Form CMS-10289 Supplemental Dental Benefits Under Title XXI

Draft SPA Template

Addendum on Supplemental Dental Benefits Under Title XXI

Section 1. General Description and Purpose of the State Child Health Plans and State Child Health Plan Requirements (Section 2101)

1.1-DS  The State will provide dental-only supplemental coverage. Only States operating a separate SCHIP program are eligible for this option. States choosing this option must also complete sections 1.4-DS, 4.1-DS, 4.2-DS, 4.3.1, 6.2–DS, 8.2-DS, and 9.10.1-DS of this SPA template.

1.4-DS For dental-only supplemental coverage, please provide the effective (date costs begin to be incurred) and implementation (date services begin to be provided) dates for this plan or plan amendment (42 CFR 457.65):

Effective date:

Implementation date:

Section 4. Eligibility Standards and Methodology. (Section 2102(b))

4.1-DS.        A child who is eligible to enroll in dental-only supplemental coverage, effective January 1, 2009. Eligibility is limited to only targeted low-income children who are otherwise eligible for CHIP but for the fact that they are enrolled in a group health plan or health insurance offered through an employer. The State’s SCHIP plan income eligibility level must be at least 200 percent of the FPL as of January 1, 2009. All who meet the eligibility standards and apply for dental-only supplemental coverage shall be provided benefits. States choosing this option must report these children separately in SEDS.

4.2-DS For dental-only supplemental coverage, the State assures that it has made the following findings with respect to the eligibility standards in its plan: (Section 2102)(b)(1)(B)) (42CFR 457.320(b))

4.2.1-DS  These standards do not discriminate on the basis of diagnosis.

4.2.2-DS  Within a defined group of covered targeted low-income children, these standards do not cover children of higher income families without covering children with a lower family income.

4.2.3-DS  These standards do not deny eligibility based on a child having a pre-existing medical condition.

4.3.1 Describe the State’s policies governing enrollment caps and waiting lists (if any). (Section 2106(b)(7)) (42 CFR 457.305(b))

 Check here if this section does not apply to your State. A State providing dental-only supplemental coverage may not have a waiting list or limit eligibility in any way.

Section 6. Coverage Requirements for Children’s Health Insurance (Section 2103)

6.2.-DS  The State will provide dental coverage to children eligible for dental-only supplemental services. Children eligible for this option must receive the same dental services as provided to otherwise eligible CHIP children (Section 2103(a)(5):

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

8.2- DS. For children enrolled in the dental-only supplemental coverage, please describe the amount of cost-sharing, specifying any sliding scale based on income. Please 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))

8.2.1.-D Premiums:

8.2.2.-D Deductibles:

8.2.3.-D Coinsurance or copayments:

8.2.4.-D Other:

Section 9. Strategic Objectives and Performance Goals and Plan Administration

9.10.1-DS Please include a separate budget line to indicate the cost of providing dental-only supplemental coverage.

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