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Vision: Examination

Vision: Prescription Glasses

Dental: Major Services (Root canal, oral surgery, crowns, bridges, dentures)

$15 Copay: Name Brand Prescription Drugs

Outpatient Hospital Services (unless hospitalized)

POPULATION 2 (Unborn)/POPULATION 3 (MCAP)/POPULATION 4 (MCAIP) Not applicable

8.2.4.

Other:

8.2-DS

Supplemental Dental (CHIPRA # 7, SHO # #09-012 issued October 7, 2009) For children enrolled in the dental-only supplemental coverage, describe the amount of cost-sharing, specifying any sliding scale based on income. Also describe how the State will track that the cost sharing does not exceed 5 percent of gross family income. The 5 percent of income calculation shall include all cost-sharing for health insurance and dental insurance. (Section 2103(e)(1)(A)) (42 CFR 457.505(a), 457.510(b), and (c), 457.515(a) and (c), and 457.560(a)) Please update Sections 1.1-DS, 4.1-DS, 4.2-DS, 6.2-DS, and 9.10 when electing this option.

8.2.1-DS Premiums:

8.2.2-DS Deductibles:

8.2.3-DS Coinsurance or copayments:

8.2.4-DS 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)(A)) (42CFR 457.505(b))

CA RESPONSE:

The public has been notified of cost-sharing requirements in the application, and enrollment materials and program regulations. If there is a change in the enrollee’s contribution, the program plan will provide notification in writing. Enrollee copays are also listed in plan disclosure documents, such as Evidence of Coverage (EOC) documents provided to each family. Income Guidelines and cost sharing is also available on DHCS’ website. Agencies and individuals who help families with their application will also be familiar with the program’s cost-sharing requirements and be able to communicate them to families when discussing the program.