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Effective Date: November 1, 2009 November 1, 2009 November 1, 2009 Above 200-250% FPL One child $21 Two children $42 Three or more children $63 If the family selects other than the Community Provider Plan, the family therefore has a higher premium. Again, families that pay 3 months of premiums in advance will receive the fourth month free. Families who use recurring electronic fund or credit card transfers receive a 25% discount on monthly family contributions. Disenrollment for Non-Payment of Premium California will disenroll families effective the last day of the second consecutive month that they fail to make their family contribution payments. Each family that fail to make their monthly family contribution payment is 30 days late on the payment, will receive a notice stating they are 30 days past due and that their child (ren)'s coverage will end at the end of the 60 day period, if the full family contribution payment is not received. Families will receive another notice at 45 days prior to the end of their 60 day past due period, informing this is a final past due notice. The 45 day notice contains a continued enrollment form, where families can request the HFP to keep their coverage in effective, while the program reviews any disputes the family has regarding their past due payments. After the 45 day notice, the family will receive the 60 days in arrears billing notice informing them the total amount due and again reminding them of the upcoming disenrollment date. When a family has failed to make payment for 60 days after receiving the three advanced notices the subscriber will be disenrolled effective the last day of the second consecutive month (60 days). At the end of the 60 day period, the family will receive a disenrollment notice, stating their coverage has ended. Children disenrolled pursuant to this section will not be eligible for re- enrollment until all past due premiums are paid during the past 12 months. Family Contribution Sponsors Approval Date: HFP Family Contribution Increase HFP Co-Payment Increase HFP Limited Dental Plan Choice for New Subscribers

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