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CHIP Cost Sharing

The following table includes maximum CHIP cost sharing amounts. If the MCO and the provider have negotiated a lesser amount for a benefit than the identified co-payment, then the co-payment must be capped at the lesser amount.

The following examples are provided for illustrative purposes only.

Example 1: The MCO and a provider have negotiated a $23.00 rate for an office visit. If the Member’s family income is 185% FPL, the co-payment will be capped at $23.00 for services provided on or after March 1, 2012.

Example 2: The MCO and a pharmacy provider have negotiated a $9.30 total reimbursement (dispensing fee + product cost) for a prescription of 800mg of Ibuprofen, 50 tablets. If the Member’s family income is 185% FPL, the co-payment will be capped at $9.30 for that prescription provided on or after March 1, 2012.

Co-payments do not apply, at any income level, to:

1. well-baby and well-child care services, as defined by 42 C.F.R. §457.520;
2. preventative services;
3. pregnancy-related services;
4. Native Americans or Alaskan Natives;
5. Members of the CHIP Perinatal subprogram (Perinates (unborn children) and Perinate Newborns). An MCO is not responsible for payment of unauthorized non-emergency services provided to a CHIP Member by an out-of-network provider. In such circumstances, the CHIP Member will be responsible for all costs.

An MCO is not responsible for payment of unauthorized non-emergency services provided to a CHIP Member by an out-of-network provider. In such circumstances, the CHIP Member will be responsible for all costs.

                CHIP Cost-Sharing


Effective January 1, 2014
Enrollment Fees (for 12-month enrollment period):
Charge
At or below 151% of FPL*
$0
Above 151% up to and including 186% of FPL $35
Above 186% up to and including 201% of FPL $50
Co-Pays (per visit)
At or below 100% of FPL Charge
Office Visit $3
Non-Emergency ER
$3
Generic Drug $0
Brand Drug $3
Facility Co-pay, Inpatient
$15
Cost-sharing Cap
5% (of family’s
income)***
Above 100% up to and including 151% FPL Charge
Office Visit $5
Non-Emergency ER
$5
Generic Drug $0
Brand Drug $5
Facility Co-pay, Inpatient (per admission)
$35
Cost-sharing Cap
5% (of family’s
income)***
Above 151% up to and including 186% FPL
Charge
Office Visit $20
Non-Emergency ER
$75
Generic Drug $10
Brand Drug $35
Facility Co-pay, Inpatient (per admission)
$75
Cost-sharing Cap
5% (of family’s
income)***
Above 186% up to and including 201% FPL Charge 
Office Visit $25
Non-Emergency ER $75
Generic Drug $10
Brand Drug $35
Facility Co-pay, Inpatient (per admission) $125
Cost-sharing Cap 5% (of family's income)

*The federal poverty level (FPL) refers to income guidelines established annually by the federal government.
** Effective March 1, 2012, CHIP members will be required to pay an office visit copayment for each non-preventive dental visit.
*** Per 12-month term of coverage.

Corporate Office

12238 Silicon Drive, Suite 100

San Antonio, TX 78249

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Community Office

1410 Guadalupe Street Ste. 222

San Antonio, TX 78207

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Monday - Friday

8:30am - 5:00pm

Member Services

210-358-6070 Commercial
210-358-6060 Star Medicaid
210-358-6403 STAR Kids
1-855-607-7827 STAR Kids Toll-Free
210-358-6300 Chip/Chip Perinatal
210-358-6080 TDD Local
1-800-390-1175 TDD Toll-Free
210-358-6400 HIE
888-512-2347 HIE Toll-Free

Behavorial Health

210-358-6100 Commercial

Behavorial Health & Substance Abuse

1-877-221-2226 Crisis Hotline 24/7 CHIP and Medicaid

Nurse Hotline

210-227-2347
Toll-Free 1-800-434-2347