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families the co-payments required and the annual out-of-pocket limit. The CoverKids eligibility and enrollment TPA will notify families of the dollar amount of their out-of-pocket limit based on 5% of their annual income in the same letter that notifies the family of enrollment into the health plan. The TPA will also notify the health plan of the limit on out-of-pocket spending for enrollees. The health plan will electronically accumulate the money spent for cost sharing for eligible children in a family and notify the family via a letter when the dollar amount is met. The health plan’s electronic claims system will annotate the child’s file to notify providers that no further cost sharing is required.

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))

Very few families are likely to exceed the 5 percent limit on out-of-pocket expenses because of the CoverKids copayment structure. For example, a single parent with one child (two person family) at 101 percent of the FPL ($13,332 annually) would have an annual out-of-pocket maximum of $667. This family could have a total of 134 doctor visits and prescriptions before reaching the limit on out-of-pocket expenses. A child in family of two at 151 percent of FPL ($19,932 annually) could have 66 physician office visits before reaching the out-of-pocket maximum of $996.

Families will be informed in all literature and outreach workers will be trained to educate families about the limit on out-of-pocket expenses. Upon enrollment in CoverKids, families will receive notification of the dollar amount of their out-of-pocket limit based on 5% of their annual income. The 5 percent annual cost sharing limit will be calculated by the CoverKids

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