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

Effective Date:

Approval Date: 46

are eligible only for dental coverage, the premium shall be assessed as follows: a. The total premium shall be no more than what the family would pay if all the children were eligible for both health and dental coverage. b. If the family has one child eligible for both health and dental coverage and one child eligible for dental-only supplemental coverage only, the premium shall be the total of the health and dental premium for one child and the dental premium for one child. c. If the family has two or more children eligible for both health and dental coverage, no additional premium shall be assessed for dental-only supplemental coverage for the children who do not qualify for health coverage under hawk-i because they are insured. 8.2.2.-D Deductibles: There are no deductibles for the dental-only supplemental coverage. 8.2.3.-D Coinsurances or copayments: There are no coinsurances or copayments for the dental-only supplemental coverage. 8.2.4.-D Other: No cost-sharing is assessed for eligible Native American / Alaskan Native children regardless of family income. The maximum total cost-sharing for a family may have is $40 per month or $240 per 12-month enrollment period. See response to 8.5 below regarding the 5 percent income limit for cost sharing.

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)) Cost sharing is described in the Iowa Administrative Rules and in printed materials about the program, including the informational brochure that contains the application form. (See Attachment 7) Additionally, when approved, each family will receive an approval notice that lists their countable income calculation and the amount of cost sharing, if any.

8.4. The state assures that it has made the following findings with respect to the cost sharing in its plan: (Section 2103(e)) 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)