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STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 8-55

Effective Date: 07/01/05

55 Approval Date: _____________/06 family with an annual income equal to or less than 150% of the FPL, the lesser of (a) 2.5% of a family’s income, and (b) $180.00; and (2) for a family with an annual income greater than 150% of the FPL, the lesser of (a) 5% of a family’s income, and (b) $350.00.

The co-payment and coinsurance maximums are set at thresholds that are well below the maximum allowable per CMS for families with annual incomes equal to or below 150% of FPL and for those with annual incomes above 150%. The maximum yearly co- payment limit for families in FAMIS with annual incomes at or below 150% FPL is $180.00 per year. Families enrolled in FAMIS and receiving benefits through FAMIS contracted health plans are advised of the amount of maximum allowable cost-sharing that they may be responsible for during the year. Families are required to submit documentation to DMAS or its contractor, showing that the co-payment cap is met for the year. Once the cap is met, DMAS or its contractor will issue a new card excluding families from paying additional co-pays.

Enrollees are not held liable for any additional costs, beyond the standard co-payment amount for emergency services furnished outside of the individual’s managed care network. Only one co-payment charge is imposed for a single office visit.

The proposed cost sharing caps to be applied toward copayments and/or coinsurance ($180 and $350) were included in the Plan document.

No cost-sharing will be charged to American Indians and Alaska Natives.

8.2.4. Other

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))

The public is notified of FAMIS’ cost-sharing requirements, including differences based on income and plans, in the outreach and enrollment materials.

• Web site; • Handbook; • The public also has the opportunity to become involved during the regulatory process. Implementing regulations must go through a mandatory 60-day comment period consistent with the Code of Virginia; • Outreach Oversight Committee; • Managed care organization member handbooks; and • Outreach grantees.