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 $20.00.

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.

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, including immunizations;

3. pregnancy-related services;

4. Native Americans or Alaskan Natives;

5. CHIP Perinatal Members (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.

Effective January 1, 2014
Enrollment Fees (for 12-month enrollment):
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 151% of FPLCharge
Office Visit$5
Non-Emergency ER$5
Generic Drug$0
Brand Drug$5
Facility Co-pay, Inpatient$35
Cost-sharing Cap5% (of family’s income)***
Above 151% up to and including 186% FPLCharge
Office Visit (non-preventative)$20
Non-Emergency ER$75
Generic Drug$10
Brand Drug$35
Facility Co-Pay, Inpatient (per admission)$75
Cost-sharing Cap5% (of family’s income)***
Above 186% up to and including 201% FPLCharge
Office Visit (non-preventative)$25
Non-Emergency ER$75
Generic Drug$10
Brand Drug$35
Facility Co-pay, Inpatient (per admission)$125
Cost-sharing Cap5% (of family’s income)***

*The federal poverty level (FPL) refers to income guidelines established annually by the federal government.

*** Per 12-month term of coverage.