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month (with a maximum family contribution of $14 per family per month). Table 1 below demonstrates that the maximum premium payments for a family at 100% FPL under Healthy Families (Column II) falls within the maximum monthly charges established under Section 447.42 of Title 42 CFR. I. II. III. IV. Family Size Income of a Single Parent Family at 100% FPL + $1* Premium Contribution Medicaid Maximum Monthly Charge (Unadjusted for Inflation)** 1 child $1,217 $7 mo. / $84 yr. $19 mo./ $228 yr. 2 children $1528 $14 mo. / $168 yr. $15-$16 mo./ $180-$192 yr. *Dollar amounts are based on April 1, 2009 FPL. **Source: Code of Federal Regulations, Section 447.52 of Title 42 Table 2: Aggregate Cost Sharing for Families Above 150 – 200% FPL for HFP California ensures that the annual aggregate cost-sharing for a family does not exceed 5% of a family’s income as is required by Section 2103(3)(B) of Title XXI. Healthy Families’ premiums are established in statute, along with a limit of $250 on the total copayments which would be required of a family annually. The table below demonstrates that the maximum cost sharing falls well within the 5% annual cap. Although dental and vision benefits are optional in SCHIP, this table shows how many such visits a child could have before exceeding the limit. Table 2 demonstrates the aggregate cost sharing for families above 150% FPL up to and including 200% FPL, I II III IV V VI VII Family Size Annual Income of a Single Parent Family @ 150% FPL +$1* 5% Ceiling Annual Premium Contribution** Annual Premium + $250 Family Cap on Health Copays Percentage of Annual Income Number of Dental and Vision Visits for Non- Preventive Services Needed to Exceed Ceiling 1 child $21,865 $1,093 $192 $442 2 % 65 2 children $27,481 $1,374 $384 $634 2.3% 74 3+children $33,085 $1,654 $576 $826 2.5% 83 *Dollar amounts are based on April 1, 2009 FPL. **Dollar amounts do not include premium discounts for pre-payment. If included, it would reduce the premium contribution amounts by 25%. 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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