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CHIP-Income-Guidelines-Chart

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23 views1 page

CHIP-Income-Guidelines-Chart

Uploaded by

Jeff
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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CHIP Income Guidelines Chart

How to use this chart:


Step 1: Locate the number of people in your household.
Step 2: Find the box that matches your household’s annual gross income and age of your children.
Step 3: Look down the row to the COST BOX to see your appropriate, average monthly cost per child and the co-payments per child, per visit.

Example: A four-person household with an annual income of $69,840 will have an average monthly premium of $58 per child, plus any co-pays for services.

INCOME* (Effective March 1, 2024)


Free Low Cost Full Cost
HOUSEHOLD SIZE ages 1-5 ages 6-18 ages 0-1 ages 1-18 ages 0-18 ages 0-18 ages 0-18
1 $ 23,645 - $ 31,325 $ 20,030 - $ 31,325 $ 32,379 - $ 39,458 $ 31,325 - $ 39,458 $ 39,458 - $ 43,373 $ 43,373 - $ 47,289 $ 47,289 - No Limit
2 $ 32,091 - $ 42,516 $ 27,186 - $ 42,516 $ 43,946 - $ 53,553 $ 42,516 - $ 53,553 $ 53,553 - $ 58,868 $ 58,868 - $ 64,182 $ 64,182 - No Limit
3 $ 40,538 - $ 53,706 $ 34,341 - $ 53,706 $ 55,513 - $ 67,649 $ 53,706 - $ 67,649 $ 67,649 - $ 74,362 $ 74,362 - $ 81,075 $ 81,075 - No Limit
4 $ 48,984 - $ 64,896 $ 41,496 - $ 64,896 $ 67,080 - $ 81,744 $ 64,896 - $ 81,744 $ 81,744 - $ 89,856 $ 89,856 - $ 97,968 $ 97,968 - No Limit
5 $ 57,431 - $ 76,087 $ 48,652 - $ 76,087 $ 78,647 - $ 95,840 $ 76,087 - $ 95,840 $ 95,840 - $ 105,351 $ 105,351 - $ 114,862 $ 114,862 - No Limit
6 $ 65,878 - $ 87,277 $ 55,807 - $ 87,277 $ 90,214 - $ 109,936 $ 87,277 - $ 109,936 $ 109,936 - $ 120,845 $ 120,845 - $ 131,755 $ 131,755 - No Limit
7 $ 74,324 - $ 98,468 $ 62,963 - $ 98,468 $ 101,781 - $ 124,031 $ 98,468 - $ 124,031 $ 124,031 - $ 136,340 $ 136,340 - $ 148,648 $ 148,648 - No Limit
8 $ 82,771 - $ 109,658 $ 70,118 - $ 109,658 $ 113,348 - $ 138,127 $ 109,658 - $ 138,127 $ 138,127 - $ 151,834 $ 151,834 - $ 165,541 $ 165,541 - No Limit
9 $ 91,217 - $ 120,848 $ 77,273 - $ 120,848 $ 124,915 - $ 152,222 $ 120,848 - $ 152,222 $ 152,222 - $ 167,328 $ 167,328 - $ 182,434 $ 182,434 - No Limit
10 $ 99,664 - $ 132,039 $ 84,429 - $ 132,039 $ 136,482 - $ 166,318 $ 132,039 - $ 166,318 $ 166,318 - $ 182,823 $ 182,823 - $ 199,328 $ 199,328 - No Limit

COST
Free Low Cost Full Cost
Average monthly premium per
child (Effective July 1, 2024) $0 $0 $58 $58 $81 $92 $240

CO-PAYMENTS (PER CHILD, PER VISIT)


Doctor visit $ 0 $ 0 $ 5 $ 5 $ 5 $ 5 $ 15
Brand name prescription $ 0 $ 0 $ 9 $ 9 $ 9 $ 9 $ 18
Generic prescription $ 0 $ 0 $ 6 $ 6 $ 6 $ 6 $ 10
Specialist visit $ 0 $ 0 $ 10 $ 10 $ 10 $ 10 $ 25
Emergency room visits** $ 0 $ 0 $ 25 $ 25 $ 25 $ 25 $ 50

*If your income is below any amount listed, your family could be eligible for Medical Assistance. For more details, please call 1-800-986-KIDS.
**Emergency room visit co-pay applies if the child is not admitted for a hospital stay. (Updated 6/4/24)

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