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Model Application Template for the State Children’s Health Insurance Program
Effective Date:
31 Approval Date: 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: Families with income from 151% through 200% FPL, pay premiums for MaineCare coverage for children based on a sliding scale applied to gross family income as follows:
• Below 150% FPL - no premium; • 150% to 160% FPL - premiums are $8 per month for the first child and $16 per month for 2 or more children; • 160% to 170% FPL - premiums are $16 per month for the first child and $32 per month for 2 or more children; • 170% to 185% FPL - premiums are $24 per month for the first child and $48 per month for 2 or more children; • 185% to 200% FPL - premiums are $32 per month for the first child and $64 per month for 2 or more children.
8.2.2 Deductibles: Not applicable
8.2.3 Coinsurance or copayments: Coinsurance - Not applicable Copayments - Not applicable
8.2.4 Other: Not applicable
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))