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eligibility and enrollment TPA at the time of eligibility determination. The TPA’s accuracy in calculating the limit will be monitored by the State as a part of the audits it will conduct to verify the accuracy of the TPA’s eligibility determinations. The TPA will also notify the health plan of the limit to the amount of copayments. The health plan will electronically accumulate the money spent on cost sharing for eligible child(ren) 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. In case of error caused by filing delays, families may request a manual review of their receipts and families will be reimbursed should computer notification fail to work. The health plan will be asked to submit reports to the State identifying families who have met their annual out-of-pocket limit.

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 brochure explaining application and enrollment procedures will state that there is no cost sharing for American Indian/Alaska native children. If the family indicates on the application form that a child is American Indian or Alaskan Native, but does not provide tribal membership documents, a letter will be sent by the TPA requesting this information when the child is determined otherwise eligible. Upon receipt of proof of federally recognized tribe status, the TPA will notify the health plan to flag the child's electronic account to notify providers that copayments are not required. The health plan will be responsible to reimburse the family for any co-payments that may have been made prior to notification of exempt status.

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))

A family that does not pay a required copayment remains enrolled in the program. An individual provider may at his or her discretion refuse service for non-payment of a copayment. The state does not participate in collection action or impose any benefit limitations if enrollees do not pay copayments.

8.7.1 Please provide an assurance that the following disenrollment protections are being applied:

The CoverKids Program does not disenroll anyone under the current system for non-payment of copayments. If the State makes

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