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Guidance: The State should be able to demonstrate upon request its rationale and justification regarding these assurances. This section also addresses limitations on payments for certain expenditures and requirements for maintenance of effort.

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))

CA RESPONSE: Chapter 3 of California Statute 2011 (AB 97) assures that cost-sharing is consistent with Section 2103 of the Social Security Act.

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))

CA RESPONSE:

POPULATION 1 (CCHIP)

Copayments DHCS sets health benefit copayments from $5 to $15 for CCHIP. Copayments are not applicable in CCHIP for preventive services. In addition, DHCS has set a $250 annual maximum out-of-pocket so that no family is required to pay copayments after it has contributed $250 during a given year. Enrollees are encouraged to retain all of their copayment receipts and notify the health plan when $250 maximum has been reached. The CCHIP health plans also electronically track the number of enrollees who meet the annual maximum to ensure that no family’s copay goes over the annual maximum out-of-pocket contribution. However, the $250 limit does not apply to dental or vision coverage. California does not have copays for most dental services that children receive (preventive exams, cleanings, restorations, sealants, and fluoride treatments), and has lowered all other copays to a maximum of $5. Children who meet CCS conditions receive their services (orthodontics) from CCS without a copay. Therefore, California has determined that including dental services in the $250 maximum is not needed. Very few