601-1 Cost Sharing Requirements

Effective Date: March 1, 2017

Previous Policy

Resource

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, jwadman@utah.gov).

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.