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Model Application Template for the State Children‟s Health Insurance Program

Effective Date:

Approval Date: 44

Section 8. Cost Sharing and Payment (Section 2103(e))

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state‟s Medicaid plan, and continue on to Section 9.

8.1. Is cost-sharing imposed on any of the children covered under the plan? (42CFR 457.505) 8.1.1.

YES 8.1.2.

NO, skip to question 8.8.

8.2. Describe the amount of cost-sharing, any sliding scale based on income, the group or groups of enrollees that may be subject to the charge and the service for which the charge is imposed or time period for the charge, as appropriate. (Section 2103(e)(1)(A)) (42CFR 457.505(a), 457.510(b) &(c), 457.515(a)&(c)) 8.2.1. Premiums: For enrollees with countable income exceeding 200 percent but not exceeding 300 percent of the FPL, premiums will be $20 per month per child with a monthly family maximum of $40. For enrollees with countable income equal to or exceeding 150 percent but not exceeding 200 percent of FPL, premiums will be $10 per month per child, with a monthly family maximum of $20. For enrollees with countable earned and unearned income less than 150% of the FPL, no premium is assessed. No cost-sharing is assessed for eligible Native American / Alaskan Native children regardless of family income. If a family reports a decrease in income anytime during the 12-month eligibility period and the new income is less than 150% of the FPL, the family does not pay a premium for the reminder of the eligibility period. For the months of June 2008 and July 2008, the premiums for families with countable income that equals or exceeds 150% of FPL are waived. The basis for this waiver is good cause due to the financial hardship for those families with limited income in any of the Iowa counties that have been declared a disaster by the Governor of Iowa and/or Presidential Declaration of Disaster for Individual Assistance. See Attachment 14 for the list of Iowa counties affected as of June 30, 2008. 8.2.2. Deductibles: None 8.2.3. Coinsurance or copayments: Families whose countable income is equal to or greater than 150% of the FPL shall be assessed a $25 copayment for each emergency room visit if the child's medical condition does not meet the definition of