Common use of Hypothetical Clause in Contracts

Hypothetical. (member months and expenditures for these children are only reported if XXI funds are exhausted) CommonHealth The CommonHealth program was in existence prior to the separate XXI Children’s Health Insurance Program and was not affected by the maintenance of effort date. The CommonHealth program is contained in the separate XXI state plan and as authorized under this demonstration. Certain children derive eligibility from both the authority granted under this demonstration and via the separate XXI program, but expenditures are OVERVIEW OF CHILDREN’S ELIGIBLITY IN MASSHEALTH Children Aged 1 through 18 and Disabled Above 300% Any Yes XXI via demonstratio n authority only CommonHealth Hypothetical CommonHealt h/ Premium Assistance With wraparound to OVERVIEW OF CHILDREN’S ELIGIBLITY IN MASSHEALTH CommonHealth Children Aged 19 and 20 Non-disabled 0 through 133% Any Yes XIX via Medicaid state plan Base Childless Benchmark 1 Medicaid Expansion Children Ages 19 and 20: Any Yes XIX via Medicaid state plan 1902(r)(2) Children Without waiver Standard Children Aged 19 and 20 and 0 through 150% Any Yes XIX via Medicaid state plan Base Disabled Without Waiver Standard ATTACHMENT B COST SHARING Cost-sharing imposed upon individuals enrolled in the demonstration varies across coverage types and by FPL. However, in general, no co-payments are charged for any benefits rendered to individuals under age 21 or pregnant women. Additionally, no premiums are charged to any individual enrolled in the demonstration whose gross income is less than 150 percent of the FPL. In the event a family group contains at least two members who are eligible for different coverage types and who would otherwise be assessed two different premiums, the family shall be assessed only the highest applicable premium. Family group will be determined using MassHealth rules for the purposes of assessing premiums as described in section IV of the STC. Demonstration Program Premiums (only for persons with family income above 150 percent of the FPL) Co-payments MassHealth Standard/Standard ABP $0 All co-payments and co-payment caps are specified in the Medicaid state plan. MassHealth CarePlus $0 MassHealth Standard co-payments apply. MassHealth Breast and Cervical Cancer Treatment Program $15-$72 depending on income MassHealth Standard co-payments apply. MassHealth CommonHealth $15 and above depending on income and family group size MassHealth Standard co-payments apply. CommonHealth Children through 300% FPL Children with income above 300% FPL adhere to the regular CommonHealth schedule $12-$84 depending on income and family group size MassHealth Standard co-payments apply. MassHealth Family Assistance: HIV/AIDS $15-$35 depending on income MassHealth Standard co-payments apply. MassHealth Family Assistance: Premium Assistance $12 per child, $36 max per family group Member is responsible for all co-payments required under private insurance with a cost sharing limit of 5 percent of family income ATTACHMENT B COST SHARING MassHealth Family Assistance: Direct Coverage $12 per child, $36 max per family group Children only-no copayments. Above 150 to 160 $15 Above 160 to 170 $20 Above 170 to 180 $25 Above 180 to 190 $30 Above 190 to 200 $35 Above 200 to 210 $40 Above 210 to 220 $48 Above 220 to 230 $56 Above 230 to 240 $64 Above 240 to 250 $72 Above 150% FPL—start at $15 Add $5 for each additional 10% FPL until 200% FPL $15 $35 Above 200% FPL—start at $40 Add $8 for each additional 10% FPL until 400% FPL $40 $192 Above 400% FPL—start at $202 Add $10 for each additional 10% FPL until 600% FPL $202 $392 Above 600% FPL—start at $404 Add $12 for each additional 10% FPL until 800% FPL $404 $632 Above 800% FPL—start at $646 Add $14 for each additional 10% FPL until 1000% FPL $646 $912 Above 1000% FPL—start at $928 Add $16 for each additional 10% FPL $928 greater *A lower premium is required of CommonHealth members who have access to other health insurance per the schedule below. ATTACHMENT B COST SHARING Above 150% to 200% 60% of full premium per listed premium costs above Above 200% to 400% 65% per above Above 400% to 600% 70% per above Above 600% to 800% 75% per above Above 800% to 1000% 80% per above Above 1000% 85% per above Small Business Employee Premium Assistance* provides premium assistance to certain employees who work for a small employer Above 150% to 200% $40.00 $80.00 Above 200% to 250% $78.00 $156.00 Above 250% to 300% $118.00 $236.00 * Premium requirements for individuals participating in the Small Business Employee Premium Assistance program are tied to the state affordability schedule, as reflected in the minimum premium requirement for individuals enrolled in QHP Wrap coverage through the Health Connector. The premium amounts listed in this table reflect the 2013 state affordability schedule and are subject to change without any amendment to the demonstration. ATTACHMENT C