Basic HTML Version
Benefit
changes
Dear Parent of CHIP Member :
As of March 1, your CHIP co-payments and
cost-sharing cap have gone up for medical and
prescription drug (generic and brand-name) services.
The following table shows the co-payment and cost-
sharing cap increases.
If you have any questions, please call us at
1-877-
532-3778
, Monday through Friday, 7 a.m. to 5 p.m.
Sincerely,
Member Services Department
member news
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health
First
CHIP
cost sharing
Effective
March 1, 2011,
through
Feb. 29, 2012
Increases
effective
March 1,
2012***
Co-pays (per visit,
per child):
Co-pays (per visit,
per child):
At or below 100% of FPL* Charge
Charge
Office visit
$3
$3
Nonemergency ER
$3
$3
Generic drug
$0
$0
Brand-name drug
$3
$3
Facility co-pay, inpatient $10
$15
Cost-sharing cap
1.25% of family’s
income**
5% of family’s
income
Above 100% up to and
including 150% of FPL* Charge
Charge
Office visit
$5
$5
Nonemergency ER
$5
$5
Generic drug
$8
$10
Brand-name drug
$5
$5
Facility co-pay, inpatient $25
$35
Cost-sharing cap
1.25% of family’s
income**
5% of family’s
income**
Above 150% up to and
including 200% of FPL* Charge
Charge
Office visit
$12
$20
Nonemergency ER
$50
$75
Generic drug
$8
$10
Brand-name drug
$25
$35
Facility co-pay, inpatient $50
$75
Cost-sharing cap
2.25% of family’s
income**
5% of family’s
income**
Above 185% up to and
including 200% of FPL* Charge
Charge
Office visit
$16
$25
Nonemergency ER
$50
$75
Generic drug
$8
$10
Brand-name drug
$25
$35
Facility co-pay, inpatient $100
$125
Cost-sharing cap
2.25% of family’s
income**
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.
***Effective March 1, 2012, CHIP members will be required to pay an office co-payment for each non-preventive dental visit.