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Members

CHIP Cost Sharing and Premiums

Enrollment Fees (for 12-month enrollment period)
At or below 151% of FPL* $0
Above 151% up to and including 186% of the FPL $35
Above 186% and including 201% of FPL $50
Co-Pays (per visit):
At or below 151% FPL Charge
Office Visit (non-preventive) $5
Non-Emergency ER $5
Generic Drug $0
Brand Drug $5
Facility Co-pay, Intpatient (per admission) $35
Cost-sharing Cap 5% (of family's income)**
Above 151% up to and including 186% of the 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 186% up to and including 201% of the 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.

No co-payments for Medicaid Members, CHIP Perinate Members and/or CHIP Perinate Newborn Members and CHIP Members who are Native Americans or Alaskan Natives. No co-payments for well-baby and well-child services, preventive services, or pregnancy-related assistance for CHIP Members.

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