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

Effective Date:

Approval Date: 45 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))

For all members of federally recognized Native American tribes there is no cost sharing.

For families below 150% of the federal poverty level (FPL), there is cost sharing for prescription drugs only.

For families above 150% FPL, there is an annual enrollment fee of $50 for one child or $100 for two or more children ($100 annual maximum) plus copays.

8.2.1. Premiums:

8.2.2. Deductibles: 8.2.3. Coinsurance or copayments

Copayments:

Families below 150% will pay copayments as follows:

• For prescription drugs: $1 for generic, $1 for brand with no generic available, $3 for generic with a brand available

Families above 150% will pay copayments as follows:

• For prescription drugs: $1 for generic, $1 for brand with no generic available $10 for generic with a brand available; • $5 for each physician visit, dental and optometry visit except for preventive services,