Children's Health Insurance Expansions: State Experiences in Developing Benefit Packages and Cost-Sharing Arrangements. Cost-Sharing Requirements Under Title XXI


Title XXI establishes certain cost-sharing requirements on states, including: prohibiting cost-sharing policies that favor higher-income families over lower-income families; disallowing cost-sharing for well-baby and well-child care, including immunizations; and not permitting states to consider money raised through cost-sharing as state dollars for purposes of meeting matching requirements. Cost-sharing requirements for children under 150% of the federal poverty level (FPL) must be "nominal." Children in families below 150% FPL cannot be charged premiums higher than premiums established for "medically needy" Medicaid beneficiaries. For families above 150% of the FPL, cost-sharing cannot exceed 5% of family income. In light of these restrictions, states will need to determine how they will administratively handle cost-sharing arrangements, ensuring compliance while adhering to the Title XXI's 10% cap on state administrative costs.