N-7900, Cost-Sharing

Revision 11-3; Effective September 1, 2011

Cost-sharing is the amount a person pays out of their own pocket for health care. Cost-sharing includes MBIC premiums. Recipients will receive information from the premium processing vendor regarding what expenses are included in cost-sharing.

N-7910 Cost-Share Limit

Revision 22-3; Effective September 1, 2022

Each recipient has a cost-share limit. TIERS will calculate a cost-share limit for each recipient and populate the cost-share limit on Form TF0001-MBIC, Initial Certification.

There is no cost-share limit for the prior months.

Cost-share limit is set at the eligibility determination group level. If there is more than one MBIC-eligible recipient in the family unit, there will be only one cost-share limit per family unit. Each EDG will have a cost-share limit calculated. However, the lowest cost-share limit of all EDGs will be used at a case level.

The cost-share limit for each family is set at:

  • 5% of countable gross annual income for a family whose countable gross annual income is at or below 200% of the FPL.
  • 7.5% of countable gross annual income for a family whose countable gross annual income is 201% to 300% of the FPL.

The amount of monthly gross countable income in the month following disposition is multiplied by 12 in order to determine the gross annual income used in calculating the cost-share limit. This is the total gross countable income prior to the MBIC exclusion of $85 + one-half.

The cost-share limit can change if there is a change in income during that initial 12-month period. Example: MBIC application is received in January and certified in March. The cost-share limit is based on income budgeted for April and begins in April. In August, a change in income is reported and case action is taken in August (cut-off is taken into consideration). A new cost share limit will begin in September.

N-7920 Cost-Share Period

Revision 11-3; Effective September 1, 2011

A cost-share period is established for each recipient. This period begins the first day of the disposition month and lasts for 12 months. This is the period during which an MBIC recipient's medical costs and MBIC premiums can be counted toward the cost-share limit.

There is no cost-share period for the prior months.

The original cost-share period is retained for MBIC eligibility determination groups when:

  • an individual is denied in error and then reactivated; and
  • a previously certified MBIC client enters a facility (transfer) and then returns to MBIC within the same cost-share period.

A new cost-share period will be set (based on the new disposition date) when a person reapplies if an MBIC EDG is denied or terminated for any reason except for:

  • denied in error, or
  • transfer between programs.

N-7930 Tracking Cost-Share Expenses

Revision 11-3; Effective September 1, 2011

A recipient is exempt from MBIC monthly premiums for the remainder of the coverage period when the cost-share expenditures for the recipient reach the cost-share limit.

For a recipient without employer-sponsored health insurance, the premium processing vendor will determine when the MBIC premium payments reach the cost-share limit.

For a recipient with employer-sponsored health insurance and the Health Insurance Premium Payment Program, the recipient must track cost-share expenses. A form will be provided by the premium processing vendor for the recipient to report when the cost-share limit is reached. This form is entitled "Medical Costs List."

The premium processing vendor will provide a refund if a monthly premium payment is received after the cost-share limit has been met. This is automatically tracked by the premium processing vendor.