CHIP Co-pays and Cost Sharing

How much do I have to pay for my child's dental care?

You must pay for:

• Non-covered or optional dental services that you choose to have done.
• Services that you have done more often than is allowed by the plan.
• Services given by a non-contracted dentist.

This program:

• Covers dental treatment using the most cost-effective option.
• Regularly gives good professional practice.
• Is limited to the benefit level for the least costly, best alternative (you will be responsible for all charges that exceed covered dental benefit).

If your child gets services before their dental coverage starts, you must pay for them. You will also have to pay for services that:

• Are non-covered services.
• Exceed the benefit limits.

CHIP Members have a yearly maximum of $564 (per 12-month term of coverage). CHIP members must pay a co-payment for each dental visit when non-preventive services are given, unless the member's cost sharing has been met. A list of non-preventive services is listed at the top of this page. Co-pays do not apply to initial and periodic exams, x-rays, cleanings or sealants.

Co-Pays are based on the Federal Poverty Level (FPL). The federal government sets the FPL every year. Below are examples of the co-pay that is set for each level. Your Member ID Card will tell you what co-pay you will need to pay for each non-preventive visit.

Effective January 1, 2014

Enrollment Fees	Charge
At or below 151% of FPL*	$0
Above 151% up to and including 186% of FPL	$35
Above 186% up to and including 201% of FPL	$50
Co-Pays (per visit):
At or below 151% FPL:
Office Visit (non-preventative)	$5
Non-Emergency ER	$5
Generic Drug	$0
Brand Drug	$5
Facility Co-pay, Inpatient (per admission)	$35
Cost-sharing Cap	5% (of family's income)**
Above 151% up to and including 186% of FPL
Office Visit (non-preventative)	$20
Non-Emergency ER	$75
Generic Drug	$10
Brand Drug	$35
Facility Co-pay, Inpatient (per admission)	$75
Cost-sharing Cap	5% (of family's income)**
Above 186% up to and including 201% of FPL
Office Visit (non-preventative)	$25
Non-Emergency ER	$75
Generic Drug	$10
Brand Drug	$35
Facility Co-pay, Inpatient (per admission)	$125
Cost-sharing Cap	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.

Contact the DentaQuest Member Call Center for information about benefit limits and frequency toll-free at 1-800-508-6775.

How much do I have to pay for services not covered by the CHIP Dental Program or services that are over the yearly maximum?

Members do have to pay for services that are:

• Non-covered services.
• Non-preventive services given after the member has reached their yearly maximum