Page 6

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

Effective Date:

Approval Date: September 19, 2002 6 children under 19 years of age with family incomes above 133% FPL and at or below 185% FPL.

With the implementation of KidCare, the State has created a continuum of insurance plans with varying degrees of family financial responsibility. In an effort to reduce the stigma of being on Medicaid and to create health plans that resemble the private sector, KidCare includes five plans. These include:

1) KidCare Assist – Children with family income at or below 133% of the FPL enroll and receive services through the State’s Medicaid Program under Title XIX or through the Medicaid Phase I expansion under Title XXI. This program is publicly known as KidCare Assist. No monthly copayments or premiums are charged under KidCare Assist. This plan is currently in place under the State’s approved Medicaid State Plan and Title XXI State Plan.

2) KidCare Moms and Babies – Pregnant women and their babies up to age one with family income at 200% of the FPL or less, receive benefits with no monthly premiums or copayments. This program is publicly known as KidCare Moms and Babies. This plan is currently in place under the State’s approved Medicaid State Plan.

3) KidCare Share – KidCare Share provides benefits for children with family income over 133% through 150% of the FPL, who are not covered by KidCare Moms and Babies. Under KidCare Share, no monthly premiums are imposed, but modest co-payments for prescriptions, office visits, emergency room visits are required. Co- payments are not required for well-baby visits, well-child visits, or immunizations. This plan is currently in place under the State’s approved Title XXI State Plan.

4) KidCare Premium – KidCare Premium provides benefits for children with family income above 150% through 185% of the FPL, who are not covered by KidCare Moms and Babies. KidCare Premium imposes modest premiums and copayments. Co-payments are not required for well-baby visits, well-child visits, or immunizations. This plan is currently in place under the State’s approved Title XXI State Plan.

5) KidCare Rebate – KidCare Rebate is the fifth plan and is not included under this State Plan. KidCare Rebate is available to those with family income above 133% through 185% of the FPL whose