CMS ICN No. 909438-N • August 2017

@CMSGov #CMSNativeHealth

Types of cost sharing

When cost sharing applies to you

Eligibility for cost-sharing reductions in the Marketplace 

Medicaid and CHIP cost-sharing protections

Understanding Cost

Sharing Protections 

for American Indian 

and Alaska Natives in 

Medicaid, CH IP, and 

the Marketplace

Medicaid and CHIP costsharing protections

Members of federally recognized Indian tribes and individuals who are 

otherwise eligible for services from an Indian health care provider have 

the following Medicaid and CHIP protections from cost sharing.

 You do not have to pay Medicaid premiums or enrollment fees 

if they are eligible to receive care from an Indian health care 

provider or through referral to a non-Indian provider (such as 

Purchased/Referred Care (PRC). 

 You do not have to pay any cost sharing, like deductibles, 

coinsurance, or copayments, for any Medicaid service from any 

Medicaid provider if they have ever received a service or referral 

from and Indian health care provider. 

 Children who are American Indian or Alaska Native cannot be 

charged any premium, enrollment fee, copayment, coinsurance, 

or deductible in CHIP.

Learn more about when cost sharing 

applies to you

Visit https://www.healthcare.gov/american-indiansalaska-natives/coverage/
What is cost sharing? 

Cost sharing is what you pay for medical services covered by your 

health insurance. Types of cost sharing include:

Deductible: The amount you must spend for health care services that 

your plan covers before your health insurance begins to pay 

Your deductible may not apply to all services. For instance, most 

plans do not require you to pay off your deductible before having 

insurance cover routine doctor visits or preventive care.

For example, if your deductible is $1,000, your plan won’t pay 

anything until you’ve met your $1,000 deductible for covered 

health care.

Copayment: A fixed amount that you pay for a covered health care 

service

For example, you may need to pay $20 to visit your doctor or for a 

prescription.

Coinsurance: Your share of the costs of a covered health care service, 

calculated as a percentage 

For example, you may pay 30% for lab tests or 80% for a 

prescribed medication that is not listed on your insurance plan’s 

approved medication list.

Premium: The amount that must be paid for your health insurance or 

plan — you or your employer usually pay the premium monthly, quarterly, 

or yearly 

Members of federally recognized tribes who qualify for costsharing reductions are not exempt from premiums. However, 

you may qualify for the advance payment of premium tax credits 

(APTC), depending on your income. Some tribes participate 

in a tribal sponsorship program where they pay premiums on 

behalf of their tribal members. Please contact your tribe for more 

information.

Cost sharing and the federal 

poverty level

For American Indians and Alaska Natives who buy health insurance in the 

Marketplace, the federal government has protections in place to reduce 

cost sharing. The federal poverty level (FPL) is a measure of income to 

determine your eligibility for certain programs and benefits. 

Calculate your FPL

Your income will determine if you qualify for cost-sharing reductions. 

To calculate your FPL, visit https://aspe.hhs.gov/poverty-guidelines

Cost-sharing reductions based on your FPL

There are two types of cost-sharing reductions based on your FPL.

Zero cost sharing for income between 100%–300% of the FPL

 You do not have to pay copayments, deductibles, or coinsurance 

when getting care from an Indian health care provider or when 

getting essential health benefits through a Marketplace plan. 

 You do not need a referral from an Indian health care provider when 

getting essential health benefits through a Marketplace plan.

Limited cost sharing for income below 100% or above 300% of the FPL

 You do not have to pay copayments, deductibles, or coinsurance 

when getting care from an Indian health care provider. 

 You do need a referral from an Indian health care provider when 

getting essential health benefits through a Marketplace plan to avoid 

paying copayments, deductibles, or coinsurance.

Cost-sharing eligibility using FPL

Limited cost 

sharing

Zero cost 

sharing

Limited cost 

sharing

0 100% 200% 300% 400% 500% +