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

Effective Date:

32 Approval Date:

The public is notified through the rule-making process, as provided under the Maine Administrative Procedures Act.

In addition, outreach materials include information informing individuals that, depending on household income, some families may have to pay a premium for their child’s coverage and the dollar amounts of the premiums.

8.4 The state assures that it has made the following findings with respect to the cost sharing in its plan: (Section 2103(e))

8.4.1

Cost-sharing does not favor children from higher income families over lower income families. (Section 2103(e)(1)(B)) (42CFR 457.530)

8.4.2

No cost-sharing applies to well-baby and well-child care, including age-appropriate immunizations. (Section 2103(e)(2)) (42CFR 457.520)

8.4.3

No additional cost-sharing applies to the costs of emergency medical services delivered outside the network. (Section 2103(e)(1)(A)) (42CFR 457.515(f))

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))

As shown in the following table, the premium is never higher than the equivalent of 3.3 % of family income for those at the lowest end of the FPL range.

Premium as a % of Benefit Cost Monthly Premium Cost* Minimum Monthly Income** Premium as a % of Minimum Income*** No. of Children 1 2 1 2 1 2 1 2 FPL:

150% - 160% 5% 10% $8 $16 $1164 $1562 0.7% 1% 160% - 170% 10% 20% $16 $32 $1250 $1666 1.3% 1.9% 170% - 185% 15% 30% $24 $48 $1319 $1770 1.8 % 2.7% 185% - 200% 20% 40% $32 $64 $1436 $1926 2.2% 3.3%

* Based on an estimated annual benefit cost of $1920 per child or $160 monthly.