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

Effective Date:

Approval Date: 54 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? (42CFR 457.505)

8.1.1.

YES, Cost sharing applies to Healthy KidsConnect, FHIAP and Healthy Kids ESI. As long as the Section 1115 waiver authority is effective, children who opt to take up premium assistance under FHIAP and Healthy Kids ESI are not subject to Title XXI cost sharing rules. These children are subject to cost sharing rules through ESI plans. Healthy KidsConnect children are subject to the 5% cap.

8.1.2.

NO, skip to question 8.8. CHIP OHP Plus children have no cost sharing requirement.

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: Member premiums will be a maximum of 10% of the overall premium for members over 200 up to and including 250% of the FPL. Member premiums will be a maximum of 15% of the overall premium for members over 250 up to and including 300% of the FPL. Members will be sent an enrollment confirmation letter at the time of initial plan enrollment and each eligibility redetermination. This notice will include, but is not limited to monthly premium, the member’s premium cost and the state paid portion. The notice will also include the maximum cost-sharing allowed for the family, including premiums, co- insurance and copayments and will clearly state that the carrier will track the out of pocket costs. Under Express Lane Eligibility when a child is found eligible for HKC which require premiums, the Department sends a notice informing the client that the child may be eligible for lower or no premiums using our regular eligibility methods. If a child were found to be ineligible using an ELE finding the Department would do a full eligibility determination.