CHIP Premiums and Cost Sharing

CHIP Cost-Sharing

  Effective Januray 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.

 

CHIP Cost-Sharing

Effective through February 28, 2011 Effective March 1, 2011 – February 29, 2012 Effective march 1, 2012** – December 31, 2013

Enrollment Fees (for 12-month enrollment period):

Charge Charge Charge
At or below 150% of FPL* $0 $0 $0
Above 150% up to and including 185% of FPL $35 $35 $35
Above 185% up to and including 200% of FPL $50 $50 $50

Co-Pays (per visit):

At or below 100% of FPL Charge Charge Charge
Office Visit $3 $3 $3
Non-Emergency ER $3 $3 $3
Generic Drug $0 $0 $0
Brand Drug $3 $3 $3
Facility Co-pay, Inpatient $10 $10 $15
Cost-sharing Cap 1.25% (of family’s income)*** 1.25% (of family’s income)*** 5% (of family’s income)***
Above 100% up to and including 150% FPL Charge Charge Charge
Office Visit $5 $5 $5
Non-Emergency ER $5 $5 $5
Generic Drug $0 $0 $0
Brand Drug $5 $5 $5
Facility Co-pay, Inpatient (per admission) $25 $25 $35
Cost-sharing Cap 1.25% (of family’s income)*** 1.25% (of family’s income)*** 5% (of family’s income)***
Above 150% up to and including 185% FPL Charge Charge Charge
Office Visit $7 $12 $20
Non-Emergency ER $50 $50 $75
Generic Drug $5 $8 $10
Brand Drug $20 $25 $35
Facility Co-pay, Inpatient (per admission) $50 $50 $75
Cost-sharing Cap 2.5% (of family’s income)*** 2.5% (of family’s income)*** 5% (of family’s income)***
Above 185% up to and including 200% FPL Charge Charge Charge
Office Visit $10 $16 $25
Non-Emergency ER $50 $50 $75
Generic Drug $5 $8 $10
Brand Drug $20 $25 35
Facility Co-pay, Inpatient (per admission) $100 $100 $125
Cost-sharing Cap 2.5% (of family’s income)*** 2.5% (of family’s income)*** 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.