DEPARTMENT OF HEALTH & HUMAN SERVICES 
Centers for Medicare & Medicaid Services 
7500 Security Boulevard, Mail Stop S2-26-12 
Baltimore, Maryland   21244-1850 
 
Center for Medicaid and State Operations 
SHO #09-012 
                    CHIPRA # 7 
October 7, 2009 
 
                   RE: Dental Coverage in CHIP 
 
Dear State Health Official:           
  
The Childrens Health Insurance Program Reauthorization Act of 2009 (CHIPRA), 
Public Law 111-3, reauthorizes the Childrens Health Insurance Program (CHIP) under 
title XXI of the Social Security Act (the Act).  CHIPRA ensures that States are able to 
continue their existing CHIP programs and provides funding to expand health insurance 
coverage to additional low-income uninsured children including children already eligible 
for CHIP or Medicaid but not enrolled.  The purpose of this letter is to provide general 
guidance on some of the provisions in section 501 of CHIPRA, including the dental 
benefit provisions and the State option to provide dental-only supplemental coverage, 
pending the issuance of regulations.   
  
Required Dental Services 
 
Section 2103(c)(5) of the Act, as added by section 501 of CHIPRA, requires that child 
health assistance provided to a targeted low-income child shall include coverage of dental 
services necessary to prevent disease and promote oral health, restore oral structures to 
health and function, and treat emergency conditions.  This requirement applies to all 
child health assistance coverage described in section 2103 and is effective October 1, 
2009.   
 
Medicaid Expansions 
States that provide title XXI coverage to children through a Medicaid expansion program 
are required to provide Early and Periodic Screening, Diagnostic and Treatment (EPSDT) 
services, as defined in section 1905(r) of the Act.  The dental services provided under a 
Medicaid expansion program through EPSDT will be considered to meet the 
requirements of this provision.   
 
Separate CHIP Programs 
States that provide coverage in a separate CHIP program may choose between two 
methods of providing the dental services as required by section 2103(c)(5) of the Act.  
The State may define the services in the dental benefit package and demonstrate that the 
package includes all of the services required by the statute.  In so doing, the State should 
specify the periodicity schedule with which preventative and restorative services, such as 
cleanings and fillings, would be provided, as well as whether these services are sufficient  Page - 2  State Health Official  
to prevent further disease, as required by section 2103(c)(5).  This applies to State-
defined benefit packages and dental benchmark packages as described below. 
 
Alternatively, the State may provide a dental benefit package that is equivalent to one of 
the three dental benchmark packages described in the CHIPRA statute.  Under the statute, 
there is no option in new section 2103(c)(5) of the Act for proving actuarial equivalence 
or modifying the benefit package.  States may, however, cover benefits in addition to the 
dental benchmark plan consistent with the standards in section 2103(c)(5). 
 
In order to fully describe a State dental benefit package under a separate CHIP program, 
and ensure that the benefits are sufficient to meet the statutory requirements, a State 
should describe both the types of covered benefits and the covered amount or duration of 
those benefits.  The amount or duration should also be expressed through identification of 
the periodicity schedule that the State will use in its program.  The periodicity schedule 
sets the frequency by which certain services should be provided and will be covered.  We 
encourage States to rely on nationally recognized standards, including Medicaid dental 
periodicity guidelines used for children under EPSDT or the guidelines from the 
American Academy of Pediatric Dentistry (AAPD).  The link to AAPDs periodicity 
guidelines can be found at:  
http://www.aapd.org/media/Policies_Guidelines/G_Periodicity.pdf. 
 
State-Defined Dental Benefit Package 
 
All States currently include some level of diagnostic and preventive dental services in 
their CHIP program.  Under new section 2103(c)(5) of the Act, the dental benefit package 
must include coverage of dental services necessary to prevent disease and promote oral 
health, restore oral structures to health and function, and treat emergency conditions.  
States are not required to meet the EPSDT level of services to provide all medically 
necessary services under their CHIP plans.  However, to be consistent with this dental 
benefit package requirement, a State-defined dental package must include coverage for 
dental services in each of the defined categories.   
 
Dental Service Categories 
The following categories of services identified by reference to the American Dental 
Associations Current Dental Terminology (CDT) Code of Dental Procedures and 
Nomenclature must be covered in the CHIP dental benefit package.  Coverage of dental 
services within these categories must be consistent with a dental periodicity schedule 
adopted by the State and be medically necessary.   
1.  Diagnostic (i.e., clinical exams, x-rays) (CDT codes: D0100-D0999) (must follow 
periodicity schedule) 
2.  Preventive  (i.e., dental prophylaxis, topical fluoride treatments) (CDT codes: 
D1000-D1999) (must follow periodicity schedule) 
3.  Restorative  (i.e., fillings, crowns) (CDT codes: D2000-D2999)  
4.  Endodontic (i.e., root canals) (CDT codes: D3000-D3999)  
5.  Periodontic (treatment of gum disease) (CDT codes: D4000-D4999)    Page - 3  State Health Official  
6.  Prosthodontic (dentures) (CDT codes: D5000-D5899, D5900-D5999, and D6200-
D6999) 
7.  Oral and Maxillofacial Surgery (i.e., extractions of teeth and other oral surgical 
procedures) (CDT codes: D7000-D7999)  
8.  Orthodontics (i.e., braces) (CDT codes: D8000-D8999)  
9.  Emergency Dental Services  
 
States are not required to provide all services within each dental category, however, a 
State must be able to show that it is providing coverage consistent with the requirements 
of section 2103(c)(5).  For example, under oral and maxillofacial surgery a State may 
elect to cover extractions (D7140) and extractions of impacted teeth (D7220-7241), but 
may choose not to cover tooth transplantation (D7272).  States may not impose a limit on 
dental services that would be inconsistent with the statutory requirement to include 
coverage necessary to prevent disease, promote and restore oral health, and treat 
emergency conditions.  Any such limits should comply with the States chosen 
periodicity schedule.   For example, a State may not limit a child to one cleaning per year 
if the periodicity schedule requires one cleaning every 6 months.  However, a State may 
limit any service that is beyond the scope of coverage required by section 2103(c)(5), 
specifically those services that are cosmetic or not medical in nature. 
 
Dental Benchmark Plan  
 
A State may elect to meet the dental coverage requirements by providing dental coverage 
that is equal to one of the three benchmark dental benefit packages described below:   
 
  Federal Employee Health Benefits Program Childrens Dental Coverage States 
may offer a dental benefit plan equal to those described at 5 U.S.C. 89A, which 
describes the requirements for supplemental dental coverage available to a 
Federal employee and that is selected most often by employees seeking dependent 
coverage in either of the previous two plan years.  States must attach a copy of the 
plan benefits and the applicable CDT codes to their State plan amendment (SPA) 
request.  For example, the supplemental MetLife dental plan is currently the plan 
most frequently selected by Federal employees seeking dependent coverage in 
either of the previous two plan years (2007-2009).  MetLifes benefit information 
is provided in their brochure and can be accessed through the following link:  
http://www.opm.gov/insure/health/planinfo/2009/brochures/MetLife.pdf   Should 
a different plan be chosen more frequently in the future, CMS will inform States 
of the change and provide plan benefit information. 
 
  State Employee Dependent Dental CoverageStates may offer the dental 
benefits plan that is generally available to State employees in the State involved 
and has been selected most frequently by employees seeking dependent coverage 
in either of the previous two plan years.  States must specify which plan in their 
State meets these criteria and attach a copy of the benefit package, including 
applicable CDT codes, when they submit their CHIP SPA to implement this 
provision.    Page - 4  State Health Official  
  Coverage Offered Through Commercial Dental PlanStates may use the dental 
benefit plan that has the largest insured commercial, non-Medicaid enrollment of 
dependent covered lives of such plans that is offered in the State involved.  States 
choosing this benchmark must specify which plan in their State meets these 
criteria and attach a copy of the benefit package, including applicable CDT codes, 
when they submit their SPA to implement this provision. 
 
States that select one of the approaches described above must provide a benefit package 
that is equal to the dental services offered through the selected dental benchmark.  The 
dental benefit package provided by the State must be equal to the scope, level, and type 
of services in the selected dental benchmark package in order to use this option.  As 
discussed below, cost sharing must fall within the parameters required for CHIP.  Any 
modifications to benefits render it no longer equal to the benchmark plan, and the State 
will have to revert to showing that their plan meets the requirements of a State-defined 
dental benefit package as previously discussed.  As noted above, States may cover 
benefits in addition to the dental benchmark plan consistent with the standards in 
2103(c)(5) of the Act. 
 
Compliance with Current Regulations 
As noted above, cost sharing for dental services must comply with Federal regulations at 
42 CFR 457.520(b)(5), which requires that States not impose co-payments, deductibles, 
coinsurance, or other cost sharing with respect to routine preventive and diagnostic 
dental services (such as oral examinations, prophylaxis and topical fluoride applications, 
sealants, and x-rays) as described in the most recent guidelines issued by the AAPD, 
regardless of the cost-sharing requirements applied in the benchmark plan.  States must 
also comply with 42 CFR 457.560(a) that requires that the calculation of the five percent 
of family income limit on cost sharing must be cumulativeincluding cost sharing for 
physical health and oral health if applicable. 
 
Dental-only Supplemental Coverage 
 
CHIPRA also added section 2110(b)(5), an important new provision which provides 
States with the option to provide dental-only supplemental coverage to children who have 
health insurance coverage through an employer but are uninsured or underinsured with 
respect to dental coverage.  Such children are eligible to enroll in the dental-only 
supplemental coverage even if their group health plan or other health insurance coverage 
includes some dental benefits.  This option is available to States that have a separate 
CHIP program. 
 
The dental-only supplemental coverage would ensure that eligible children have overall 
dental coverage consistent with the State-defined dental package or is equal to the dental 
benefit plan provided to children who are eligible for the entire CHIP benefit package.  
The supplemental coverage will in essence make an eligible child whole for purposes 
of having dental services available to them that are not otherwise available under their 
current health insurance coverage.  The supplemental coverage applies to children who 
have dental services covered by a group health plan or other health insurance coverage  Page - 5  State Health Official  
only to the extent necessary to ensure that aggregate dental coverage would be the same 
as the dental coverage for other CHIP children.  Consistent with section 2105(c)(6)(A) of 
the Act, the CHIP supplemental dental coverage would pay secondary to the childs 
private group health plan or other health insurance coverage.   
 
In order to choose this option, States must comply with all other requirements of the Act 
regarding cost sharing (including 42 CFR 457.520(b)(5) and 457.560(a) as previously 
described) and the approved income eligibility level.  CHIP regulations stipulate a cap of 
5 percent of family income on total cost sharing for all health services.  In addition, the 
State may not use a waiting list or numerical limitation in enrollment for the CHIP 
program (not just for dental coverage), and may not provide more favorable treatment to 
children eligible for the supplemental dental benefit under this option than provided to 
other enrollees under the State child health plan.  
 
CMS looks forward to its continued work with States on the implementation and 
oversight of the CHIP program in ensuring that all eligible children have access to the 
dental coverage they need.  Draft SPA template pages to implement these options are 
enclosed.  These pages would be an Addendum to the CHIP State child health plan, 
describing dental coverage under the plan.  CMS is in the process of obtaining the 
required Office of Management and Budget (OMB) clearance for the SPA templates.  
Given that States may need considerable time to complete these templates, CMS is 
sharing, in draft, the SPA template under the guidelines of the Paperwork Reduction Act 
(PRA) currently under OMB review.  Until the PRA process is completed, States are not 
obligated to use the recommended template.  After CMS obtains the necessary PRA 
clearance number from OMB, States will be required to complete the SPA template.   
  
If you have any questions on the guidance provided in this letter, please send an email to 
CMSOCHIPRAQuestions@cms.hhs.gov  or contact Ms. Maria Reed, Deputy Director, 
Family and Childrens Health Programs Group, at 410-786-5647.  We look forward to 
working with States to implement these important provisions. 
  
                                                     Sincerely,   
                                                                
                  /s/   
 
                                                    Cindy Mann  
                                                    Director  
 
 
Enclosures 
 
cc:  
CMS Regional Administrators 
 
CMS Associate Regional Administrators 
Division of Medicaid and Childrens Health  Page - 6  State Health Official  
Ann C. Kohler                                                   
NASMD Executive Director 
American Public Human Services Association 
  
Joy Wilson 
Director, Health Committee 
National Conference of State Legislatures 
  
Matt Salo 
Director of Health Legislation 
National Governors Association 
  
Debra Miller 
Director for Health Policy 
Council of State Governments 
  
Christine Evans, M.H.P. 
Director, Government Relations 
Association of State and Territorial Health Officials 
 
Alan R. Weil, J.D., M.P.P. 
Executive Director 
National Academy for State Health Policy 
 
John S. Findley, D.D.S 
President 
American Dental Association 
 
Robert Birdwell, D.D.S. 
Chair 
Medicaid and CHIP Dental Directors Association 
 
William C. Berlocher, D.D.S., M.A. 
President 
American Academy of Pediatric Dentistry 
    Page - 7  State Health Official  
 
Enclosure 
Questions and Answers Regarding CHIP Dental Coverage 
Question 1:  Will States be required to submit a SPA in order to comply with the new CHIPRA 
dental requirements? 
Answer:  Yes.  CMS is anticipating that States will be able to submit a single compliance SPA for all 
CHIPRA provisions, including the dental requirements once the final regulation is published.   
Question 2:  Will States be required to provide dental benchmark packages?   
Answer:   No.  States may choose to provide a State-defined dental benefit package or choose to 
provide a benefit equal to one of the three benchmark plans as outlined in the CHIPRA legislation.   
STATE-DEFINED DENTAL BENEFIT PACKAGE 
Question 3:  If a State elects not to offer dental coverage that is equal to one of the benchmark 
plans, what standards will CMS use in determining whether or not the dental coverage 
provided under a separate program meets the requirements of the new section 2103(c)(5)(A) 
which requires generally that States provide coverage of dental services necessary to prevent 
disease and promote oral health, restore oral structures to health and function and treat 
emergency conditions.   
Answer:  The State-defined dental benefit package must cover certain specified categories of benefits 
to assure that the benefit includes the statutorily-required dental services necessary to prevent 
disease and promote oral health, restore oral structures to health and function and treat emergency 
conditions.  These services are represented by the range of Current Dental Terminology (CDT) 
codes listed in the SPA template.  CMS will not ask States to list every individual code that will be 
covered; however, States will have to provide an assurance in their State plan that services within 
those codes will be available, to the extent necessary, to provide the required range of services.    
Question 4:  What types of services are considered to be amongst those that restore oral 
structures to health and function under mandatory dental benefits coverage?   
Answer:  The CDT codes that represent restorative, endodontic, periodontic, prosthodontic, oral and 
maxillofacial surgery, and orthodontic services could be considered to restore oral structures to health 
and function.  These services could include, but not be limited to, root canals, treatment of gum 
disease, dentures, tooth extractions, and braces. 
Question 5:  Will orthodontia be required?   
Answer:  Orthodontia is required to the extent necessary to prevent disease and promote oral health, 
[and] restore oral structures to health and function.  States are not required to pay for orthodontia 
that they determine is not medically necessary, such as services for cosmetic reasons.  
    Page - 8  State Health Official  
 
Question 6: The definition in the CHIPRA legislation indicates that coverage includes dental 
services necessary to prevent disease and promote oral health, restore oral structures to health 
and function and treat emergency conditions.  Please confirm that this definition is not the 
same as dental services under EPSDT and that we do not have to cover all medically necessary 
services.   
Answer:  There is no requirement that the dental benefits in CHIPRA must meet the EPSDT 
requirements of 1905(r).  States may design their benefit package consistent with the statutory 
definition. 
BENCHMARK PLANS 
Question 7: One of the benchmark plans is the State employees plan.  Many have orthodontic 
coverage as part of the package but it has a maximum allowable limit.  If orthodontics is not 
necessary, can a State limit or change their benchmark coverage to exclude orthodontics?   
Answer:  Although a State can supplement the dental benefit package, if it modifies the benchmark 
(other than by supplementing), the State is no longer considered to be providing a benchmark plan.  
Such packages will be considered a State-defined benefit package.  A State that elects one of the 
three possible benchmark plans may not change the coverage package it offers.  States are not 
required to cover dental services that are determined not to be medically necessary.  
Question 8: Will CMS allow a State to submit a dental benchmark-equivalent (actuarially 
equivalent) plan?   
Answer:  There is no authority in CHIPRA for CMS to accept a dental benchmark-equivalent plan.  If 
a State chooses not to provide a plan that is equal to one of the benchmark plans, it should offer a 
State-defined benefit plan that includes dental services necessary to prevent disease and promote 
oral health, restore oral structures to health and functioning and treat emerging conditions. 
SUPPLEMENTAL DENTAL COVERAGE 
Question 9: Can children of State employees qualify for supplemental dental coverage 
(assuming that the State doesnt contribute to the cost of health benefits coverage at all)?   
Answer:  Only States with separate CHIP programs will have the option to provide supplemental 
dental coverage to targeted low-income children who would be eligible for CHIP but for the fact that 
they have insurance.  Children of State employees who are eligible for State health benefits coverage 
are not generally within the definition of a targeted low-income child.  There is an exception under 
CHIP regulations at 42 CFR 457.310(c)(1) when the State makes no more than a nominal payment 
for the cost of coverage ($10 or less per month).  To the extent that this exception is met, children of 
State employees who have insurance could qualify for supplemental dental coverage through CHIP.  
Adult State employees (or other adults) cannot qualify for supplemental dental coverage. 
States should be aware that they may not only provide children of State employees with the 
supplemental dental coverage.  Should a State choose this option, they must cover all targeted low-
income children in the state who meet the criteria.    Page - 9  State Health Official  
 
Question 10:  Does the no waiting list prerequisite for the offering of a supplemental dental 
coverage apply to the States CHIP program, to the States CHIP dental program or both?   
Answer:  A State may not offer supplemental dental coverage if it has implemented a waiting list for 
their CHIP medical or their CHIP dental program.   
Question 11:  Must a child have absolutely no dental coverage in their private or employee-
sponsored insurance plan in order to qualify for a supplemental dental plan? 
Answer:  No.  Supplemental dental coverage can be provided through the new CHIP option to 
children in order to supplement limited dental coverage in their private insurance plan.   
COST SHARING  
Question 12:  On what are the premiums for supplemental dental coverage based?  Can they be 
different from the combined medical/dental premiums?   
Answer:  States can have separate premiums for medical and dental coverage.  As in cost sharing for 
medical care, States will have to develop a methodology for establishing cost sharing for dental care 
and submit it to CMS for approval.  States will also need to inform the families that the combined 
cost sharing of CHIP dental and medical coverage may not exceed 5 percent of family income and 
how the family should work with the State to track their cost sharing so they do not exceed the limit.  
CMS is available to provide technical assistance if needed. 
Question 13:    Is cost sharing supposed to be at the level required in the benchmark or at the 
CHIP level?   
Answer:  Cost sharing for CHIP dental benefits is governed by the CHIP rules, not by the rules 
associated with the benchmark plan.  As with the broader CHIP benefit package, States are permitted 
to establish cost-sharing requirements, as long as the combined cost sharing for CHIP dental and 
medical coverage does not exceed 5 percent of the familys income as specified in 42 CFR 457.565 
and receives approval for a State plan amendment to implement such cost sharing.     
   
 
    Page - 10  State Health Official  
 
Enclosure 
Draft SPA Template:  Addendum on Dental Benefits Under Title XXI 
 
Section 6.  Coverage Requirements for Childrens Health Insurance (Section 2103) 
   
 
      6.2.-D The State will provide dental coverage to children through one of the following.  
Dental services provided to children eligible for dental-only supplemental 
services must receive the same dental services as provided to otherwise eligible 
CHIP children (Section 2103(a)(5)):  
   
6.2.1.-D    State Specific Dental Benefit Package.  The State assures dental services 
 
represented by the following categories of common dental terminology (CDT) 
codes are included in the dental benefits: 
1.  Diagnostic (i.e., clinical exams, x-rays) (CDT codes: D0100-D0999) (must 
follow periodicity schedule) 
2.  Preventive  (i.e., dental prophylaxis, topical fluoride treatments, sealants) 
(CDT codes: D1000-D1999) (must follow periodicity schedule) 
3.  Restorative  (i.e., fillings, crowns) (CDT codes: D2000-D2999)  
4.  Endodontic (i.e., root canals) (CDT codes: D3000-D3999)  
5.  Periodontic (treatment of gum disease) (CDT codes: D4000-D4999)   
6.  Prosthodontic (dentures) (CDT codes: D5000-D5899, D5900-D5999, and 
D6200-D6999) 
7.  Oral and Maxillofacial Surgery (i.e., extractions of teeth and other oral 
surgical procedures) (CDT codes: D7000-D7999)  
8.  Orthodontics (i.e., braces) (CDT codes: D8000-D8999)  
9.  Emergency Dental Services  
 
6.2.1.2-D  Periodicity Schedule.  The State has adopted the following periodicity schedule:  
  State-developed Medicaid-specific  
 
American Academy of Pediatric Dentistry  
 
Other Nationally recognized periodicity schedule 
 
Other (description attached)  
   
  
6.2.2-D  Benchmark coverage; (Section 2103(c)(5), 42 CFR 457.410, and 42 CFR 457.420)   
 
 
6.2.2.1.-D    FEHBP-equivalent coverage; (Section 2103(c)(5)(C)(i)) (If checked, attach copy 
of the dental supplemental plan benefits description and the applicable 
CDT codes.  If the State chooses to provide supplemental services, please 
also attach a description of the services and applicable CDT codes) 
 
6.2.2.2-D    State employee coverage; (Section 2103(c)(5)(C)(ii))  (If checked, identify the 
plan and attach a copy of the benefits description and the applicable CDT 
codes. If the State chooses to provide supplemental services, please also 
attach a description of the services and applicable CDT codes) 
  
  Page - 11  State Health Official  
 
6.2.2.3.-D    HMO with largest insured commercial enrollment (Section 2103(c)(5)(C)(iii))  (If 
checked, identify the plan and attach a copy of the benefits description 
and the applicable CDT codes.  If the State chooses to provide 
supplemental services, please also attach a description of the services and 
applicable CDT codes) 
 
Section 10.  Annual Reports and Evaluations 
Section 10.3-D     Specify that the State agrees to submit yearly the approved dental  benefit 
 
package and to submit quarterly the required information on dental providers in the State to 
the Health Resources and Services Administration for posting on the Insure Kids Now! 
Website.   
 
 
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 (30 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.  
 
 
 
 
Please note: this form has not been approved by OMB pursuant to the PRA and States are not obligated to use it.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  Page - 12  State Health Official  
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, 6.2DS, 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 States 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 States policies governing enrollment caps and waiting lists (if any). (Section 
2106(b)(7)) (42 CFR 457.305(b))   
  Page - 13  State Health Official  
    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 Childrens 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-XXXX.  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.  
 
 
Please note: this form has not been approved by OMB pursuant to the PRA and States are not obligated to use it.