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State Children’s Health Insurance Program

Phase 1 Effective Date: April 1, 1998

Revised: 1/26/98, 2/19/98, 3/3/98, 3/6/98 Phase 2 Effective Date: July 1, 1998

Revised: 8/20/98, 8/24/98, 10/1/99, 7/28/00, 1/31/01, 7/02/02, 7/22/02, 1/3/03, 2/13/04, 9/27/04, 11/15/04, 8/11/05, 10/1/06, 7/1/09, 7/1/10, 7/1/11, 7/1/12 101 Florida Healthy Kids Co-payments Service Co-payment Amount Behavioral Health Outpatient Visits *$5.00 per visit Emergency Room, Inappropriate Use

$10.00 (waived if admitted) Emergency Transportation

$10.00 (waived if admitted) Eyeglasses, Prescription

$10.00 Office Visits, Primary Care

*$5.00 per visit Office Visits, Specialty Care

*$5.00 per visit Prescribed Medicine

*$5.00 per prescription Therapy Services (PT, OT, ST) *$5.00 per session Hospice and Home Health Services *$5.00 per visit * increases effective October 1, 2003

8.3. Describe how the public will be notified, including the public schedule, of this cost sharing (including the cumulative maximum) and changes to these amounts and any differences based on income. (Section 2103(e)((1)(B)) (42CFR 457.505(b)) Florida KidCare Application In 1998, the original Florida Healthy Kids application was modified to become the first joint Florida KidCare/Medicaid application. Since then, the application has gone through several modifications and is now known as the Florida KidCare application. It includes necessary information for Title XIX eligibility determination as well as the KidCare components (MediKids, Healthy Kids and the Children’s Medical Services Network). Families will be informed through a separate brochure that is attached to the application packet that, except for Medicaid, monthly premium payments are required. Schedules of the co-payments for the Healthy Kids program are also included on the Healthy Kids web page, in member materials produced by the participating Healthy Kids health plans and through correspondence sent to families who have begun the application process. The Florida KidCare application has undergone significant revisions and was distributed beginning March 17, 2003. The application was field-tested with target audiences and includes additional data fields that were not captured on the previous application. Effective with the January 1, 2004 change to a two-tiered premium of $15 and $20, enrollees received correspondence advising them if their premium changed. The