Superior HealthPlan > For Members > Benefits > Co-Payments

Co-Payments

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The table below lists the CHIP co-payment schedule. It is listed according to a family’s income. Co-payments for health-care services or prescription drugs are paid to the health care provider at the time of service. You do not have to pay co-payments for preventive care such as well-child or well-baby visits or vaccines.

Your child’s ID card lists the co-payments that apply to your family. Present your ID card when your child gets office visits or emergency room services or has a prescription filled.

CHIP Cost-Sharing Effective March 1, 2011 – February 29, 2012 Effective March 1, 2012***
Enrollment Fees (for 12-month enrollment period): Charge Charge
At or below 150% of FPL* $0 $0
Above 150% up to and including 185% of FPL $35 $35
Above 185% up to and including 200% of FPL $50 $50
Co-Pays (per visit):
At or below 100% of FPL Charge Charge
Office Visit $3 $3
Non-Emergency ER $3 $3
Generic Drug $0 $0
Brand 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
Non-Emergency ER $5 $5
Generic Drug $0 $0
Brand Drug $5 $5
Facility Co-pay, Inpatient (per admission) $25 $35
Cost-sharing Cap 1.25% (of family’s income)** 5% (of family’s income)**
Above 150% up to and including 185% of FPL Charge Charge
Office Visit $7 $20
Non-Emergency ER $50 $75
Generic Drug $8 $10
Brand Drug $25 $35
Facility Co-pay, Inpatient (per admission) $50 $75
Cost-sharing Cap 2.5% (of family’s income)** 5% (of family’s income)**
Above 185% up to and including 200% of FPL Charge Charge
Office Visit $16 $25
Non-Emergency ER $50 $75
Generic Drug $8 $10
Brand Drug $25 $35
Facility Co-pay, Inpatient (per admission) $100 $125
Cost-sharing Cap 2.5% (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 visit co-payment for each non-preventive dental visit.

CHIP Cost-sharing Limits
The Member Guide you received from CHIP when you enrolled your child in CHIP includes a tear-out form that you should use to track your CHIP expenses. To make sure that you do not go over your cost-sharing limit, please keep track of your CHIP-related expenses on this form. The enrollment packet welcome letter tells you exactly how much you must spend before you are eligible to mail the form back to CHIP. If you lose your welcome letter, please call CHIP at (800) 647-6558. They will tell you what your annual cost-sharing limit is.

When you reach your annual cost-sharing limit, please send the form to CHIP. They will notify us at Superior HealthPlan. We will issue a new member ID card for your child. This new card will show that no co-payments are due when your child receives services for the remainder of the enrollment period.

Incrementos a partir del 1ero de Marzo del 2011.