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Table 3: Aggregate Cost Sharing for Families Above 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 3 demonstrates the aggregate cost sharing for families above 200% FPL up to and including 250% FPL, I II III IV V VI VII Family Size Annual Income of a Single Parent Family @ 200% 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 $29,149 $1,457 $288 $538 1.9% 92 2 children $36,625 $1,831 $576 $826 2.3% 101 3+children $44,101 $2,205 $864 $1,114 2.5% 109 *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%. Copays. Healthy Families sets health benefit copayments from $5 to $15. A copayment level of $5 is reasonable for families with incomes below 150% FPL for a number of reasons. First, Healthy Families will charge no copays for any preventive services, and no family will be required to pay any copayments after it has contributed $250 annually. Also, Healthy Families will not charge any copay for institutional services, in contrast to Medicaid law which allows a 50% copayment for the first day of institutional care. Finally, Title XXI requires that cost sharing not exceed an amount that is “nominal” under Medicaid law, with appropriate adjustment for inflation or other reasons as the Secretary determines to be reasonable. The maximum copayment for a service costing over $50 is $3 under Medicaid law and was established in 1978. When adjusted for 1996 using the California Consumer Price Index (CPI), that copayment level rises to over $7, well above the $5 copay proposed by California. The $250 limit does not apply to dental or vision coverage. Further, as California does not have copays for most dental services that children receive (preventive exams, cleanings, restorations, sealants, and fluoride treatments) it has 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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