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

Effective Date:

October 1, 2009 43 Approval Date: November 19, 2010 Premiums and co-pays are now listed in the Benefit Booklet revised 10/1/03 (Attachment A). Regional workers and administrative staff who answer phone inquiries are trained to discuss with families the premiums and co-payments required, and the $500 annual limit.

8.4. The state assures that it has made the following findings with respect to the cost sharing in its plan: (Section 2103(e))

8.4.1. X Cost-sharing does not favor children from higher income families over lower income families. (Section 2103(e)(1)(B)) (42CFR 457.530) 8.4.2. X No cost-sharing applies to well-baby and well-child care, including age-appropriate immunizations. (Section 2103(e)(2)) (42CFR 457.520) 8.4.3 X No additional cost-sharing applies to the costs of emergency medical services delivered outside the network. (Section 2103(e)(1)(A)) (42CFR 457.515(f))

8.5. Describe how the state will ensure that the annual aggregate cost-sharing for a family does not exceed 5 percent of such family’s income for the length of the child’s eligibility period in the State. Include a description of the procedures that do not primarily rely on a refund given by the state for overpayment by an enrollee: (Section 2103(e)(3)(B)) (42CFR 457.560(b) and 457.505(e))

Alabama ensures that the annual aggregate cost-sharing for a family does not exceed five percent (5%) of a family’s income as is required by Section 2103(3)(B) of Title XXI. In addition, cost sharing both premiums and co-payments, for children in families with incomes less than 150% FPL, are in compliance with CHIP regulations.

There is minimal cost sharing for families, other than Native Americans and Alaskan Natives who have no cost sharing. No family is charged for more than three (3) premiums even if the family has more than three children.

To protect families against excessive medical expenses and comply with the statutory limit of no more than five percent of family income being expended on cost sharing expenses, ALL Kids has an annual $500 limit on out of pocket expenses per family. For a single parent family with three children at 150 percent of poverty the statutory maximum would be about $1,654 based on 2009 FPL. Because of the low premium and low copayment structure very few families, if any, are likely to exceed the $500 limit on out of pocket expenses and would certainly not approach the 5 percent of income limit. Families are informed in all literature and outreach workers are trained to educate families about the $500 limit on out of pocket expenses. Families will be encouraged to keep receipts for all copayments and premiums in a “shoe box” method so that once the $500 maximum is reached they will have the necessary documentation to stop cost-sharing. If a family reaches this $500 limit and notifies the ALL Kids program of this, new insurance cards will be issued, to the family, which state that the child(ren) are not subject to any co-pays.