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 rate for an office visit. If the Member’s family income is 185% FPL, the co-payment will be capped at $20.
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 FPL | CHARGE |
| Office Visit | $5 |
| Non-Emergency ER | $5 |
| Generic Drug | $0 |
| Brand Drug | $5 |
| Facility Co-pay, Inpatient | $35 |
| Cost-sharing Cap | 5% (of family’s income)*** |
| Above 151% up to and including 186% FPL | CHARGE |
| Office Visit (non-preventative) | $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 (non-preventative) | $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.
*** Per 12-month term of coverage.