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CHIP Medical Benefits and Copayments

Blue Cross and Blue Shield of Texas wants to make sure you and your child get the health care you need. That’s why we offer benefits and programs to help keep you healthy. From routine care to urgent care, family planning to mental health care, BCBSTX is there for you. 

What is Covered?

The table below contains just some types of health care covered by your CHIP plan. BCBSTX covers any medically necessary care that Medicaid covers. Some types of care may need to be approved before you are treated. Without approval, BCBSTX will not pay for the service. Learn more about prior authorization.

Covered Service

Needs Prior Authorization?

Coverage

Ambulance Services

No

  • Only covered when ambulance is used for emergency transport.
  • A licensed ambulance company

Diagnostic and Therapeutic Radiology

Some radiology services need an “okay” from us before you get the service. These include CT, MRI, MRA, PET and SPECT.

  • Testing and X-rays that are:
    • not invasive
    • done to find out what is wrong
    • ordered and done by (or under the guidance of) your provider

Doctor Services

No

  • Visits to in-network primary care providers (PCPs), specialists or other health care providers
  • Well exams

Durable Medical Equipment (DME) and Disposable Supplies

Yes

  • Medical equipment that is used in the home
  • Must be within the limits of what is covered by Medicaid

Emergency Services

No

  • Treatment in an emergency room (ER)
  • Ambulance services

Family Planning Services

No

  • Medical visits for birth control
  • Marriage and family planning, education and counseling services
  • Birth control medicines, including long-acting reproductive contraception (LARC)

Home Health Care

Yes

  • Home health aid services
  • Speech therapy
  • Physical therapy visits
  • Occupational therapy visits
  • DME
  • Medical supplies that are thrown away after use

Hospital Services (inpatient)

Yes

  • Hospital room with two or more beds
  • Nursing care
  • Operating room
  • Surgery
  • Anesthesia

Hospital Services (outpatient)

Yes

  • Dialysis
  • Giving you someone else’s blood

Lab Services

Yes

  • All authorized lab services such as blood and urine testing

Pregnancy-related and Maternity Care

No

  • Pregnancy care
  • After-delivery care when medically necessary
  • Newborn exams

Well Child Checkups

No

  • Doctor visits for members ages 18 and younger
  • Routine shots
  • Hearing, vision and dental checks

Urgent Care

No

  • Treatment at an in-network urgent care clinic for an illness or injury that is not an emergency, but should be treated within 24 hours

What Is Not Covered?

Some services we do not cover include:

  • Cosmetic surgery that is not medically necessary
  • Procedures that are still new and being tested
  • Service received outside of the United States

Check Part 19 of your CHIP Member Handbook to get a full list of what your plan covers.

CHIP Copayments

If you get CHIP Perinatal benefits, you do not have cost-sharing obligations. This means you do not pay enrollment fees or copayments (copays).

How much are copays and when do they apply? 

Your member ID card shows if you have a copay. You will not have to pay copays for:

  • Primary Care Provider (PCP) visits for well-baby and well-child services
  • Preventive care
  • Pregnancy-related care

Are you a Native American or an Alaskan Native and your member ID card shows an amount other than $0? Please call BCBSTX to have this copay amount corrected.

The chart below shows your copays for some services. These are based on income guidelines.

Copays and Cost-Sharing

Service

At or below 151% FPL1

Above 151% up to and including 186% FPL1

Above 186% up to and including 201% FPL1

Enrollment Fee

$0

$35

$50

Office Visit

(No copay is applied for MH/SUD residential treatment services.)

$5

$20

$25

Non-emergency ER (per visit)

$5

$75

$75

Emergency room (ER)

$0

$0

$0

Facility Copay, Inpatient (per admission)

(No copay is applied for MH/SUD residential treatment services.)

$35

$75

$125

Generic Drug

$0

$10

$10

Brand Drug

$5

$25 for insulin, $35 for all other drugs2

$25 for insulin, $35 for all other drugs2

Cost-sharing Cap (limit)

5% of family's income2

5% of family's income2

5% of family's income2

1 The federal poverty level (FPL) refers to income guidelines established annually by the federal government.
2 Per 12-month term of coverage.

If you received a bill or paid out of pocket for a covered service, call the Customer Advocate Department. They can review your covered benefits with you and help you submit a claim if needed.

GET MORE FROM YOUR PLAN

Value-Added Services

Your plan offers more than just your standard Medicaid benefits. We offer extra services called value-added services (VAS). These services are designed to help keep you and your family healthy.

Check out VAS

MEMBER RESOURCES

Helpful Tools and Resources

Get the information you need. We’re here to help. 

Find Care

Need to search for providers in your area? Or figure out where to go for care?

Find a Provider

Transportation Services

Learn how you can get a no-cost ride to your medical appointments.

Schedule a Ride

Forms and Documents

For details about your plan, check your Member Handbook.

Go to Forms and Documents

Contact Us

If you have questions about your plan, call the Customer Advocate Department.

Get More Help