Page 46

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

Effective Date:

Approval Date: 46 • $5 for outpatient hospital visits, and • $20 co-payment for unnecessary emergency room use.

Families who have been exempted from cost-sharing as members of federally recognized Native American Tribes will not be subject to copayments and a $0 copayment will be printed on their health insurance card.

8.2.4. Other:

Enrollment fees are required only of those families above 150% of the federal poverty level. These fees, $50 for one child, $100 for two or more children, are used to offset the cost of administration by county Departments of Social Services. These funds are retained by the counties for this use. In a similar fashion, providers keep any copayments paid to them.

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)) (42CFR 457.505(b))

These charges are prominently posted on the website for the program, in all literature produced for the program, on the application form and on membership cards. Any changes are made through an act of the NC General Assembly which both publicly debates proposed changes and receives media coverage for the changes it makes. Once a change is made, letters are sent to all members in accordance with North Carolina Medicaid’s ten day notification rule. This rule requires that a letter be sent in order for the recipient to know about the change ten days before it goes into effect.

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))