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Effective Date:

Approval Date:

Updated and amended effective August 24, 2001

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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))

Children with a family net income of 200% of FPL or less will not be subject to any cost sharing requirements.

8.2.1. Premiums: If the family net income is determined to be above 200% FPL, the family will be required to share in the cost of the coverage. The negotiated rate for calendar year 2007 is expected to average approximately $149 statewide. The per child monthly premiums are:

Percent FPL Per Child >200 – 250 25 percent of the state negotiated rate (approx $37.25for 2007) >250 – 275 35 percent of the state negotiated rate (approx $52.15 for 2007) >275 – 300 40 percent of the state negotiated rate (approx $59.60 for 2007) >300 Full cost of coverage as negotiated by the Commonwealth with each of the contractors. This (>300% coverage) is a full payment program and is not included in any Title XXI funding.

Premiums will be due to the contractors on an established date prior to the first of the month for which premiums are paid.

8.2.2. Deductibles: Not applicable

8.2.3. Coinsurance or copayments: Coinsurance is not applicable

Copayments: For children in families with net income greater than 200% FPL, but less than 300% FPL, the Commonwealth has established reasonable copayments for services other than the following: well-baby; well-child; immunizations; or emergency care that results in admissions.

Copayments are as follows:

Primary Care visits $5 Specialists

$10