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

Effective Date:

Approval Date: 8-2

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))

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 Department has reviewed the cost sharing requirements for each family size and income level to ensure that in no instance will the cost sharing requirement exceed five percent of a family’s annual income for the coverage period. There are no co-payments for the CHPlus program, therefore, aggregate cost sharing is based on the family contributions towards the health care premium and does not exceed five percent of a family’s annual income.

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)

The Access NY application has a question which identifies children who are American Indians or Alaskan Natives. Once the child is determined to be an American Indian or Alaskan Native through appropriate tribal documentation, their family contribution is waived and they are fully subsidized by the program if their income is below 400 percent of the non-farm federal poverty limit.

8.7. Please provide a description of the consequences for an enrollee or applicant who does not pay a charge. (42CFR 457.570 and 457.505(c))

Enrollees are billed monthly, either 60 or 90 days in advance prior to their month of coverage. The family premium contribution is due 30 days in advance of the month of coverage. The State does not terminate enrollees who failed to pay their family premium contribution prior to the beginning of the month of coverage. Enrollees are given an additional 30 day grace period (the actual month of coverage) to pay their family premium contribution.