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 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.

Cost-sharing does 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);

6. Outpatient office visits for mental health (MH) and substance use disorder (SUD) services and MH/SUD residential treatment services, in accordance with 42 C.F.R. §457.496(d)(2).

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.

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

** Per 12-month term of coverage.

***Copays for insulin cannot exceed $25 per prescription for a 30-day supply, in accoradance with Section 1358.103 of the Texas Insurance Code.