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

Effective Date:

Approval Date: 51 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

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))

8.2.1. Premiums: See costing sharing table. Unborn children are exempt from cost-sharing through the duration of their 12-month eligibility.

8.2.2. Deductibles: None.

8.2.3. Coinsurance or co-payments: See costing sharing table. Unborn children are exempt from cost-sharing through the duration of their 12- month eligibility.

Cost Sharing Enrollment Fees (for 6-month enrollment period): Charge At or below133% of FPL, American Indians and Alaska Natives $0 Above 133% up to and including 150% of FPL 0 Above 150% up to and including 185% of FPL $35 Above 185% up to and including 200% of FPL $50 Co-Pays (per visit):

At or below 100% of FPL Charge Office Visit $3 Non-Emergency ER $3 Generic Drug $0 Brand Drug $3 Cost Sharing Cap 1.25% (of family’s income)* Facility Co-pay, Inpatient $10 Above 100% up to and including 150% of FPL Charge Office Visit $5 Non-Emergency ER $5 Generic Drug $0 Brand Drug $5