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Model Application Template for the State Children‟s Health Insurance Program
Effective Date:
Approval Date: 48
same size, the premium is $15 per child per month with a $20 monthly maximum per family. Since the premiums are the only cost sharing incurred by the family, the annual cost sharing will not exceed 5% of the family‟s income. See response in 8.2.4 D. c. Premiums for families that include children who are eligible for both health and dental coverage under hawk-i and insured children who are eligible only for dental coverage are: i. 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. ii. If the family has one child eligible for both health and dental coverage and one child eligible for dental-only supplemental coverage, the premium shall be the total of the health and dental premium for one child and the dental premium for one child. iii. 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 because they are insured. B. Emergency copayment: For families that have health care coverage and their income is equal or exceeds 150% of the FPL, a copayment of $25.00 applies for inappropriate use of the emergency room. At current poverty levels, the family that pays premiums would have to incur the number of inappropriate emergency room visits indicated below to exceed 5%. Health plans will report enrollee ER usage, resulting in a copayment obligation, to the third party administrator. The third party administrator will track the ER copayment to ensure cost sharing does not exceed 5% of the family income. At the point the ER copayment results in cost sharing exceeding 5%, enrollees will be reimbursed for the cost. It is expected that the health plans will intervene to educate enrollees about the appropriate use of ER services prior to any family utilizing the ER inappropriately in as many instances indicated in the chart.