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

Effective Date:

Approval Date: 28 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: Enrollees in the Basic Benchmark Benefit Package with family incomes at or above 150% FPL will be subject to a premium in the amount of $10 per member per month for medical services and an additional $5 per member per month for dental services. Premium amounts paid apply first to medical services in determining delinquency. Enrollees in the Basic Benchmark Benefit Package with family incomes above 133% FPL up to 150% FPL will be subject to a premium in the amount of $10 per member per month for medical services and are not subject to the dental premium. Delinquent payments must be paid before re-enrollment (see Section 8.7 for further delinquency and disenrollment protection information). Enrollees in the Enhanced Benchmark Benefit Package are not subject to premiums.

Wellness Preventive Health Assistance (PHA): The state has established a mechanism to assist participants with their premium payment obligations. This mechanism is called Wellness PHA. Each participant who is required to make premium payments can earn 30 points every 3 months by receiving recommended wellness visits from their PCP and demonstrating up-to-date immunizations. These Wellness PHA points can be used to offset premium payments. Each point equals one dollar.

A child with family income below 150% FPG may have all his premium obligations met by utilizing Wellness PHA. Children in families 150-185% FPG may offset up to two-thirds (two out of every three) of their payments.