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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 - 34A - • In no case shall the family be charged more than 5% of the family's gross income. The premium invoicing system is designed to not invoice a monthly premium in excess of 5% of the family’s gross annual income divided by twelve (12). The following table presents an example of the premium calculation.

8.2.2 Deductibles: Response: None 8.2.3 Coinsurance or copayments: Response: None 8.2.4 Other: Response: 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)) (42 CFR 457.505(b)) Response: The Eligibility Specialist at FSD mails an approval notice to recipients when they are approved for SCHIP 1. The approval notice advises the recipients if they must pay a premium to be eligible for coverage and the premium chart is attached to the approval notice. Following initial approval for coverage, an invoice is mailed to recipients each month billing them for the next month's premium. The monthly invoice also directs recipients to contact their FSD Eligibility Specialist to report any changes in income, family size, or address. The recipient is asked to report such changes within 10 days of receipt of the invoice. The premium chart and information