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STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT
STATE: Virginia Page 8-54
Effective Date: 07/01/05
54 Approval Date: _____________/06 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))
No cost-sharing will be charged to American Indians and Alaska Natives.
8.2.1. Premiums:
None.
8.2.2. Deductibles:
None.
8.2.3. Coinsurance or copayments:
Co-payments shall not be imposed on any of the children covered under the Secretary- approved coverage offered through the fee-for service program and the PCCM program. No co-payments are required for well-baby and well-child and other preventive services, and families for Secretary-approved coverage modeled after the state employee plan.
Income levels are provided as a percentage of Federal Poverty Level ("FPL") based on gross income. The FPL reflects changes made effective February 13, 2004.
Copayments for Secretary-approved coverage modeled after the state employee plan are:
Description of Service ≤ 150% FPL > 150% FPL Outpatient $2 per visit $5 per visit Prescription Drugs $2 per prescription $5 per prescription Inpatient $15 per admission $25 per admission Non-Emergency use of Emergency Room $10 per visit $25 per visit
Poverty Levels ≤ 150% FPL > 150% FPL Maximum Yearly Co- Payment Limit Per Family
$180
$350
Total cost-sharing for each year (or 12-month eligibility period) is limited to: (1) for a