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.