Page 108

lowered all other copays to five dollars. Children who meet CCS conditions will receive their services (orthodontics) from CCS without a copay. Therefore, including dental services in the $250 maximum is not needed. Very few families will have to pay a copay at all for dental services and those that do will be for a specific condition (root canal) which should have limited utilization. COUNTY CHILDREN’S HEALTH INSURANCE PROGRAM (C-CHIP) Table 4: Aggregate Cost Sharing for Families Above 250% for C-CHIP California’s approved State Plan demonstrates that the cost sharing requirements do not exceed those allowable under Title XXI. Even though the cost sharing requirements are slightly higher in the C-CHIP projects compared to the Healthy Families Program, the higher income level is commensurate with the difference. Using 250% FPL as the baseline income, Table 4 below provides an analysis of the five percent cost sharing limit compared to the highest premium that would be charged by any given county. Therefore California provides assurances that the cost sharing requirements continue to be within the allowable limits established under Title XXI. Included in the cost sharing limit California assures that the $250 copayment cap also applies to the C-CHIP projects. This is also reflected in Attachment 6 and 7. I II III IV V VI Family Size Annual Income of a Single Parent Family @ 250% FPL +$1* 5% Ceiling Annual Premium Contribution** Annual Premium + $250 Family Cap on Health Copays Number of Dental and Vision Visits for Non- Preventive Services Needed to Exceed Ceiling 1 child $36,433 $1,822 $288 $538 128 2 children $45,781 $2,289 $576 $826 146 3 children $55,129 $2,756 $864 $1,114 164 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

108