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Missouri Application for the State Children’s Health Insurance Program Effective Date: 05/01/2009 Approval Date:

Prior Approval Date: 09/28/2007 - 34 - 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? (42 CFR 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)) (42 CFR 457.505(a), 457.510(b) &(c), 457.515(a)&(c)) 8.2.1 Premiums Response: The premium amounts are calculated according to Missouri State law (the State Fiscal Year Budget and MO Revised Statute Section 208.640). Families of children in SCHIP 1 shall pay the following premium based on family size and income to be eligible to receive services: • Enrollees with incomes above 150 percent of the FPL and up to 185 percent of the FPL shall pay four percent of the difference in income between 150 and 185 percent of the FPL. • Enrollees with incomes above 185 percent of the FPL and up to 225 percent of the FPL shall pay: o four percent of the difference in income between 150 and 185 percent of the FPL; o plus eight percent of the amount of difference in income between 185 percent of the FPL and 225 percent of the FPL. • Enrollees with incomes above 225 percent of the FPL and up to 300 percent of the FPL shall pay: o four percent of the difference in income between 150 and 185 percent of the FPL; o plus eight percent of the amount of difference in income between 185 percent of the FPL and 225 percent of the FPL; o plus 14 percent of the amount of difference in income between 225 and 300 percent of the FPL.