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

Effective Date:

Approval Date: 47

8.4.2.

No cost-sharing applies to well-baby and well-child care, including age-appropriate immunizations. (Section 2103(e)(2)) (42CFR 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)) (42CFR 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)) There are only two forms of cost sharing in the hawk-i program, premiums and a copayment for treatment in an emergency room for a non-emergent medical condition. In both cases, they apply only to families with income that equals or exceed 150% of FPL. A. Premiums There are three premium tiers based on family income and the benefits received. a. Premiums for full coverage (medical and dental) in the hawk-i program are: i. 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. ii. 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. b. Premiums for dental-only supplemental coverage are: i. If the family‟s countable income equals or exceeds 150% of the 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. ii. 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. iii. 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