Page 55

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

Effective Date:

Approval Date: 55 8.2.2. Deductibles: None 8.2.3. Coinsurance or copayments: Coinsurance or copayments: Each carrier will offer one or two plan options, described as follows: Option A has a combination of copayments and coinsurance. Each benefit or service will have either a copayment or coinsurance percentage associated with it. In no case will there be both a copayment and coinsurance applied to the benefit. Option B has copayments only for each benefit or service. 8.2.4. Other: Medical out of pocket maximums are the same for both Options A & B: $900 for families with 1 child and $1800 for families with 2 or more children. Prescription out of pocket maximum is the same for both options A&B: $100 for families with 1 child and $200 for families with 2 or more children; Dental out of pocket maximums are also the same: families with 1 child are $200 and families with 2 or more children are $400. In no case will total out of costs exceed 5 percent of the family’s annual income.

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)) Benefits and cost-sharing information will be available to the public through the Office of Healthy Kids website at: www.oregonhealthykids.gov as well as the Office of Private Health Partnerships website: www.oregon.gov/ophp. Outreach and marketing materials will also include the information. Additionally, Oregon Administrative Rules will reference the HKC benefits and cost sharing. The rule filing process includes public notification in writing, public advisory committee review, rule posting on the agency website and a public feedback hearing prior to rule implementation. As indicated in sec 8.2.1 Members will receive 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 portion paid by OPHP. 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.

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