What is a cost share, and will I have to pay one?
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A cost share is an amount some Medicaid members owe each month toward the cost of their own care, based on their income. It is determined by the State of Georgia, not by a provider or a case management agency. Case management itself is never billed to the member or the family.
What a cost share is
A cost share is an amount that some Medicaid members are expected to contribute each month toward the cost of their own care. It exists because Medicaid is a needs-based program: where a member has income above the level the rules let them keep for themselves, part of that income is counted toward their care rather than left with them.
You will hear it called other things – a patient liability, a share of cost, a client participation amount. They refer to the same idea. The words vary by program and by who is speaking.
The important part is that it is a determination about a person’s income, not a price for a service. Two members receiving exactly the same services can owe different amounts, or one can owe nothing at all.
Who decides it
The State does. A cost share is calculated through the Medicaid eligibility process using the member’s countable income and the deductions the rules allow. A case management agency does not set it, cannot negotiate it, and cannot waive it.
This matters when something looks wrong. If a household believes the amount is incorrect – income recorded that no longer comes in, a deduction that was not applied, a change that was reported and not acted on – the place to raise it is the eligibility side that issued the determination. A provider cannot fix a figure it did not calculate.
If a determination reduces or ends something the member was receiving, it comes with a written notice, and that notice carries appeal rights. The appeals and fair hearings page explains how that structure works.
What is never billed to the member
Case management. Medicaid pays the case management agency directly, and no bill for case management ever goes to the member or the family. That is true at enrollment, true at the annual reassessment, and true for every phone call in between. If anyone presents a family with a bill for case management, it is wrong and should be questioned.
That is a separate matter from a cost share. A cost share, where one applies, sits against the cost of care and is handled in the way the member’s eligibility notice describes.
Questions worth asking
Do not accept a verbal figure. Ask for these in writing, and keep the notice.
- Is a cost share owed at all in this case, and what determination says so?
- What amount, for what period, and where is it paid?
- Which income and which deductions were used to reach it?
- What has to be reported if income changes, and to whom?
- What happens if the amount is not paid?
Why we have not put numbers on this page
Cost-share rules and figures change, and a stale number on a website is worse than no number, because families budget against it. The amounts that apply to a particular household come from that household’s own determination, not from a general figure published on a provider’s site.
If a member or family wants help reading a notice they have received, a case manager can walk through what the document says and who to contact about it. That is part of the coordination work, and it does not generate a bill.
Nothing on this page is a determination of eligibility or of any amount owed. Only Medicaid’s own eligibility process can decide that.
Questions people ask about this
Does every waiver member owe a cost share?
No. Many members owe nothing. A cost share applies only where a member's countable income exceeds the level the rules allow them to keep, and the amount depends on that individual determination rather than on the services received.
Who decides how much a cost share is?
The State of Georgia decides, through the Medicaid eligibility process. A case management agency does not set it, cannot change it, and cannot waive it. If a member believes their determination is wrong, that is challenged through the eligibility side, not through a provider.
Is case management part of a cost share?
No. Medicaid pays the case management agency directly for case management, and no bill for case management goes to the member or the family. A cost share, where one exists, applies to the cost of care and is handled separately.
Who does a cost share get paid to?
It is normally paid toward the provider delivering the member's care, in the way the member's eligibility notice sets out. The notice is the document that says the amount and where it goes, so it should be kept.
What if the member's income changes during the year?
Report the change. Income changes can affect both eligibility and any cost share, and reporting them promptly avoids an overpayment that has to be repaid later. The case manager can point to who takes the report, but the determination itself is made on the eligibility side.
Related questions
- Do I qualify? Two tests decide eligibility for Georgia's Elderly and Disabled Waiver: nursing-home level of care and Medicaid financial rules. Work through both here.
- The annual reassessment What Georgia's annual EDWP reassessment reviews, what to have ready, and what happens to the care plan if a member's needs have grown or eased since last year.
- Appeals and fair hearings How Medicaid appeals work when a Georgia waiver service is denied, reduced or stopped: the written notice, the appeal, and the right to a fair hearing before a hearing officer.
- The case manager's role What an EDWP case manager does month to month, and the Georgia rule that gives a member the right to choose their case management agency and to change it.