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Family Choices

Benefit/Service Children of Caretaker Relatives Categorically Needy Children KCHIP Children – Medicaid Expansion Program

KCHIP Children – Separate Chip Program Medical Out-of-Pocket Maximum $225 per 12 months $225 per 12 months $225 per 12 months $225 per 12 months Pharmacy Out-of-Pocket Maximum $225 per 12 months $225 per 12 months $225 per 12 months $225 per 12 months Acute Inpatient Hospital Services $0 co-pay $0 co-pay $0 co-pay $0 co-pay Laboratory, Diagnostic and Radiology Services $0 co-pay $0 co-pay $0 co-pay $0 co-pay Outpatient Hospital/ Ambulatory Surgical Centers $0 co-pay $0 co-pay $0 co-pay $0 co-pay Physician Office Services* $0 co-pay $0 co-pay $0 co-pay $0 co-pay Behavioral Health Services** $0 co-pay $0 co-pay $0 co-pay $0 co-pay Allergy Services $0 co-pay $0 co-pay • $2 co-pay for office visit and testing • $0 co-pay for injections • $2 co-pay for office visit and testing • $0 co-pay for injections Preventive Services $0 co-pay $0 co-pay $0 co-pay $0 co-pay Emergency Ambulance $0 co-pay $0 co-pay $0 co-pay $0 co-pay Dental Services Including but not limited to two cleanings per 12 months, one set of x-rays per 12 months and extractions $0 co-pay $0 co-pay $0 co-pay $0 co-pay Family Planning $0 co-pay $0 co-pay $0 co-pay $0 co-pay Occupational Therapy Limited to 15 visits per 12 months $0 co-pay $0 co-pay $0 co-pay $0 co-pay