Medicaid copay limits by income: what a state can charge for a visit, a prescription or the ER

The ceilings are ceilings. Section 447.52(b)(1) of the regulation says a state may set cost sharing "at or below" the table amounts, so a state that charges nothing, or one dollar, is inside the rule. The federal table also leaves out the thing most people want to know first: the printed dollar figures are 2013 figures, and the regulation itself says they rise every year with the medical care component of the Consumer Price Index. That raises the $4 base to about $5.50 for the year that started October 1, 2026, by the arithmetic in the indexing section, and to as much as $5.95 under the least favorable of three open readings, because the rule leaves the method open. Separately, Public Law 119-21 will force a different regime for adults in the expansion group above the poverty level on October 1, 2028, capped at $35 per item or service.

The ceilings by income band and service

Four sections of 42 CFR part 447 hold the numbers: 447.52 for ordinary services, 447.53 for drugs, 447.54 for non-emergency use of an emergency department and 447.56 for the exemptions and the household cap. The table puts the three income bands side by side. Income here means family income measured against the federal poverty level, which 447.51 defines as the level HHS updates periodically in the Federal Register.

Source: 42 CFR 447.51, 447.52, 447.53, 447.54 and 447.56, eCFR text current through October 30, 2026, read November 3, 2026. "Printed" is the amount in the regulation's table; only the dollar cells are indexed, never the percentages. These are the most a state may charge, not what a state does charge.

The columns split in different places for different services. For ordinary services the dividing lines are 100 and 150 percent of poverty, so the bottom band pays a flat dollar amount and the two upper bands pay a share of what the state pays. Drugs and emergency-room visits split only once, at 150 percent. That layout follows the statute. Section 1916A(a)(2)(A) of the Social Security Act says the flexible cost-sharing authority does not apply to anyone at or below 100 percent of poverty, who stay under section 1916 and its "nominal" amounts. The statute leaves the definition of nominal to the Secretary, and the regulation fills it with the dollar column. Above 100 percent, section 1916A(b) allows up to 10 percent of the cost of an item or service between 100 and 150 percent, and up to 20 percent above 150 percent, which are the two percentage columns.

The $8 figures are not arbitrary either. Section 1916(a)(3) allows a state with a waiver from the Secretary to charge up to twice the nominal outpatient amount for non-emergency use of an emergency room, where the state has shown that alternative sources of care are actually available and accessible, and section 1916A(e)(2)(A) repeats "twice the amount determined to be nominal" for the 100-to-150 band. Twice the $4 outpatient base is $8, the number in 447.54(b). The non-preferred drug figure is the same $8 and follows the same logic in section 1916A(c)(2)(A)(i), which limits non-preferred drug charges for incomes up to 150 percent to the nominal amount.

The words "cost the agency pays" in the percentage cells matter. A percentage is applied to what the Medicaid agency pays the provider, which is a different number from the provider's billed charge. Ten percent of an agency payment of $85 is $8.50, and 20 percent is $17.00. The statute's text is "the cost of such item or service," and the regulation's phrase is the narrower "cost the agency pays"; the percentages here follow the regulation. Section 447.52(c) adds a backstop for every kind of charge: the maximum a state sets can never equal or exceed the amount the agency pays for the service.

Three other features of 447.52 shape what the table means in practice. A state may target cost sharing to specified groups above 100 percent of poverty (447.52(d)(1)), so one group above the line can be charged while another is not; for non-preferred drugs and non-emergency emergency-department use the targeting can ignore income altogether (447.52(d)(2)). A state may set different charges at different income levels, but if it does it must charge lower-income people less (447.52(g)). And a state cannot stack charges: for any service the agency may not impose more than one type of cost sharing (447.52(f)). A visit cannot carry both a copay and a coinsurance percentage.

The regulation also handles states that do not have fee-for-service payment rates. In those states the dollar column becomes the ceiling for every income: any cost sharing at any income may not exceed the amount for people at or below 100 percent of poverty (447.52(b)(3)), and for drugs the cost sharing may not exceed the amount for people at or below 150 percent (447.53(c)). The percentage columns are tied to the cost the agency pays, and for these states the regulation substitutes the dollar amounts. Managed care plans that charge cost sharing must follow the state plan's amounts and sections 447.50 through 447.57 (447.52(h)).

One line in 447.52(b)(2) is history now: states that charged more than $75 for an inpatient stay as of July 15, 2013 were required to file a plan with CMS to reduce it to $75 by July 1, 2017. The inpatient row therefore has a $75 printed ceiling for the lowest band and a percentage of the entire stay for the upper bands, subject always to the household cap described further down.

Why the printed $4 is not the current figure

Every dollar cell in the table above carries the same sentence in the regulation, in slightly different positions. Section 447.52(b)(1) says the maximum for people at or below 100 percent of poverty "shall be increased each year, beginning October 1, 2015, by the percentage increase in the medical care component of the CPI-U for the period of September to September of the preceding calendar year, rounded to the next higher 5-cent increment." Section 447.53(b) says the same for drug amounts and adds that the increase "shall not be applied to any cost sharing that is based on the amount the agency pays for the service," which is why the 20 percent cells never move. Section 447.54(b) applies it to the emergency-department amount for incomes at or below 150 percent. The statute behind the nominal amounts, section 1916(h), tells the Secretary to raise them every year, beginning with 2006, by the annual increase in the medical care component of the CPI-U, "rounded up in an appropriate manner."

The regulation and the statute give the formula but not the resulting amounts, and neither the regulation nor the CMS bulletins cited here prints them, so the figures below are MyCarePrice arithmetic, not federal numbers. Three choices in the sentence are open, and each one moves the answer.

• The window. The step that takes effect on October 1, 2015 cannot use the September 2015 index, which is released only after that month ends. The reading used here is the September 2013 to September 2014 change for that first step: the step effective October 1 of year Y uses September of Y-2 to September of Y-1. The current step, effective October 1, 2026, therefore uses September 2024 to September 2025. CMS used the same offset in its September 30, 2011 bulletin on nominal cost sharing, which applied the change in the medical care component of the CPI-U from September 2009 to September 2010 to amounts effective October 1, 2011. That bulletin applied the older nominal-amount rules, so it is an analogy for this regulation, not a ruling on it.
• Rounding. "Rounded to the next higher 5-cent increment" can be applied once to the cumulative change since the base, or every year to the previous year's rounded amount. Rounding up every year ratchets the figure by an average of about two and a half cents a year in addition to the index. The same 2011 bulletin rounded up to the next highest 5-cent increment "without considering any rounding adjustment in the prior year," which is the once-from-the-base reading and the one this page leads with.
• A year when the index fell. The regulation says "increased," and the medical care index was lower in September 2023 than in September 2022. A state or CMS could skip that step, or apply it as a decrease.

The inputs are the September values of series CUUR0000SAM, the U.S. city average CPI-U for medical care, not seasonally adjusted, from the Bureau of Labor Statistics. The base is the printed 2013 amount, with the first step applied on October 1, 2015. The cumulative index ratio at the current step is 584.858 divided by 428.026, which is 1.36641. By hand: 428.026 x 1.3664 is 584.85, within a cent of 584.858.

Computed by MyCarePrice from BLS series CUUR0000SAM (medical care, CPI-U, U.S. city average, not seasonally adjusted), retrieved from the BLS public data API on November 3, 2026, and the base amount printed in 42 CFR 447.52(b)(1). Not a figure published by CMS or any state.

The regulation's dollar cells start from three different printed numbers, so the same three methods are applied to each base in the table below, for the step effective October 1, 2026.

Computed by MyCarePrice, same inputs as the table above; the step shown is the one effective October 1, 2026 (federal fiscal year 2027). Not a figure published by CMS or any state. The 10 and 20 percent cells are not indexed.

The headline figures re-derive in one line each. For the $4 base rounded once: $4 x 1.36641 = 5.4656, and the next higher 5-cent increment above that is $5.50. For $8: 8 x 1.36641 = 10.9313, which rounds up to $10.95. For $75: 75 x 1.36641 = 102.481, which rounds up to $102.50. For the year-by-year method the first two steps show the mechanism: $4 x (436.575 / 428.026) = 4.0799, rounded up to $4.10, and $4.10 x (447.289 / 436.575) = 4.2006, rounded up to $4.25.

Show the numbers behind this figure

Step effective October 1	Rounded once against the 2013 base	Rounded up every year
2015	$4.10	$4.10
2016	$4.20	$4.25
2017	$4.40	$4.50
2018	$4.50	$4.60
2019	$4.55	$4.70
2020	$4.70	$4.90
2021	$4.90	$5.15
2022	$4.95	$5.20
2023	$5.20	$5.55
2024	$5.15	$5.50
2025	$5.30	$5.70
2026	$5.50	$5.90

The two lines separate because of rounding, not because of a different index. Rounding up to the next nickel adds on average two and a half cents to an amount of about $4 each year, and the year-by-year method adds that again on top of itself. By October 2026 the gap between the two methods on the $4 base is $0.40. Ignoring the one year the index fell widens it again, to $0.45. The index fell 1.42 percent in the window that feeds the October 1, 2024 step, from 556.323 to 548.431.

The range is useful mainly as a sense of scale. A federal ceiling for an outpatient visit near $5.50 to $6, a drug ceiling in the same range for preferred drugs and near $11 to $11.50 for non-preferred drugs and non-emergency ER use, and an inpatient ceiling of roughly $102 to $104 are what the printed numbers have grown into. The step that will take effect on October 1, 2027 can be calculated now from published data, though not yet applied: September 2026 stands at 593.651, up 1.50 percent on September 2025, and the rounded-once method would move the $4 base to $5.55. That is arithmetic about the next step, not a figure in force. Which method a state follows, if it indexes at all, is something to read in its own published schedule, not here.

Where 100 and 150 percent of poverty fall in dollars

The bands are defined as percentages of the poverty level, but a household sees dollars. The HHS poverty guidelines for 2026 for the 48 contiguous states and the District of Columbia are in the table with the 150 percent line computed from them.

Source: HHS Office of the Assistant Secretary for Planning and Evaluation, 2026 poverty guidelines for the 48 contiguous states and DC, read November 3, 2026; each additional person adds $5,680. Monthly figures are the annual amounts divided by 12 and rounded to the dollar; the 150% column is 1.5 times the guideline. Alaska and Hawaii have their own, higher guidelines.

Two cautions keep the table honest. First, the regulation says only that the FPL is the level "updated periodically" by HHS; when a given state starts using a new year's guideline, and which income rules it applies to decide a household's percentage, is part of that state's plan and is not in 447.51. Second, the percentage is measured on family income. The 2028 provision, in section 1916(k)(3), points to section 1902(e)(14) of the Act for how family income is determined, which is the section that governs the modified adjusted gross income method states use for most Medicaid eligibility. A household's countable income can differ from its paycheck.

Groups and services a state cannot charge, and the two exceptions

Section 447.56(a) is the exemption list, and it comes in two parts. Paragraph (a)(1) protects people by who they are, and paragraph (a)(2) protects services by what they are. The first part is tied to eligibility groups, not to a general label like "children," so the group named in the regulation controls.

Source: 42 CFR 447.56(a)(1) and (a)(2), eCFR text current through October 30, 2026, with 435.118 read for the child group; read November 3, 2026. Premiums have their own, partly different, exemptions in 447.55 and 447.56(a)(1)(ii).

The pregnancy rule is wider than it sounds. Section 447.56(a)(2)(iv) says all services provided to a pregnant woman are considered pregnancy-related unless the state plan specifically identifies a service as not related to the pregnancy, so the default is no charge for anything. The postpartum end date is also precise: it runs to the end of the month in which the 60th day after the pregnancy ended falls, not to day 60.

The protection for children depends on the income band. At or below 100 percent of poverty, section 1916(a)(2)(A) of the Act bars charges for services furnished to anyone under 18 and, at a state's option, to those under 21, 20 or 19 or any reasonable category of people 18 or older. Above 100 percent, section 1916A(a)(1) applies "notwithstanding section 1396o," and section 1916A(b)(3)(B)(i) exempts only children under 18 whom the state must cover under section 1902(a)(10)(A)(i), plus children in foster care and children receiving title IV-E assistance at any age. The group-based list in the regulation follows that narrower text. A parent whose own child is in an exempt group can still be charged for the parent's care, and a 19-year-old in a group not listed can be charged.

Now the two exceptions, which answer a question the exemption table does not. A person in an exempt group is not shielded from every charge. Under 447.53(d), "for individuals otherwise exempt from cost sharing under § 447.56(a), the agency may impose cost sharing for non-preferred drugs," up to the dollar amount in the 447.53(b) table. And 447.54(c) lets the agency impose cost sharing for non-emergency use of the emergency department on exempt individuals, up to the amount for incomes at or below 150 percent, which is the $8 base before indexing. The text of both is written around individuals exempt under 447.56(a); it does not spell out whether the service exemptions in (a)(2), such as family planning, are also set aside, and that question is left open here. The statute matches in outline. Sections 1916A(c)(2)(B) and 1916A(e)(2)(B) limit such charges for exempt people to a nominal amount, and 1916A(e)(2)(B) allows the emergency-department charge only so long as no cost sharing is imposed for the same care through an outpatient department or other alternative provider in the hospital's area, which is the point of the alternative-provider step in the next section.

Those two charges are options, not requirements. Section 447.53(a) says the exemptions in 447.56(a) apply "except as the agency exercises the option" in (d). A state that never chose the option cannot charge an exempt child for a non-preferred drug or a non-urgent ER visit. A state that did must name the group and the amount in its state plan, which 447.52(i) requires for every charge: the service, the groups, the amount, how exempt people are identified so they are not charged, and how providers learn whether a charge applies.

For people who have both Medicare and Medicaid, the guide to Medicare Savings Programs: QMB, SLMB and QI notes that an SLMB Plus enrollee pays no more than a nominal Medicaid copay on Medicaid-covered services, and it covers the Medicare side of the same bill.

A hospital emergency department: emergency care, non-emergency care and the steps between

Everything about the ER copay turns on one classification, and the hospital does not make it at the front desk. Section 447.51 defines emergency services by pointing to 42 CFR 438.114, which defines an emergency medical condition as acute symptoms of sufficient severity, including severe pain, that "a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in" serious jeopardy to health, serious impairment of bodily functions or serious dysfunction of any organ or part. Emergency services are the covered inpatient and outpatient services needed to evaluate or stabilize such a condition. The definition is written in terms of symptoms and what an ordinary person could reasonably expect, not a final diagnosis.

Two details in 438.114 narrow what a plan can do with that definition. A managed care plan may not limit what counts as an emergency medical condition by lists of diagnoses or symptoms (438.114(d)(1)(i)), and it may not deny payment for treatment where an emergency medical condition existed, "including cases in which the absence of immediate medical attention would not have had the outcomes" listed in the definition (438.114(c)(1)(ii)(A)). Section 447.54(e)(2) states that the cost-sharing section does not modify obligations under federal or state prudent-layperson standards for payment or coverage of emergency services by managed care organizations. Those two provisions govern what a managed care plan may deny, and they show how the definition is applied: by symptoms, not by a list of diagnoses.

Non-emergency services in 447.51 are "any care or services that are not considered emergency services," with one carve-out: the term "does not include any services furnished in a hospital emergency department that are required to be provided as an appropriate medical screening examination or stabilizing examination and treatment under section 1867 of the Act." The screening that EMTALA requires cannot be charged as non-emergency care. A state that wants to charge must have chosen to in its plan, and 447.52(i)(5) requires the plan to describe how hospital ER services get identified as non-emergency.

Before a hospital can impose the charge, 447.54(d) requires a sequence, and the order matters because the money comes last.

1. The hospital conducts an appropriate medical screening under 42 CFR 489.24 to determine that you do not need emergency services.
2. Before providing the non-emergency services and imposing the charge, it tells you the amount of your cost-sharing obligation.
3. It gives you the name and location of an available and accessible alternative non-emergency provider.
4. It determines that the alternative provider can see you in a timely manner with a lesser charge, or no charge if you are otherwise exempt.
5. It gives you a referral to coordinate scheduling of treatment with that provider.

The statute says the same in different words. Section 1916A(e)(1) lists the conditions as access to an alternative provider and notice that includes the name and location of the alternative provider, the fact that it can treat you without the charge, and a referral to coordinate scheduling. The regulation makes the steps a condition of imposing the charge at all, and 447.52(e)(1)(iii) ties any right to demand payment up front to the 447.54(d) steps having been satisfied.

The "No Limit" cell for incomes above 150 percent is easy to misread. It means the regulation sets no dollar figure for a non-emergency visit above that line, not that the state can charge any amount. Section 447.52(c) still says the charge may not equal or exceed what the agency pays for the service. The household cap in 447.56(f) still applies, and a state must also be able to show the visit was non-emergency and complete the same steps. The statute likewise sets no dollar limit for that band, only the aggregate cap in section 1916A(e)(2)(C). Section 447.57(a)(4) requires each state's public schedule to include "a list of hospitals charging cost sharing for non-emergency use of the emergency department," so a local hospital’s decision to charge at all is a published fact.

None of this describes the charges that come from the hospital and physician bills themselves. Medicaid pays those under the state's rates and the copay is a small deduction from the provider's payment. For the layers that appear on an ER bill and how levels 1 to 5 are priced, see the guide to emergency room visit levels, and for how to decide between settings in terms of price, the guide to urgent care versus emergency room. Neither is a view on where to seek care.

Prescriptions: preferred, non-preferred and a prescriber's override

The drug rules are the narrowest in the regulation and the easiest to apply. Section 447.51 defines preferred drugs as those the state has identified on a publicly available schedule, determined by a pharmacy and therapeutics committee, as the most cost-effective drugs within each therapeutically equivalent or similar class. Under 447.53(a), a state may charge differently for preferred and non-preferred drugs, and "all drugs will be considered preferred drugs" if the agency does not differentiate. A state with no preferred drug list therefore faces the preferred ceiling on everything.

The ceilings are the three drug cells in the main table. A preferred drug carries the same dollar ceiling at every income; a non-preferred drug carries the dollar ceiling up to 150 percent of poverty and 20 percent of what the agency pays above it. For an invented non-preferred drug for which the state pays $60, the ceiling above 150 percent of poverty is $12 (20 percent of $60), and at or below it the ceiling is the indexed dollar amount. The 20 percent is never indexed. Section 447.53(c) caps drug charges at the dollar amount for incomes at or below 150 percent in states without fee-for-service rates.

The step that matters at the pharmacy counter is the prescriber's override in 447.53(e). If the agency has labelled a drug as non-preferred, it must have a timely process so that cost sharing is limited to the preferred amount "if the individual's prescribing provider determines that a preferred drug for treatment of the same condition either will be less effective for the individual, will have adverse effects for the individual, or both." The agency must make sure the pharmacy is reimbursed on the basis of the appropriate cost-sharing amount. Section 1916A(c)(3) of the Act is the statutory source. This is a procedure the prescriber starts, not something the pharmacy can decide on its own, and it does not remove the charge; it moves the charge from the non-preferred amount to the preferred one. Section 1916A(c)(4) separately lets a state exclude specified drugs or classes from the non-preferred scheme.

Percentage charges and the five percent household ceiling

Percentages are limited to people above 100 percent of poverty for visits and stays, and to people above 150 percent for non-preferred drugs, and they come with a second limit that protects the household's budget. Section 447.56(f)(1) says "Medicaid premiums and cost sharing incurred by all individuals in the Medicaid household may not exceed an aggregate limit of 5 percent of the family's income applied on either a quarterly or monthly basis, as specified by the agency." The number is a share of income, not of the bill, and it covers every person in the household together.

Take a household of three at 120 percent of the 2026 poverty guideline. The guideline for three is $27,320, so 120 percent is $32,784 a year, or $2,732.00 a month. Five percent of $2,732.00 is $136.60. If the state counts quarterly, three months of income is $8,196.00 and the cap is $409.80. Now suppose, as an assumed figure, the state pays $85 for an office visit and charges the 10 percent maximum, which applies between 100 and 150 percent of poverty: that is $8.50 a visit. The 16th charge in a month brings the total to $136.00, which is $0.60 under the monthly cap.

A hospital stay shows where the cap does real work. If the same household member is admitted and the state pays $6,000 for the stay, the 10 percent maximum would be $600.00, more than four times the $136.60 monthly cap. The state's own plan may set a lower charge. The cap, not the percentage, sets what the household can owe for the month.

The regulation puts the work on the state. Under 447.56(f)(2), a state with rules that could put families at risk of reaching the limit must set up a process to track each family's premiums and cost sharing "through an effective mechanism that does not rely on beneficiary documentation." Under (f)(3) it must tell beneficiaries and providers when a family has reached the cap, after which individual family members are no longer subject to cost sharing for the rest of that monthly or quarterly period. Under (f)(4) it must have a process for a family to ask for a reassessment after a change in circumstances. A state may also add limits of its own, such as a monthly limit for one service (f)(5). If you think your household has reached its cap and the pharmacy is still collecting, the state's notice process is the thing to point to, and the guide to appealing a health insurance denial notes that Medicaid appeals and hearings run through the state agency.

At the counter: payment, refusal and the debt

What a clinic or pharmacy can do when you cannot pay at the window depends on three conditions that are all in 447.52(e)(1). The provider may require payment as a condition of the service only if the family income is above 100 percent of poverty, the person is not in an exempt group under 447.56(a), and, for non-emergency ER care, the 447.54(d) steps were completed. The word is "may permit": the state has to allow it. In all other cases the state plan "must specify that no provider may deny services to an eligible individual on account of the individual's inability to pay the cost sharing" (447.52(e)(2)). So someone at or below the poverty level cannot be turned away for an unpaid copay, and neither can anyone in an exempt group.

Providers are also free to be more generous than the rule. Section 447.52(e)(3) says nothing prevents a provider from reducing or waiving the charge case by case. The incentive, though, runs the other way: under 447.56(c)(1) the agency must reduce its payment to the provider by the amount of the beneficiary's cost sharing, "regardless of whether the provider has collected the payment or waived the cost sharing." A provider that waives the charge is out the money. The exception in 447.56(c)(3) lets a state raise payments to a provider paid on Medicare reasonable cost principles to offset uncollected charges treated as bad debt. And 447.56(e) removes federal matching funds for any cost sharing that recipients should have paid.

The statute adds a sentence that is easy to miss. Section 1916(e) of the Act requires the state plan to say no provider may deny care because of inability to pay a charge, and then states that the requirement "shall not extinguish the liability of the individual to whom the care or services were furnished for payment of the deduction, cost sharing, or similar charge." A provider that treated you without collecting the copay can still bill you for it. A balance that stays unpaid can reach a collector, and the guide to a medical bill in collections covers what follows; the guides to hospital financial assistance and community health center sliding-fee scales cover the programs that sit outside Medicaid.

Managed care changes the payer but not the ceilings. A plan's charges must match the state plan, and under 447.56(d) the agency calculates what it pays the plan to include the cost sharing in the state plan whether or not the plan collects it from you. The practical consequence is the same as for a fee-for-service provider: the plan is paid net of the charge.

One more rule keeps the charges honest at scale. Under 447.56(b), apart from the targeting allowed in 447.52(d), the agency may not exempt additional individuals from cost sharing obligations that apply generally to the population at issue. A state cannot quietly excuse a favoured group from a charge it imposes on the rest of a population. If a charge applies to a population, the exemptions are the ones in the regulation plus any targeting the state plan states.

Reading a state's public schedule

Federal limits cannot tell you what a given state charges. The state's own schedule does, and the regulation requires every state to publish one. Section 447.57(a) lists what it must contain: the groups subject to premiums or cost sharing and the current amounts; how payments are made; the consequences of not paying; the list of hospitals charging for non-emergency emergency-department use; and the list of preferred drugs or a way to get it, including on the agency website.

Where it must reach people is also specified. Under 447.57(b), the schedule goes to beneficiaries at enrollment and at re-enrollment after a redetermination, and when charges or aggregate limits change, in a form that follows 435.905(b); to applicants at the time of application; to all participating providers; and to the general public. Before a state files a plan amendment to set up or substantially change charges, 447.57(c) requires advance public notice of the amount and who is subject to it, with a reasonable opportunity to comment. A copay that changed should have left a trail: a notice, a comment period, an amendment.

A state operating under a federal demonstration can be different. Section 1916(f) of the Act says no charge may be imposed "under any waiver authority of the Secretary" except as provided in the cost-sharing provisions, unless a demonstration meets conditions that include testing a unique and previously untested use of copayments, lasting no more than two years, and being voluntary or providing for liability for preventable damage to health. A waiver's terms live in the demonstration document and the state's notices, not in 447.52. Demonstration terms are outside the scope of this guide, as is the Children's Health Insurance Program, which runs under a separate part of the regulations (42 CFR part 457).

A short list of what to find in the schedule, then, with the regulation's own words as the guide: the amount for your service, written in your group's row; the list of preferred drugs; the list of hospitals that charge for non-emergency ER use; the monthly or quarterly period the household cap uses; and the person or office to contact if the cap is reached. The schedule must also reach participating providers, so a clinic or pharmacy should be able to show the amount that applies to your group, and the state's published copy is the one the rule requires the public to be able to see.

October 1, 2028: expansion adults above the poverty level

Section 71120 of Public Law 119-21, signed July 4, 2025, adds a new subsection (k) to section 1916 of the Social Security Act. It changes the rules for a defined group, called "specified individuals" in the text, beginning October 1, 2028 (139 Stat. 315 to 317). That is the first day of federal fiscal year 2029, not January 1, 2028 and not January 1, 2029. The group is adults whose family income exceeds the poverty line for their family size and who are enrolled in the Medicaid expansion adult group (section 1902(a)(10)(A)(i)(VIII)), or who are in that group but enrolled through a waiver of the state plan that provides coverage equivalent to minimum essential coverage. It applies in the 50 states and the District of Columbia and not in the territories. An expansion adult at or below 100 percent of poverty is not a specified individual and stays under today's rules.

Source: Public Law 119-21, section 71120, enrolled text on govinfo.gov (139 Stat. 315 to 317); 42 U.S.C. 1396o as shown on uscode.house.gov, current through Public Law 119-136 (October 22, 2026); CMS Informational Bulletin dated November 18, 2025, section 71120; 42 CFR 447.52, 447.53, 447.55 and 447.56. Read November 3, 2026.

The $35 is the part most often repeated and most often misread. The new subsection says "in no case may" a charge on a specified individual "exceed $35." It does not set a $35 copay, and it does not say how many services must carry a charge. The state "shall" provide for charges "determined appropriate by the State (in an amount greater than $0)" on "certain care, items, or services... as determined by the State." The mandate is that charges exist, and the ceiling is $35 each. Section 71120 does not define "item or service" for this purpose, and neither the section nor the November 2025 bulletin says whether an office visit and the lab work done during it are one charge or two.

The exclusions are where the practical size of the change is set. The list in section 1916(a)(2)(B) to (J) carries forward the existing exemptions for pregnancy-related services, people in institutions who give up their income to the cost of care, emergency services, family planning, hospice, and several COVID-19 and vaccine services. The new text adds primary care, mental health care, substance use disorder services, and anything delivered by a federally qualified health center, a certified community behavioral health clinic or a rural health clinic. Section 71120 does not define "primary care services," and the CMS bulletin repeats the list without defining it either. Rules or guidance may do so. The new text is made "subject to" section 1916(j), the existing rule that bars every premium, enrollment fee and cost-sharing charge against an Indian who is furnished an item or service directly by the Indian Health Service, an Indian Tribe, a Tribal Organization or an Urban Indian Organization, or through referral under contract health services. The CMS bulletin says the existing exemptions for American Indians and Alaska Natives "are not changed by this section and still apply."

For prescriptions the statute is a cross-reference. Section 1916(k)(2)(B)(ii)(II) says a prescription drug charge may not exceed "the limit that would be applicable under paragraph (2)(A)(i) or (2)(B) of section 1396o-1(c)," the nominal-amount limits, "if such drug so furnished were subject to cost sharing under such section." It does not mention the 20-percent limit in paragraph (2)(A)(ii), which governs non-preferred drugs for incomes above 150 percent of poverty. The CMS bulletin says only that drug amounts "remain subject to cost sharing rules and limitations established by section 1916A." Which limit applies to a non-preferred drug for an expansion adult above 150 percent of poverty is a question the cited text and bulletin do not resolve.

What is certain is the date and the structure. Congress appropriated $15,000,000 to CMS for fiscal year 2026 to carry out section 71120 (section 71120(c)). The CMS bulletin of November 18, 2025 summarizes the provision and does not say when further guidance on it will come. As of November 3, 2026 the Federal Register lists no document mentioning "Section 71120" or "1916(k)" published since July 4, 2025, the eCFR text of 447.52 to 447.54 is the same table described above, and that bulletin is the latest CMS document on how states should set these charges. Until CMS issues rules or guidance, the statute and that bulletin are the text there is, and what a state will charge in 2028 is a state matter to read when the state publishes it.

The other 2027 changes in the same law, the shorter look-back for old bills in section 71112, the community engagement condition in section 71119 and six-month renewals under section 71107, are covered in the guide to Medicaid retroactive coverage in 2027, and the hub for this part of the site is Medicare and Medicaid costs.

Questions on Medicaid copays, from the rule text

Regulation, statute and index data used here

• eCFR, 42 CFR 447.51 (definitions), 447.52 (cost sharing, amounts and indexing, targeting, denial of service), 447.53 (drugs), 447.54 (non-emergency emergency-department use), 447.55 (premiums), 447.56 (exemptions, payment to providers, aggregate limit) and 447.57 (public schedule and notice). Text current through October 30, 2026, read November 3, 2026.
• eCFR, 42 CFR 438.114 (emergency medical condition, emergency services, prudent layperson), 435.118 (infants and children under 19) and 435.116 (pregnant women). Read November 3, 2026.
• U.S. House Office of the Law Revision Counsel, 42 U.S.C. 1396o (Social Security Act section 1916, including subsections (a), (e), (f), (h) and (k)) and 1396o-1 (section 1916A), current through Public Law 119-136 (October 22, 2026). Read November 3, 2026.
• Public Law 119-21, section 71120, Modifying Cost Sharing Requirements for Certain Expansion Individuals under the Medicaid Program, enrolled text, 139 Stat. 315 to 317. Read November 3, 2026.
• CMS, CMCS Informational Bulletin of November 18, 2025, "Working Families Tax Cut" Legislation, Public Law 119-21: Summary of Medicaid and CHIP Related Provisions, section 71120. Read November 3, 2026.
• CMS, CMCS Informational Bulletin of September 30, 2011, Medicaid Cost Sharing, FY 2012 Update to Nominal Cost Sharing (cited as an analogy for the window and rounding). Read November 3, 2026.
• U.S. Bureau of Labor Statistics, Consumer Price Index, series CUUR0000SAM (medical care, CPI-U, U.S. city average, not seasonally adjusted), September values 2013 to 2026, retrieved from the BLS public data API November 3, 2026.
• HHS Office of the Assistant Secretary for Planning and Evaluation, 2026 poverty guidelines, 48 contiguous states and DC. Read November 3, 2026.
• Federal Register (federalregister.gov API), documents on 42 CFR part 447 and documents mentioning "Section 71120" or "1916(k)", published on or after July 4, 2025, as of November 3, 2026: none amends 447.52 to 447.54 or implements section 71120.

General billing information, not medical, legal or insurance advice and not an eligibility determination. Federal ceilings are not what a state charges; the state Medicaid agency's published schedule controls. Indexed dollar amounts here are MyCarePrice arithmetic. Confirm your price in writing before service.