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

Effective Date:

Approval Date: 8-1 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? (42 CFR 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))

8.2.1. Premiums:

Income

Individual Contribution Family Maximum < 160% FPL

$0

$0 160% - 222%*

$9

$27 223%-250%*

$15

$45 251%-300%*

$30

$90 301%-350%*

$45

$135 351%-400%*

$60

$180 *American Indians/Native Americans exempt from Family contribution

8.2.2. Deductibles:

There are no deductibles.

8.2.3. Coinsurance or copayments:

Coinsurance is not allowed and there are no co-payments.

8.2.4. Other: ______________

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))

The cost sharing information is disseminated to potential enrollees through an informational brochure, a toll-free information and enrollment number and through the enrollment process with the health plans and facilitated enrollers. This information is also explained in the application.