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

Effective Date:

Approval Date: 47 8.5. Describe how the state will ensure that the annual aggregate cost sharing for a family does not exceed 5 percent 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)) (42CFR 457.560(b) and 457.505(e))

The type and amount of co-payment is set at levels that are extremely unlikely to exceed the upper limit. The Division of Medical Assistance, through EIS, will notify the State Employees Health Plan of the limit to the amount of co-pay. The State Employees Health Plan will electronically accumulate the money spent on cost sharing by each individual and notify the family via a letter when the dollar amount is met. The notification can be shown to providers who will then forgive any further co-payment. As a precaution, a report will be generated annually that lists income levels for individuals for whom co-payment amount exceeds 5% of 100% of annual federal poverty guidelines for an individual. This assures that the lowest possible annual income for a Title XXI eligible is the threshold. During federal fiscal years 2002- 03 and 2003-04 period, no families have exceeded the five percent threshold.

In the cases of families who are at or below 150% of federal poverty level, the medication management claims processing system receives computer based case file numbers, when the family reaches the $14 per month limit, the automatic eligibility system will notify pharmacists that no copay is required. In case of error caused by filing delays, a manual review of the data will be run on the fifth of every month and families will be reimbursed should computer notification fail to work.

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)) (42CFR 457.535)

Counties will collect enrollment fee when family income is at or above 150% FPL unless the family when declaring race has presented evidence (such as a Tribal Membership Card) that they are members of a federally recognized Native American tribe. If this has occurred, no enrollment fee is owed. When eligibility is determined and the membership card issued, the figure $0 will be printed on the copayments lines for those families who presented a tribal membership card upon enrollment. In addition, a letter has been sent to the federally recognized Native American Tribal Councils of North Carolina, asking for their assistance in making sure that their tribal members identify themselves at enrollment as members of a federally recognized Native American tribe.