CMS-10300 Additional State Plan Option for Providing Premium Assis

Attachment 3

Additional State Plan Option for Providing Premium Assistance

CHIP SPA Template

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

1.4.-APA 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 6: Coverage Requirements for Children’s Health Insurance (Section 2103)

Section 6.4.3: Additional State Option for Providing Premium Assistance

A State may elect to offer a premium assistance subsidy for qualified employer sponsored coverage as defined in 2105(c)(10)(B) to all targeted low-income children who are eligible for child health assistance under the plan and have access to such coverage. No subsidy shall be provided to a targeted low-income child (or the child’s parent) unless the child voluntarily elects to receive such a subsidy. A state may not require such an election as a condition of receipt of child health assistance. (Section 2105(c)(10)). Does the State provide this option to targeted low-income children?

 Yes

 No

6.4.3.1: Qualified Employer Sponsored Coverage and Premium Assistance Subsidy

6.4.3.1.1.  Please provide an assurance that the qualified employer sponsored insurance meets the definition of qualified employer-sponsored coverage as defined in Section 2105(c)(10)(B), and that the premium assistance subsidy meets the definition of premium assistance subsidy as defined in 2105(c)(10)(C).

6.4.3.1.2. Please describe whether the State is providing the premium assistance subsidy as reimbursement to an employee or for out-of-pocket expenditures or directly to the employee’s employer.

6.4.3.2: Requirement to Provide Supplemental Coverage for Benefits and Cost Sharing Protections Provided under the State Child Health Plan.

6.4.3.2.1  Check here if the State ensure that group health plans or health insurance coverage offered through an employer has been certified by an actuary as health benefits coverage that is equivalent to the benefits coverage in a benchmark benefit package described in section 2103(b) or benchmark equivalent coverage that meets the requirements of section 2103(a)(2).

6.4.3.2.2  If the box above is not checked, please provide an assurance that the State is providing for each targeted low-income child enrolled in qualified employer sponsored coverage, supplemental coverage consisting of items or services that are not covered or are only partially covered, under the qualified employer sponsored coverage consistent with 2103(a) and cost sharing protections consistent with section 2103(e).

6.4.2.2.3. Please describe whether these benefits are being provided through the employer or by the State providing wrap around benefits.

6.4.3.3: Application of Waiting Period Imposed Under State Plan: States are required to apply the same waiting period to premium assistance as is applied to direct coverage children under their CHIP State plan as specified in 2105(c)(10)(F).

6.4.3.3.1  Please provide an assurance that the waiting period for children in premium assistance is the same as for those children in direct coverage.

6.4.3.4: Opt-Out and Outreach, Education and Enrollment Assistance

6.4.3.4.1. Please describe the State’s process for ensuring parents are permitted to disenroll their child from qualified employer sponsored coverage and enroll in CHIP effective on the first day of any month for which the child is eligible for such assistance and in a manner that ensures continuity of coverage for the child (2105(c)(10)(G)).

6.4.3.4.2. Please describe the State’s outreach, education and enrollment efforts related to premium assistance. How does the State inform families of the availability of premium assistance, and assist them in obtaining such subsidies? What are the specific significant resources the State intends to apply to educate employers about the availability of premium assistance subsidies under the State child health plan? (2102(c))

6.4.3.5: Purchasing Pool: A State may establish an employer-family premium assistance purchasing pool and may provide a premium assistance subsidy for enrollment in coverage made available through this pool (2105(c)(10)(I)). Does the State provide this option?

 Yes

 No

6.4.3.5.1. Please describe the plan to establish an employer-family premium assistance purchasing pool.

6.4.3.5.2  Please provide an assurance that employers who are eligible to participate: 1) have less than 250 employees, 2) have at least one employee who is a pregnant women eligible for CHIP or a member of a family that has at least one child eligible under the State’s CHIP plan.

6.4.3.5.3 Please provide an assurance that the State will not claim for any administrative expenditures attributable to the establishment or operation of such a pool except to the extent such payment would otherwise be permitted under this title.

6.4.3.6.: Notice of Availability of Premium Assistance: Please describe the procedures that assure that if a State provides premium assistance subsidies under this section, it must: 1) include information about premium assistance on the CHIP application or enrollment form, 2) provide as part of the application and enrollment process, information describing the availability of premium assistance and how to elect to obtain a subsidy, and 3) establish other procedures to ensure that parents are fully informed of the choices for child health assistance or through the receipt of premium assistance subsidies (2105(c)(10)(K)).

Section 9: Strategic Objectives and Performance Goals and Plan Administration (Section 2107)

9.9.-APA Describe the process used by the State to accomplish involvement of the public in the design and implementation of the plan and the method for ensuring ongoing public involvement. (Section 2107(c) and 42 CFR 457.120(a) and (b))

9.9.1 Describe the process used by the State to ensure interaction with Indian Tribes and organizations in the State on the development and implementation of the procedures required at 42 CFR section 457.125. (Section 2107(c) and 42 CFR 457.120(c))

9.10. Provide a 1-year projected budget. (Section 2107(d) and 42 CFR 457.140)

The budget must describe:

• Planned use of funds, including:

• Projected amount to be spent on health services;

• Projected amount to be spent on administrative costs, such as outreach, child health initiatives, and evaluation; and

• Assumptions on which the budget is based, including cost per child and expected enrollment.

• Projected sources of non-Federal plan expenditures, including any requirements for cost-sharing by enrollees.

States must include a separate budget line item to indicate the cost of providing coverage to premium assistance children.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-XXXX. The time required to complete this information collection is estimated to average 4 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

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