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51 Effective Date: July 1, 2009

Approval Date: 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))

The only cost sharing requirement is the premium payment. For Tier 1 families, the monthly premium amount of $20 per child per month up to a maximum premium amount of $40 per month per family, will not exceed 1.4 percent of the family income. For Tier 2 families the monthly premium amount of $30 per child per month up to a maximum premium amount of $60 per month per family, will not exceed 1.5 percent of the family income.

8.6. Describe the procedures the State will use to ensure American Indian (as defined by the Indian Health Care Improvement Act of 1976) and Alaska Native children will be excluded from cost-sharing. (Section 2103(b)(3)(D)) (42CFR 457.535) American Indian and Alaska Native (AI/AN) children are self-identified at the time of application. This information is put into MMIS, which codes them appropriately so that no premium billing statement is sent to the household for those children.

If a child is not self-identified at the time of application, client materials, as well as the billing invoice, provide information on excluding AI/AN children from the cost-sharing requirement. If premiums were inadvertently paid for an AI or AN child, a refund is issued.

8.7. Please provide a description of the consequences for an enrollee or applicant who does not pay a charge. (42CFR 457.570 and 457.505(c))

8.7.1 Please provide an assurance that the following disenrollment protections are being applied: