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Application for the State of Indiana Children’s Health Insurance Program Amendment #7

Effective Date:

29

Approval Date:

PREMIUMS Income (As a percent of FPL) One Child Two or More Children Over 150 to 175 percent $22.00 $33.00 Over 175 to 200 percent $33.00 $50.00 Over 200 to 225 percent $42.00 $53.00 Over 225 to 250 percent $53.00 $70.00 Over 250 to 275 percent $62.00 $73.00 Over 275 to 300 percent $73.00 $90.00

8.2.2. Deductibles:

Not Applicable.

8.2.3. Coinsurance or copayments:

Copayments for certain services will be imposed under the CHIP program. (See chart below). These copayments will be established primarily as a utilization control mechanism. Providers will be responsible for collecting these nominal copayments.

COPAYMENTS

Service

Copayment

Prescription Drugs — Generic, Compound and Sole-Source

$3

Prescription Drugs — Brand Name

$10

Emergency Ambulance Transportation

$10

8.2.4. Other: None

8.3. Describe how the public will be notified, including the public schedule, of this cost- sharing (including the cumulative maximum) and changes to these amounts and any differences based on income. (Section 2103(e) ((1) (B)) (42CFR 457.505(b))

A number of methods have been used to inform the public about cost-sharing requirements and any changes to them under CHIP. These include:  Notice in the Hoosier Healthwise brochure;  Notice in the application form (if the family does not agree to the cost-sharing requirements under CHIP, the child will be considered only for Medicaid or MCHIP and will not be considered for CHIP);  Notice in the conditional approval form which is sent to the family after the child is found conditionally eligible for CHIP before the family has received the premium notice;