximum co-payments for Medical Assistance recipients, see Wis.”
Newton-Nations v. Rogers, 316 F. Supp. 2d 883 (D. Ariz. 2004).
“§§ 13960 (a)(3), (b)(3), and 42 C.F.R. § 447.54 ; and (2) from allowing providers to deny medical services to Plaintiffs and the class because of the inability of these AHCCCS participants to pay the copayments in violation of 42 U.”
Kansas Hosp. Ass'n v. Whiteman, 835 F. Supp. 1548 (D. Kan. 1993).
“It appears to this court that the maximum amount the state can charge for inpatient hospital services is controlled by 42 C.F.R. § 447.54 (e). Under that regulation, the maximum amount a beneficiary may be charged as a copay may not exceed half of the amount the defendant pays…”
Sweeney v. Bane, 996 F.2d 1384 (2d Cir. 1993).
“§ 1396o (b)(3); see also 42 C.F.R. § 447.54 (a)(3) (1992) (defining “nominal”).”
Kansas Hosp. Ass'n v. Whiteman, 967 F. Supp. 452 (D. Kan. 1997).
“On January 12, 1995, the HCFA notified the state of Kansas that it had until close of business on January 13, 1995, to comply §§ 1902(a)(14) and 1902(a)(19) of the Social Security Act and 42 C.F.R. § 447.54 (c) or the HCFA would proceed with a compliance hearing.”
— 42 C.F.R. § 447.54(c) — 1 case
Inez Williams, Vanessa Brewer, Gary Byers, Individually & on Behalf of All Similarly Situated Person, & Kansas Hosp. Ass'n, Bethany Med. Ctr., Asbury-Salina Reg'l Med. Ctr. & Stormont-Vail Reg'l Med. Ctr. v. Donna L. Whiteman, in Her Off. Capacity as Sec'y of the Kansas Dep't of Soc. & Rehab. Servs., Donna E. Shalala, in Her Off. Capacity as Sec'y of the United States Dep't of Health & Human Servs., Bruce C. Vladeck, in His Off. Capacity as Adm'r of the Health Care Fin., Admin., Kansas Hosp. Ass'n, Bethany Med. Ctr., Asbury-Salina Reg'l Med. Ctr. & Stormont-Vail Reg'l Med. Ctr., & Inez Williams, Vanessa Brewer, Gary Byers, Individually & on Behalf of All Similarly Situated Persons v. Donna L. Whiteman, in Her Off. Capacity as Sec'y of the Kansas Dep't of Soc. & Rehab. Servs., Donna E. Shalala, in Her Off. Capacity as Sec'y of the United States Dep't of Health & Human Servs., Bruce C. Vladeck, in His Off. Capacity as Adm'r of the Health Care Fin., Admin., 36 F.3d 1106 (10th Cir. 1994).
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