CHIP Premiums and Cost Sharing | Driscoll Health Plan

CHIP Premiums and Cost Sharing

CHIP Cost-Sharing
  Effective January 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 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.