Effective Date: July 1, 2024 - February 28, 2025
Use this table to determine the out-of-pocket maximum (OOPM) base amount for State CHIP. The OOPM for State CHIP is 5% of the 200% poverty limit for the family, not the child. Copays, coinsurance, and deductibles are deducted from this amount during the plan year. Once the household has met the amount listed based on the household's size, they will no longer be required to pay the copays, coinsurance, and deductibles for the remainder of the plan year.
|
HOUSEHOLD SIZE |
ANNUAL INCOME LIMIT |
STATE CHIP OOPM AMOUNT |
|
1 |
$30,120 |
$1,506.00 |
|
2 |
$40,880 |
$2,044.00 |
|
3 |
$51,640 |
$2,582.00 |
|
4 |
$62,400 |
$3,120.00 |
|
5 |
$73,160 |
$3,658.00 |
|
6 |
$83,920 |
$4,196.00 |
|
7 |
$94,680 |
$4,734.00 |
|
8 |
$105,440 |
$5,272.00 |
|
9 |
$116,200 |
$5,810.00 |
|
10 |
$126,960 |
$6,348.00 |