CHIP Cost-Sharing |
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Effective January 1, 2014 | ||
Enrollment Fees (for 12-month enrollment period): |
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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): |
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At or below 151% of FPL | Charge | |
Office Visit (non-preventive) | $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 (non-preventive) | $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 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 (non-preventive) | $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.