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DELAWARE HEALTHY CHILDREN PROGRAM (DHCP) 34

Transmittal # DHCP SPA #5 Approval Date July 28, 2009 Supersedes Transmittal # DHCP SPA #4 Effective Date April 1, 2009

8.4.1. Cost-sharing does not favor children from higher income families over lower income families. (Section 2103(e)(1)(B)) (42CFR 457.530) 8.4.2. No cost-sharing applies to well-baby and well-child care, including age- appropriate immunizations. (Section 2103(e)(2)) (42 CFR 457.520) 8.4.3. No additional cost-sharing applies to the costs of emergency medical services delivered outside the network. Section 2103(e)(1)(A)) (2CFR 457.515(f))

8.5 Describe how the state will ensure that the annual aggregate cost-sharing for a family does not exceed 5 percent of such family’s income for the length of the child's eligibility period in the State. Include a description of the procedures that do not primarily rely on a refund given by the state for overpayment by an enrollee: (Section 2103(e)(3)(B)) (42CFR 457.560(b) and 457.505(e))

Since cost sharing is per family per month (PFPM), rather than per member per month, each family will pay the same amount no matter the number of children in the household. The premium rates are significantly less than those allowed by the Balance Budget Act of 1997 for premiums (see chart below). There is a minimal copayment of $10 per inappropriate use of the emergency room that will be waived if a prudent layperson would deem the visit an emergency or if it results in an inpatient admission. Delaware believes these levels of cost sharing are affordable but, at the same time, provide an incentive for clients to responsibly use health care services and avoid unnecessary emergency room visits.

An analysis of the State's fee schedule suggests that cumulative cost-sharing will rarely exceed 1% of the family's adjusted gross income. However, should families submit evidence that they have reached the aggregate limit on cost- sharing, the State will work with the MCOs on an individual basis to exempt the family from future cost-sharing. Premiums as a percentage of Income % of FPL* Family Size 101% 133% 134% 166% 167% 200% $120 Annual Premium 1 1.47% 1.12%

2 1.09% 0.83%

3 0.87% 0.66%

$180 Annual Premium 1

1.66% 1.35%

2

1.23% 1%

3

0.98% 0.79%

$300 Annual Premium 1

2.23% 1.86%

2

1.65% 1.38%

3

1.32% 1.1% * Based on the 1998 Poverty Limit of $8050 for 1 person, $10,850 for 2, and $13,650 for 3.

8.6. Describe the procedures the state will use to ensure American Indian (as defined by the Indian Health Care Improvement Act of 1976) and Alaska Native children will be excluded from cost-sharing. (Section 2103(b)(3)(D)) (42CFR 457.535)