Cost-sharing requirements

(1) The Department for Medicaid Services and each managed care organization contracted by the department to provide Medicaid services pursuant to this chapter shall establish cost-sharing requirements for Medicaid enrollees in accordance with this section. (2) Unless otherwise required under federal law, including 42 U.S.C. sec. 1396o(k), cost-sharing requirements established under this section shall only apply to Medicaid enrolled individuals: (a) With a family income that exceeds one hundred percent (100%) of the federal poverty line; and (b) Who are enrolled in the Medicaid program under 42 U.S.C. sec. 1396a(a)(10)(A)(i)(VIII). (3) In accordance with 42 U.S.C. sec. 1396o(k)(2)(B)(i), the following services shall not be subject to cost-sharing requirements established under this section unless otherwise required by federal law: (a) Any care, item, or service described in 42 U.S.C. sec. 1396o(a)(2)(B) et seq.; (b) Primary care services; (c) Mental health care services; (d) Substance use disorder services; (e) Any services provided by a: 1. Federally-qualified health center, as defined in 42 U.S.C. sec. 1396d(l)(2); 2. Certified community behavioral health clinic, as defined in 42 U.S.C. sec. 1396d(jj)(2); or 3. Rural health clinic, as defined in 42 U.S.C. sec. 1396d(l)(1); and (f) Any other service exempted from cost-sharing requirements under federal law. (4) (a) Except as provided in paragraph (b) of this subsection and subsections (3) and (5) of this section, beginning October 1, 2028, for care or an item or service furnished to a Medicaid enrolled individual described in subsection (2) of this section, the cost-sharing requirement established under this subsection shall be in the form of a copayment requirement equal to five dollars ($5). (b) The cost-sharing requirements established under this subsection for any prescription drugs shall be in the form of a copayment requirement equal to one dollar ($1). (5) The total aggregate amount of cost sharing imposed under this section for all individuals in a family shall not exceed five percent (5%) of the family's income on a monthly or quarterly basis, as determined by the secretary.