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

Effective Date:

October 1, 2009 42 Approval Date: November 19, 2010 Inpatient Services (Hospital) $5/confinement $10/confinement

Non-Emergency ER Services $10/visit $20/visit

Allergy Testing $5/lab visit $10/lab visit

Allergy Treatment $3/visit $5/visit

Ambulance $5/occurrence $10/occurrence

Mental and Nervous (Inpatient) $5/confinement $10/confinement

Outpatient Surgical Facility $5/visit $10/visit

Substance Abuse (Inpatient) $5/confinement $10/confinement

X-ray (Outpatient Facility) $3/total x-rays in 1 visit $5/total x-rays in 1 visit

In addition, a new three (3) tiered pharmacy benefit became effective October 1, 2003 for children in both the low fee and fee groups. Prescription drugs are now divided into three groups: generic, preferred brands, non-preferred brands. The designations “preferred” and “non-preferred” are assigned by the third party administrator (which is, at this time, Blue Cross Blue Shield of Alabama). When there is more than one drug in a certain pharmacological category and the drugs within the same category are determined to be equally effective, then the lowest cost drug in the category is named the “preferred” drug and the others are named “non-preferred.” The co-payment schedule is as follows:

Generic Brands Preferred Brands Non-Preferred Brands Low-Fee Group Co-Pays $1.00 $3.00 $5.00 Fee Group Co-pays $2.00 $5.00 $10.00

Copayments are described in Attachment A, the Benefits Booklet. There will be no cost sharing for ALL Kids Plus services.

8.2.4. Other:

8.3. Describe how the public will be notified, including the public schedule, of this cost- sharing (including the cumulative maximum) and changes to these amounts and any differences based on income. (Section 2103(e)((1)(B)) (42CFR 457.505(b)) All beneficiaries are notified of the cost sharing changes through letters mailed directly to the residence addresses on file in CHIP. In addition all stakeholders, including provider organizations/associations and state agencies, were also notified by letter. Further, a meeting of stakeholders was convened, prior to the cost-sharing changes, to discuss these changes.