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Model Application Template for the State Children’s Health Insurance Program

Effective Date:

October 1, 2009 41 Approval Date: November 19, 2010 Section 8. Cost Sharing and Payment (Section 2103(e))

∼ Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue on to Section 9.

8.1. Is cost-sharing imposed on any of the children covered under the plan? (42CFR 457.505)

8.1.1. X YES 8.1.2. ∼NO, skip to question 8.8.

8.2. Describe the amount of cost-sharing, any sliding scale based on income, the group or groups of enrollees that may be subject to the charge and the service for which the charge is imposed or time period for the charge, as appropriate. (Section 2103(e)(1)(A)) (42CFR 457.505(a), 457.510(b) &(c), 457.515(a)&(c)) There will not be any cost sharing of any type for families who are Native Americans or Alaskan Natives. For all other families cost sharing will be as follows in 8.2.1. and 8.2.3.:

8.2.1. Premiums: There are three (3) categories of enrollees: No Fee (Native Americans and Alaskan Natives). Low-Fee (children with family incomes from the base through 150% FPL), and Fee (children with family incomes from 151% FPL through 300% FPL). There is no cost sharing for children in the NO Fee group. There is a $50 premium per child, per year for children in the Low-Fee group. There is a $100 premium per child, per year for children in the Fee group. Premiums can be paid in one payment or in periodic payments (weekly, monthly, quarterly…) throughout the year. A family’s total premium payments do not exceed three times the individual premium rate (i.e. $150 or $300 depending upon the income level of the family). Enrollment data systems do not allow for a family to be billed in excess of these amounts.

8.2.2. Deductibles: None 8.2.3. Coinsurance or copayments: There are no copayments for preventive services. The only permitted copayments are:

Service Low Fee Group Co-pays (for Children with Incomes < 150% FPL) Fee Group Co-pays (for Children with Incomes >150% FPL)

Dental $3/visit $5/visit

Doctor’s office visits $3/visit $5/visit

ER Services $5/facility charge $15/facility charge