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Cost-share

What is Cost-sharing?

Cost-sharing is the out-of-pocket amount that an individual pays for their health care. Indiana Medicaid cost-sharing requirements include copayments and premiums (also called contributions for HIP).

Copayments are paid to the provider at the time of service (or might be billed to the patient to pay later). Service cannot be refused due to inability to pay copayments at the time of service.

Premiums and POWER Account Contributions are invoiced and paid monthly to the MCE (for HIP) or to Gainwell Premium Vendor (for CHIP and MEDworks). Ongoing coverage might be impacted if monthly premiums are not paid. There is a 60-day grace period for premium payment--as long as payment is made within 60 days of the due date, coverage will continue.

5% Out-of-Pocket Maximum* – individual cost-sharing obligations are capped at 5% of family income as calculated on a quarterly basis. Once 5% cost-sharing is met, the MCE will turn off cost-sharing for the remainder of the quarter and resume at the beginning of the next quarter. For HIP Plus categories, if the 5% cost-share limit is met, their PAC will be reduced to $1 for the remainder of the quarter. *For CHIP, the 5% cost-share limit is calculated on an annual basis and must be tracked by the individual. If the individual feels they have met the 5% cost-share limit they must submit verification to DFR.

Health Coverage Type

Copayment amounts

Monthly Premium/Contributions amounts (based on HH income)

HHW – Package C (CHIP)

$3 – 10 for prescriptions,

$10 for ambulance transportation services

$22 – 70 per month

HCC - MEDWorks

None

$48 - $187 per month for individuals

$65 – 254 per month for married couples

Package C – CHIP Premium Amounts

This chart lists the income standards for children from birth through 18 years of age (MA 10), which is Package C, Children's Health Plan. The standard is based on 250% of the Federal Poverty Level (FPL) and effective March 1, 2024. For children with income above 158% FPL standard and below the 250% FPL standard, there are tiers to determine the premium amount, which will also take into account the number of children covered.

CHIP PREMIUMS

Income (As a percent of FPL)

One Child

Two or More Children

Over 150 to 175 percent

$22.00

$33.00

Over 175 to 200 percent

$33.00

$50.00

Over 200 to 225 percent

$42.00

$53.00

Over 225 to 250 percent

$53.00

$70.00

CHIP - At application, premium payment is required in order for coverage to begin. After that, CHIP members under age 19 are in a 12-month continuous eligibility period and cannot be disenrolled for nonpayment.

Copayments for COVID-19 Related Services

Even though some cost-sharing restarts 7/1/2024, there will still be federal flexibilities in place that will continue the pause on copayments for COVID-19 vaccinations, testing, or treatments until 10/1/2024.

As of 10/1/2024, the following can be expected for these services moving forward:

  • COVID-19 vaccinations will continue to have no copayment requirement for all Indiana Health Coverage programs.
  • COVID-19 testing:
    • No copayments for HIP Plus/Maternity, HHW-Package A, HCC/MEDworks, FFS, or Presumptive Eligibility
    • HHW-Package C (CHIP) will have a $3 or $10 copayment for prescriptions for at-home COVID-19 tests
    • HIP Basic will have a copayment of $4 or $8 for prescriptions for at-home COVID tests and outpatient services.
  • COVID-19 Related Treatments:
    • HIP Basic will have $4 to $8 copayments for prescriptions and outpatient services, and $75 copayment for inpatient hospitalizations
    • CHIP (Package C) will have $3 or $10 copayments for prescriptions. 

Groups exempt from cost-sharing:

  • American Indian/Alaska Native – verified member of a federally recognized tribe
  • Pregnant and 12 months postpartum

Services that are exempt from copayments (For applicable codes, see the table of covered procedure codes in Family Planning Eligibility Program Codes, accessible from the Code Sets page at Indiana Medicaid: Providers: Home):

  • Emergency Services
  • Family Planning Services
  • Pregnancy related services
  • Preventive care services for children and treatment for any conditions identified via EPSDT screening (EPSDT)
  • Preventive care services for HIP

Take Action to Help Keep Health Coverage

Update Your Info Online with FSSA

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What is your income?
What is your employment status?
What is your family size?

Update Your Info Now

How to Update Your Member Info

Upload Verification Documents

Some members may need to upload verification documents. Verification documents can include proof of income, such as a pay stub. Be sure to respond with any info you’re asked for.

Upload Documents

Return Your Eligibility Notice for Health Coverage Form

Some members will receive a Medicaid eligibility review packet in the mail from FSSA. The form determines your eligibility for the next coverage period and is part of the Indiana Medicaid renewal process. Complete the Eligibility Notice for Health Coverage form included in this packet as soon as possible so you can remain insured with MDwise if you qualify. You must return it by the due date listed on the form.

Need Help Filling Out Your Renewal Form?

MDwise can help! Call us at 1-833-414-1997 and we’ll be happy to assist you with completing your Eligibility Notice for Health Coverage form. If you prefer to speak with someone in person, you can visit MDwise at our Indianapolis office at 2955 N. Meridian Street, Indianapolis, IN 46208 Monday through Wednesday from 8:30 am to 5:00 pm ET.