Form CMS-10300 Additional State Plan Option for Providing Premium Assis

Attachment 4

Additional State Plan Option for Providing Premium Assistance

CHIP Medicaid Template

29d

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State: __________________ Medical Assistance Program

_________________________________________________________________________

Citation Condition or Requirement

_____________________________________________________________________________

1906 of the Act (c) Premiums, Deductibles, Coinsurance and Other Cost Sharing Obligations

The Medicaid agency pays all premiums, deductibles, coinsurance and other cost sharing obligations for items and services covered under the State plan (subject to any nominal Medicaid copayment) for eligible individuals in employer-based cost-effective group health plans.

When coverage for eligible family members is not possible unless ineligible family members enroll, the Medicaid agency pays premiums for enrollment of other family members when cost effective. In addition, the eligible individual is entitled to services covered by the State plan which are not included in the group health plan. Guidelines for determining cost effectiveness are described in section 4.22(h).

1 906A of the Act (c)-1 Premiums, Deductibles, Coinsurance and Other Cost Sharing Obligations

The Medicaid agency pays all premiums, deductibles, coinsurance and other cost sharing obligations for items and services covered under the State plan, as specified in the qualified employer-sponsored coverage, without regard to limitations specified in section 1916 or section 1916A of the Act, for eligible individuals under age 19 who have access to and elect to enroll in such coverage. The eligible individual is entitled to services covered by the State plan which are not included in the employer-sponsored coverage. For qualified employer-sponsored coverage, the employer must contribute at least 40 percent of the premium cost.

When coverage for eligible family members under age 19 is not possible unless an ineligible parent enrolls, the Medicaid agency pays premiums for enrollment of the ineligible parent, and, at the parent’s option, other ineligible family members. The agency also pays deductibles, coinsurance and other cost sharing obligations for items and services covered under the State plan for the ineligible parent.

1 902(a)(10)(F) of (d) The Medicaid agency pays premiums for individuals described in item 19 of Attachment 2.2-A.

the Act

TN No.: ______ Approval Date __________ Effective Date ___________

Supersedes TN No.______

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