Form CMS-100289 Addendum on Supplemental Dental Benefits Under Title XXI

OMB Approval #: 0938-1075

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 a employer. The State’s CHIP plan income eligibility level is at least the highest income eligibility standard under its approved State child health plan (or under a waiver) 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.

CMS-10289 (11/2012)

OMB Approval #: 0938-1075

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.

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 0938-1075. The time required to complete this information collection is estimated to average ( 20 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.

CMS-10289 (11/2012)