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C-CHIP as it is in the Healthy Families Program. The exemption from premiums will be made at the time of application submission when a family declares AI/AN status consistent with the documentation requirements listed below. The family will have two months to submit the required documentation to continue the premium waiver. If documentation is not submitted within two months from enrollment, premiums will be charged prospectively. When acceptable documentation is submitted, the copayment waiver will also be applied. Acceptable documentation for the applicant or the child includes: 1. An American Indian or Alaskan Native enrollment document from a federally recognized tribe; or 2. A Certificate Degree of Indian Blood (CDIB) from the Bureau of Indian Affairs; or 3. A Certificate of Indian Heritage from an Indian Health Service facility operating in the State of California. • Education to Certified Application Assistants about the cost sharing exemption for AI/AN families that meet the cost sharing waiver requirements. • C-CHIPs will provide the same cost sharing waivers as the Healthy Families Program. • C-CHIP will include this cost sharing exemption notice in their member handbooks consistent with the Healthy Families Program. 8.7 Please provide a description of the consequences for an enrollee or applicant who does not pay a charge. (42CFR 457.570 and 457.505(c)) Currently, if a program participant fails to make a payment, the next month’s invoice he receives includes a 30 day past due warning. The second month’s invoice includes the amount due for the previous month and the current month, the date by which payment must be remitted, and the date the coverage will end if payment is not made. If the premium is 45 days past due, a warning letter is sent to the applicant, which includes information on payment options, the disenrollment date, and an instructions on how to complete the request form for continued enrollment. If the premium has not been received on the 20th of the second month, a courtesy call is placed to the applicant. The applicant is reminded that a premium payment is due and that his or 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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