Page 40

Section 8. Cost Sharing and Payment (Section 2103(e))

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue on to Section 9.

8.1 Is cost-sharing imposed on any of the children covered under the plan? (42 CFR 457.505)

8.1.1

YES

8.1.2

NO, skip to question 8.8.

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)) (42 CFR 457.505(a), 457.510(b) & (c), 457.515(a)&(c))

8.2.1 Premiums:

Premiums will be imposed upon children with monthly family income greater than 200% FPL. The rate is based upon family income and will not exceed 5% of monthly family income. Recipients will receive a notice telling them how much their premiums will be. Children ages 1 – 18, with Incomes at or above 200 percent up to, but not including 230 percent of the FPL: $10; Incomes at or above 230 percent up to, but not including 240 percent of the FPL: $15; Incomes at or above 240 percent up to, but not including 250 percent of the FPL: $23; Incomes at or above 250 percent up to, but not including 260 percent of the FPL: $34; Incomes at or above 260 percent up to, but not including 270 percent of the FPL: $44; Incomes at or above 270 percent up to, but not including 280 percent of the FPL: $55; Incomes at or above 280 percent up to, but not including 290 percent of the FPL: $68; Incomes at or above 290 percent up to, but not including 300 percent of the FPL: $82; Incomes at 300 percent of the FPL: $97.53.

8.2.2 Deductibles:

A $200 deductible will apply for covered dental services, except preventive and diagnostic services, provided to children ages 1 to 18 with incomes from 200 - 300% FPL. Preventive and diagnostic dental services which include oral examinations, prophylaxis and topical fluoride applications, sealants and x-rays do not apply to the deductible. The deductible applies to fillings and other restorative services. The deductible is applied lies on a per member basis and is based on Benchmark Plan maximum allowable fees and is counted towards the enrollee’s 5 percent cost-sharing cumulative maximum, described in section 8.5.

WISCONSIN

Effective Date:

Approval Date: 40