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Missouri Application for the State Children’s Health Insurance Program Effective Date: 09/01/2007 Approval Date: 09/28/2007

Prior Approval Date: - 35A - 8.5 Describe how the State will ensure that the annual aggregate cost-sharing for a family does not exceed 5% 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)) (42 CFR 457.560(b) and 457.505(e)) Response: Premium adjustments are calculated annually with an effective date of July 1. The premium is based on family size and income to ensure that no family pays more than 5% of their income for coverage. The formula used to calculate the monthly premium amount each year includes a factor to ensure the annual aggregate cost-sharing for a family does not exceed 5% of the family's income for the length of the child's eligibility period. At the time of application, the recipient is advised to contact their FSD Eligibility Specialist to report any changes in income, family size, or address. The monthly invoice also directs recipients to contact their Eligibility Specialist to report any changes in income, family size, or address. The recipient is asked to report any changes within 10 days of receipt of the invoice. 8.6 Describe the procedures the State will use to ensure American Indian (as defined by the Indian Health Care Improvement Act of 1976) and Alaska Native children will be excluded from cost-sharing. (Section 2103(b)(3)(D)) (42 CFR 457.535) Response: CMS officials have held that Missouri has no federally-recognized American Indian/Native American tribes within the state, and, therefore, Missouri has no specific obligations pursuant to 42 CFR § 457. The fact that Missouri has no federally-recognized American Indian/Native American tribes was affirmed by the CMS Region VII office as recently as May 2007.  The Eastern Shawnee Tribe of Oklahoma tribe is not associated with Missouri in the Federal Register’s “Indian Entities Recognized and Eligible To Receive Services From the United States Bureau of Indian Affairs” (Vol. 72, No. 55 / Thursday, March 22, 2007).  The Eastern Shawnee Tribe of Oklahoma (http://www.easternshawnee.org/index.html and http://www.eighttribes.org/eastern-shawnee/) listed above is actually centered on the Oklahoma/Missouri border.  Article II of the Constitution of the Eastern Shawnee Tribe (http://thorpe.ou.edu/constitution/eastshawcons.html) states that “...Eastern Shawnee lands, which are located in the north east section of the State of Oklahoma, and such other territory as may hereafter be added thereto.”