D-1840, Cost Sharing Cap Amounts

Revision 18-4; Effective October 1, 2018


The cost-sharing cap is the maximum amount of out-of-pocket expenses a household is required to pay during the certification period. When a household reaches its cost-sharing cap during the certification period, the household is not required to make copayments for the remainder of the certification period. Households are assigned a cost-sharing cap and a reporting threshold at application and at each redetermination. The reporting threshold is the amount in expenditures the household must report to the enrollment broker. The threshold is a cushion to ensure additional cost-sharing expenditures are not made during the period the enrollment broker and the health plan process the documentation.

The cost-sharing cap amount and reporting threshold are based on the household’s net income as it relates to the FPIL amount.

The cost-sharing cap is 5.0% of the total net income for the term of coverage. The reporting threshold is 4.75%.

The household is informed of the reporting threshold and sent a medical payments form (MPF) with the welcome letter and enrollment packet. The MPF helps the family track medical expenditures by type, date and amount.


D—1841 Cost Sharing Processing

Revision 20-4; Effective October 1, 2020


The household must complete and submit the MPF to report that it meets the cost sharing cap.

When the MPF is submitted, the Enrollment Broker reviews the types of expenses listed on Form. The household is not required to provide receipts. Valid medical expenses include:

  • enrollment fees, if applicable;
  • office visit copayments;
  • prescription medicines;
  • emergency room visits;
  • inpatient or outpatient hospital care; and
  • out-of-pocket expenses, such as dental or vision.

The Enrollment Broker reviews the amounts and dates of the expenses to ensure that the household incurred the expenses during the current certification period.

If the household meets the cost sharing cap, a Cost Share Met (CSM) letter is sent to inform the household that it is exempt from copayments for the remainder of the current certification period. The Enrollment Broker notifies the affected health plan within two business days. The health plan is responsible for issuing a new identification card reflecting the absence of copayments.

If the household does not meet the cost sharing cap, the Enrollment Broker triggers a Cost Share Not Met (CSN) letter to inform the household that the cost sharing limit was not met. The following situations may cause the household not to meet the cost sharing cap:

  • invalid expenses;
  • expenses incurred outside the current certification period;
  • valid expenses, but the dates and amounts are blank; or
  • the total amount listed on the form is less that the cost sharing cap/threshold.

The CSN includes the cost sharing limit and the total amount of valid expenses submitted. An MPF is included with the CSN.


D—1842 Cost Sharing Re-Evaluation

Revision 13-4; Effective October 1, 2013


The household’s cost sharing is re-evaluated at redetermination and the six-month income check.

For children who are currently enrolled, the Enrollment Broker does not use new income for eligibility determination.

The Enrollment Broker determines if all information is present to complete the evaluation at the six-month income check. If the income verification is not received and the reported income:

  • increases, the Enrollment Broker recalculates the cost sharing for the household. A Cost Sharing Recalculation (CSC) letter is sent to inform the household that the change was complete and provides the household with the new cost sharing amount.
  • decreases, a cost sharing re-evaluation is not processed. The Enrollment Broker sends a CSC No Change letter to inform the household that there is no change to the family’s cost sharing obligation.

When no information is missing, the Enrollment Broker uses the new income reported during the six-month income check to determine if there has been a change in the household’s cost sharing amount.