1 Co-Payments and Deductibles
A CHIP recipients, with certain exceptions, are required to pay co-payments and deductibles.
B Deductibles must be paid only for specific services.
C Some families are exempt from CHIP cost-sharing. (See 601-3)
2 Out-of-Pocket Maximums
A The maximum dollar amount in co-payments, deductibles and quarterly premiums an individual is required to pay per certification period is no more than 5% of the individual’s total annual countable income (412-4) that was used to determine eligibility for the certification period. If the 5% disregard was applied in the calculation of countable income, the amount of income before the application of the 5% disregard is the income used when determining the out of pocket maximum.
a The maximum is per family, not per child.
b The eligibility system calculates the maximum amount by multiplying the individual’s countable income by 5% and enters it on the CHIP approval and renewal notices.
c When there are children in the household who would qualify for both Plan B and Plan C, the Plan B premium, deductibles, co-pays and out-of-pocket maximum will apply for all children.
B Table II lists services which are generally covered by CHIP, the co-payment and deductible requirements, and some of the limitations for certain services.
a Covered services may change at any time, so the list may not always be up-to-date.
b To find out if a particular service that a client needs is covered, enrollees should call their health and dental plans.
C Families are responsible to track the amount of deductibles and co-payments they pay. The eligibility system does not keep track automatically.
a When a household thinks they have met or exceeded their family out-of-pocket maximum, they should contact the CHIP administrative office (currently Justin Wadman, 801-538-6445, firstname.lastname@example.org).
b Whenever there is a reported change of income during the certification period, the worker must educate the client about how the out-of-pocket maximum could be affected. For example, if lower income is reported, the out-of-pocket maximum would go down. It may not be an advantage to the household that has nearly met their current out-of-pocket maximum.