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73 families will have to pay a copay at all for dental services and those that do will be for a specific condition (root canal) which should have limited utilization.

California rules are consistent with title XXI, which require that cost sharing not exceed an amount that is “nominal” under Medicaid law, with appropriate adjustment for inflation or other reasons as the Secretary determines to be reasonable.

Premiums CCHIP premiums are based on $21 per child per month, with a maximum of $63 per family per month, equaling annual premiums of $252 for one child, $504 for two children, and $756 for three children or more. Cost sharing requirements do not exceed those allowable under title XXI. Using 261 percent FPL as the baseline income, Table 1 below provides an analysis of the 5 percent cost sharing limit compared to the highest premium that is charged. Therefore, California provides assurances that the cost sharing requirements continue to be within the allowable limits established under title XXI and is highly unlikely the family will ever get close to the 5 percent limit.

Table 1: Aggregate Cost Sharing for Families Above 261 percent FPL up to and including 317 percent FPL under CCHIP Family Size Annual Income of a Single Parent Family @ 261% FPL +$1* 5% Ceiling Annual Premium Contribution ** Annual Premium + $250 Family Cap on Health Copays Number of Dental and Vision Visits for Non- Preventive Services Needed to Exceed 1 child $42,387 $2,119 $252 $502 101 2 children $53,297 $2,665 $504 $754 151 3 children $64,207 $3,210 $756 $1,006 202

*Dollar amounts are based on March, 1 2017 Federal Poverty Level **Does not include premium discounts for pre-payment. If included, it would reduce the premium amounts by 25 percent.