Page 7

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

Effective Date:

Approval Date: 7 1. The plan covers uninsured children age 6 through 18 whose family incomes do not exceed 200% of the federal poverty level 2. Eligible children are enrolled in a non-entitlement program. This means that the amount of funds available to serve them determines how many can be served. 3. In the event there are insufficient funds, new enrollments will be frozen 30 days following public notice. 4. The benefits package is that provided through the North Carolina Teachers’ and State Employees’ Comprehensive Major Medical Plan (also referred to as the State Employee’s Health Plan or State Employees Health Plan) with additional preventive and maintenance dental, vision and hearing benefits. Benefits for Special Needs children are provided as follows: State Employees Health Plan administers and processes claims for children’s acute medical care and other care of special needs children. Benefits for special needs children are as provided under the Medical Assistance Program except that no services for long-term care shall be provided for special needs children and except that services for respite care for special needs children are provided only under emergency circumstances. 5. Families above 150% FPL pay copayments as follows: $1 for each generic prescription; $1 for each brand name prescription for which no generic is available and $10 for each brand name prescription with an available generic; $5 for each physician visit, clinic visit, dental and optometry visit except for preventive services (for which there is no copayment); $5 for outpatient hospital visits; and a $20 copayment for unnecessary emergency room use. For those below 150% FPL, there is a copayment for prescription drugs of $1 for all generics, $1 for brand names for which no generic is available and $3 for each brand name prescription with an available generic. 6. There is an annual enrollment fee for those above 150% of the federal poverty level of $50 per child – with a $100 maximum for two or more children in the same family. 7. Existing administrative structures and delivery systems are used. 8. Extensive outreach campaigns have been conducted to ensure that eligible children are enrolled and that their health needs are met. Payment for their care has reduced some cost shifting to other payors. The state has seen some improvement in health outcomes. 9. Enrollees whose income at reenrollment increases above 200% FPL (up to 225%) are allowed to buy into the program for one year at full cost. Because this is a costly option, few families that have