Page 57

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

STATE: Virginia Page 8-57

Effective Date: 07/01/05

57 Approval Date: _____________/06 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 a family does not exceed 5 percent of such family’s income for the length of the child’s eligibility period in the State. Include a description of the procedures that do not primarily rely on a refund given by the state for overpayment by an enrollee: (Section 2103(e)(3)(B)) (42CFR 457.560(b) and 457.505(e))

Virginia has structured the cost sharing levels to make it highly unlikely that any family will exceed the allowable cost sharing levels.

Virginia ensures that the annual aggregate cost sharing for all FAMIS enrollees in a family does not exceed 5% of a family’s income as required by § 2103(e)(3)(b) of Title XXI. Co-payments are capped at levels that are extremely unlikely to exceed the upper limit. The tables below demonstrate that the maximum cost sharing for families under the Secretary-approved coverage modeled after the state employee plan falls within the required caps: For families with income equal to or below 150% of FPL, cost-sharing is capped at slightly less than 2.5% of income for a family of one at 100% of FPL. For families with income above 150% of FPL, cost-sharing is capped at slightly less than 5% of income for a family of one at 150% of FPL. (As mentioned earlier, families under the Secretary-approved coverage offered through the fee-for-service program are not subject to any cost-sharing.)

Table 1: Aggregate Cost Sharing for Families under Secretary-approved coverage modeled after the state employee plan Poverty Levels *100% 135% 150% 175% 200% Maximum Yearly Co-Payments Limit N/A $180 $350 $350 $350

Total Cost Sharing by Enrollees N/A $180 $350 $350 $350 FPL for family of one

$9,310

$12,569

$13,965

$16,293

$18,620