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

Effective Date:

Approval Date: 31 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))

The State of Idaho will ensure that the annual aggregate cost-sharing for a family does not exceed five (5) percent of such family’s income for the length of the child’s eligibility period in the State. Upon enrollment participants are sent a notice advising them of their cost-sharing responsibilities. This includes notice of the five percent maximum.

Cost-sharing in the Idaho plan is set so low that very few families will reach their 5% limit. Additionally, a family that does exceed the limit will do so due to inappropriate use of emergency services.

Through the various information strategies such as the use of eligibility workers and other avenues of information dissemination, participants and their families are informed as to the limits of their financial liability for the coverage. The first direct written communication with families instructs parents that the expenditures on their child(ren)s health care should not exceed 5% of family income.

Benefit booklets are provided to all participants at initial eligibility determination and upon request thereafter. Information is included which directs families to inform the state whenever the 5% maximum is met or exceeded.

The State has adopted the "shoe box" approach to reimburse families who exceed the 5% limit. Families are required to track expenditures based on he calculation of family income provided by the state and to submit receipts for all expenditures in excess of the 5% limit. The family will receive a refund in an amount equal to their excess payments.

Once the maximum out of pocket is met, the family is not required to pay premiums for the remainder of the eligibility period.

8.6. Describe the procedures the state will use to ensure American Indian (as defined by the Indian Health Care Improvement Act of 1976) and Alaska Native children will be excluded from cost-sharing. (Section 2103(b)(3)(D)) (42CFR 457.535)