Short answer: CHIP copays depend on income (for example, $5 to $25 for a doctor visit and $0 to $10 for a generic drug), and a family’s total cost sharing is capped at 5% of its net income for the coverage period.
HHSC’s copay schedule by household income tier (at or below 151% / above 151% to 186% / above 186% to 201% of poverty):
- Preventive care and shots: $0 / $0 / $0
- Doctor visits: $5 / $20 / $25
- Generic prescription: $0 / $10 / $10
- Brand-name prescription: $5 / $35 / $35
- Non-emergency ER visit: $5 / $75 / $75
- Inpatient hospital, per admission: $35 / $75 / $125
- Outpatient hospital: $0 at every tier
The cap is 5% of the household’s total net income for the term of coverage. The family tracks spending on a medical payments form; once HHSC’s enrollment broker confirms the cap is met, the plan issues a new card with no copays for the rest of the period. American Indian and Alaska Native members are exempt from cost sharing.
Sources
Texas Works Handbook D-1830, Copayment Requirementsfhb.hhs.texas.gov/handbooks/texas-works-handbook/d-1830-copayment-requirementsTexas Works Handbook D-1840, Cost Sharing Cap Amountsfhb.hhs.texas.gov/handbooks/texas-works-handbook/d-1840-cost-sharing-cap-amounts1 Tex. Admin. Code 370.321law.cornell.edu/regulations/texas/1-Tex-Admin-Code-SS-370-321