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Model Application Template for the State Children’s Health Insurance Program
Effective Date:
Approval Date: 52 Cost Sharing Cap 1.25% (of family’s income)* Facility Co-pay, Inpatient (per admission) $25 Above 150% up to and including 185% of FPL Charge Office Visit $7 Non-Emergency ER $50 Generic Drug $5 Brand Drug $20 Cost Sharing Cap 2.5% (of family’s income)* Facility Co-pay, Inpatient (per admission) $50 Above 185% up to and including 200% of FPL Charge Office Visit $10 Non-Emergency ER $50 Generic Drug $5 Brand Drug $20 Cost Sharing Cap 2.5% (of family’s income)* Facility Co-pay, Inpatient (per admission) $100 *Per 6-month term of coverage
8.2.4. Other: None.
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))
Outreach materials reference cost sharing requirements. The administrative services contractor provides information to SCHIP families about the required enrollment fee and co-payments for services. Health plans also include information on co-payments in member handbooks sent to SCHIP beneficiaries once enrolled.
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