Obsolete 0724 - 602 Cost Sharing Requirements

Effective Date: January 1, 2024 - June 30, 2024

Previous Policy

Most CHIP clients have cost sharing requirements with some exceptions. Cost sharing includes deductibles, co-payments, coinsurance, and quarterly premiums.  The amount the client is required to pay is determined by which CHIP benefit plan they qualify for (600).

              A. Quarterly Premiums

1. Most CHIP clients are asked to pay quarterly premiums to receive CHIP benefits. The premium amount is a set amount for each CHIP plan, no matter how many children in the household are covered on CHIP. The client will receive an invoice every 3 months (quarterly) requesting payment by the specified date.

1. 1. The quarterly premium amount for CHIP plan B is $30 per family
   2. The quarterly premium amount for CHIP plan C is $75 per family
   3. The quarterly premium amount for State CHIP is $75 per family

2. Families that have children who qualify for different plans, will be invoiced the quarterly premium for the lower cost CHIP plan for all the children. 

3. The premium is requested if at least one child included in the CHIP coverage is not an American Indian/Alaska Native.

4. Clients are not asked to pay premiums for a due process month.  (See Glossary)

5. Clients can choose any of the following options to pay their quarterly premiums:
   • • Online at: https://jobs.utah.gov/mycase/
     • By phone: 1-866-435-7414
     • By Mail:

Department of Workforce Services

Business Office

PO Box 143250

Salt Lake City Utah 84114

B. Co-Payments, Coinsurance and Deductibles

Most CHIP clients are required to pay co-payments, coinsurance and deductibles for medical and dental services. Copayments, coinsurance and deductibles are types of cost sharing fees the client is required to pay for services covered by their health plan. 

• A copayment is a fixed amount the client is required to pay for covered health care services and can vary by the type of covered services. The amount of the co-payment depends on which plan the client qualifies for (600).  
• Coinsurance is a percentage of the allowed amount that the member is required to pay (usually after the deductible for covered health care services). The percentage will vary by the plan and type of covered service.
• A deductible is the amount the client is required to pay for covered health services before the health plan begins to pay.
• Clients can view co-payment information and the types of services that require a co-payment at: www.health.utah.gov/chip/resourcematerials.htm.

C. Out-of-Pocket Maximums

Individuals enrolled in CHIP are not required to pay more than 5% of the household’s countable income for out-of-pocket expenses during the certification period with the exception of State CHIP (see table I-B for State CHIP). The maximum amount is per family, not per child. DHHS’s payment system keeps track of the member’s incurred expenses including their out-of-pocket maximum for each certification period.

1. If a 5% disregard was applied in the calculation of countable income, the amount of income before applying 5% disregard is the income used in determining the out-of-pocket maximum.

2. The eligibility system will calculate the maximum out of pocket amount for co-payments and deductibles the client will be required to pay for the certification period. The CHIP approval and renewal notices will include the maximum out of pocket amount. The member is still asked to pay their quarterly premiums.

Example:  The client’s annual countable income is $25,800 and the household was approved for CHIP plan B. They are asked to pay a quarterly premium of $30 ($120 annual). To determine their out-of-pocket maximum, take the total annual income and multiply that by .05 then subtract their annual premium amount.

3. $25,800 times .05 = $1,290 minus the annual premium of $120 = $1,170.

4. Once the household has met their annual co-pay and deductible maximum, they no longer have to pay co-pays or deductibles for that benefit period.

• If the Out-of-Pocket Maximum has been met and a due process month is issued, the co-pay and deductible exemptions are extended in the due process month(s).

D. Cost Sharing Exemptions

1. Verified American Indian/Alaska Native individuals are not required to pay co-payments, deductibles, or quarterly premiums.  The tribe must be recognized by the Federal government. The definition of who is an American Indian/Alaska Native is defined by the tribe.

• See Table VI for acceptable verification of American Indian/Alaska Native Status and how to verify if the tribe is recognized by the United States Bureau of Indian Affairs.

• 1. Applicants:  Allow CHIP coverage with the cost sharing exemption when an individual declares to be an American Indian/Alaska Native, and there is no evidence that contradicts their claim.
• Give the client reasonable time to provide documentation of their status.  "Reasonable time" is at least 30 days.  A client may request more time if needed.
• If the client has been given reasonable time and does not provide the documentation or proof that they are working on obtaining it, remove the exemption with proper 10- day notice.

2. Recipients:  Request proof of American Indian/Alaska Native status at review if their status was self-declared at application and tribal verification has not yet been provided.  

• Give the client reasonable time to provide documentation of their status. “Reasonable time” is at least 30 days.  A client may request more time if needed.
• If the client fails to provide the verification or proof that they are working on obtaining it, remove the exemption with proper 10-day notice.

3. If verification of a person's American Indian/Alaska Native status is received at any time, allow the exemption starting the month verification is received.

• The client will be refunded any premiums paid during the 12 months prior to the month of verification.