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

Effective Date:

Approval Date: 45

emergency medical condition. Copayments are not assessed for Native American, Alaskan Native children, regardless of income. An emergency medical condition means a medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, such that a prudent lay person, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in one of the following: 1. Placing the health of the person or, with respect to a pregnant woman, the health of the woman and her unborn child, in serious jeopardy, 2. Serious impairment to bodily functions or, 3. Serious dysfunction of any bodily organ or part.

8.2.4. Other:

8.2- DS For children enrolled in the dental-only supplemental coverage, please describe the amount of cost-sharing, specifying any sliding scale based on income. Please also describe how the State will track that the cost sharing does not exceed 5 percent of gross family income. The 5 percent of income calculation shall include all cost-sharing for health insurance and dental insurance (Section 2103(e)(1)(A)) (42 CFR 457.505(a), 457.510(b), and (c), 457.515(a) and (c), and 457.560(a))

8.2.1.-D Premiums: Premiums for participation in the dental-only supplemental program are assessed as follows: a. No premium is charged to families whose countable income is less than 150 percent of the FPL. b. If the family‟s countable is equal to or exceeds 150 percent of FPL, but does not exceed 200 percent of the FPL for a family of the same size, the premium is $5 per child per month with a $10 monthly maximum per family. c. If the family‟s countable income exceeds 200 percent of the FPL, but does not exceed 250 percent of the FPL for a family of the same size, the premium is $10 per child per month with a $15 monthly maximum per family. d. If the family‟s countable income exceeds 250 percent of the FPL, but does not exceed 300 percent of the FPL for a family of the same size, the premium is $15 per child per month with a $20 monthly maximum per family. For families that include uninsured children who are eligible for both health and dental coverage under hawk-i and insured children who