Medical Assistance

2.1.1.2.3 Cost Sharing (Archive)

Cost sharing includes those costs a Medical Assistance (MA) enrollee pays towards their health care. MA cost sharing includes deductibles, medical visit and prescription copays. Some enrollees also have premiums, spenddowns, waiver obligations or parental fees.

Deductibles and Copays

Adults age 21 or older have:

• A monthly deductible

• Copays for non-preventative visits

• Copays for nonemergency emergency room (ER) visits

• Copays for prescription drugs

Pregnant women, American Indians and Alaska Natives, people in hospice care, people enrolled in MA for women with breast or cervical cancer, Refugee MA enrollees and people in long-term care facilities have no deductibles or copays.

Monthly copays and deductibles are limited to 5 percent of family income.

See Summary of Coverage, Cost Sharing and Limits (DHS-3860) for more information.

Premiums

Premiums are a bill enrollees pay monthly for their health care. MA for Employed Persons with Disabilities (MA-EPD) enrollees have a monthly premium. See the MA-EPD Premium and Cost Sharing policy for more information.

Spenddowns

A spenddown is a cost-sharing approach that allows MA eligibility for people whose income exceeds financial eligibility requirements. Federal rules refer to this population as "medically needy." MA enrollees can become income eligible for MA by “spending down” their excess income to the appropriate income limit. The excess income is reduced by deducting certain medical expenses.

There are two types of spenddowns.

Medical Spenddown

Medical Spenddowns are for enrollees that live in the community. Not all MA bases of eligibility offer MA with a medical spenddown. See the MA for Families With Children (MA-FCA) Medical Spenddown policy and the MA for People Who are Age 65 and Older, Blind or Disabled Medical Spenddowns policy for more information.

Long-Term Care Spenddown

Some enrollees eligible for the payment of long-term care services may be obligated to contribute toward the cost of services. The amount of income that a person is obligated to contribute to the cost of LTC services is based on basis of eligibility and household composition.

Not all MA bases of eligibility require enrollees contribute toward the cost of long-term care facility services (nursing facility). See the MA for Long Term Care Services chapter for more information.

Parental Fees

Parents may be liable for a fee to reimburse part of their children's costs if their income is not considered in determining MA eligibility for their disabled children. Parental fees apply to children receiving MA through the TEFRA option and children receiving home and community based waiver services. See the MA under the TEFRA Option subchapter and MA for Long-Tern Care Services Home and Community-Based Service Waivers subsection for more information.

County, tribal or state servicing agencies may assess parental fees when a child lives apart from both parents or when a child has a non-custodial parent. See the MA Medical Support policy for more information.

Waiver Obligations

A waiver obligation is the amount a person is obligated to contribute toward the cost of home and community based waiver services. People age 65 and older, receiving Elderly Waiver (EW) services, with income above the Special Income Standard Elderly Waiver (SIS-EW) maintenance needs allowance pay a waiver obligation. The waiver obligation is based on actual income and deductions in a given month. See the Home and Community-Based Waiver for People Age 65 or Older subsection for more information.

Legal Citations

Code of Federal Regulations, title 42, section 447.55

Minnesota Statutes, section 256B.057

Minnesota Statutes, section 256B.063

Minnesota Statutes, section 256B.0631

Published:  June 1, 2016

Archived: January 1, 2021