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sponsorship for San Mateo and Santa Clara Counties is derived from the local Tobacco Tax dollars being invested in their C-CHIP project. Funding for sponsorship for San Francisco County is derived from County funds being invested in their C-CHIP project. Families are informed about sponsorship by the Certified Application Assistants, annual renewal form, the families Welcome Letter when enrolled in C-CHIP and in the letter advising the family that they are delinquent on the monthly premiums. Families enrolled in their C-CHIP program can apply for sponsorship at any time during their enrollment. An eligibility specialist reviews the request and approves as appropriate. All requests for sponsorship due to financial hardships are approved. The duration of sponsorship varies, as it begins from the time the request is approved until the annual renewal occurs, which is often a 12-month period. 8.2.2. Deductibles: None 8.2.3. Coinsurance or copayments: No coinsurance. Copayments are summarized below and described in more detail in Attachment 6. Health Coverage MRMIB will establish copayment levels in amounts that reflect the copayment levels for the state’s selected benchmark plan, the Public Employee’s Retirement System. However, no copayments will be charged for prenatal, well baby, well child or immunization services or benefits. Further, the amount of copayments a family will pay in a given year is limited to $250, as opposed to the $1,500 annual copayment maximum in the benchmark plan. Copayment amounts are detailed by benefit in the description of benefits in section 6.2 of this application. The copayment for most services (office visits, prescriptions) is $5.00 to $15.00. Dental and Vision Coverage MRMIB will establish co-payment levels in amounts that reflect the co­ payment levels for the plans made available to state employees through the Department of Personnel Administration. No copayments will be required for preventive and diagnostic services, including dental exams, teeth cleaning, X- Effective Date: Approval Date: November 1, 2009 HFP Family Contribution Increase November 1, 2009 HFP Co-Payment Increase November 1, 2009 HFP Limited Dental Plan Choice for New Subscribers

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