Cost Sharing & Copays
What is Cost Sharing?
Cost sharing means that you and MHS work together to pay for your health care services. MHS pays most of the costs. HIP Plus members have cost sharing through an affordable monthly payment called a POWER Account Contribution. HIP Basic members have cost sharing through copayments.
What are POWER Account Contributions?
A POWER Account Contribution (PAC) is a monthly payment you make to keep your health coverage. HIP Plus members have to make a monthly PAC payment. This amount is based on income. If you are a tobacco user, you may have an increased PAC in your second year of coverage. The following grid outlines PAC amounts:
| Tier | Federal Poverty Line | Monthly PAC Single Individual | Monthly PAC Spouses | PAC with Tobacco Surcharge | Spouse PAC when one has tobacco surcharge | Spouse PAC when both have tobacco surcharge (each) |
|---|---|---|---|---|---|---|
| 1 | Less than 22% | $1 | $1 | $1.50 | $1 & $1.50 | $1.50 |
| 2 | 23% - 50% | $5 | $2.50 | $7.50 | $2.50 & $3.75 | $3.75 |
| 3 | 51% - 75% | $10 | $5 | $15 | $5 & $7.50 | $7.50 |
| 4 | 76% - 100% | $15 | $7.50 | $22.50 | $7.50 & $11.25 | $11.25 |
| 5 | 101% - 138% | $20 | $10 | $30 | $10 & $15 | $15 |
A tobacco user is a person who uses tobacco products at least four (4) times a week on average in the last six (6) months.
Tobacco Users and POWER Account Contributions
Tobacco users will have to pay more than non-tobacco users each month. HIP members have 12 months to stop using tobacco. If you do not quit, your PAC will be 50% higher for the next year.
If you are a tobacco user, take advantage of MHS’ tobacco cessation programs in 2024/2025. You can quit now and avoid paying 50% more in January 2026. You can get healthier, save money, and earn My Health Pays rewards by quitting. Visit the MHS Tobacco Cessation webpage to learn more.
You were asked to report if you use tobacco on your HIP application. If you said yes and have stopped, call us at 1-877-647-4848 to let us know. You can also call Maximus at 1-877-GET-HIP9.
If you believe your tobacco user status was reported incorrectly to MHS, you may file a grievance to have it changed. Find out more about how to file a grievance.
What are Copayments?
A copayment (copay) is a set amount of money you pay at the time of a medical service. You might also pay this when you pick up prescriptions at the pharmacy. HIP Basic members have to pay copays for medical services. The following grid outlines copay amounts:
| Service | Copay Amount |
|---|---|
| Outpatient Services – Including Doctor’s Office Visits | $4 |
| Preferred Drugs | $4 |
| Non-Preferred Drugs | $8 |
| Non-Emergency ER Visit | $8 |
| Inpatient Services – Including Hospital Stays | $75 |
Can My Cost Sharing Change?
Yes. There are limits to what you might have to pay. Your family’s total cost sharing for healthcare can’t be more than 5% of your family’s income per quarter (3-month period). This is looked at over each quarter of the year. If you reach the limit within a quarter, your cost sharing will be reduced or stopped.
HIP Basic members will not have to pay a copay for the rest of the quarter. HIP Plus members will have a reduced PAC of $1 per month for the rest of the quarter.
How Do I Know When I Reach the 5% Limit?
MHS keeps track of your costs for you*. You do not need to do anything. If you reach the 5% limit within a quarter, your cost share will change. HIP Basic members will not have to pay for the rest of the quarter. HIP Plus members will have a reduced PAC for the rest of the quarter.
Remember, your costs are looked at each quarter. Even if your cost sharing is stopped or reduced in one quarter, you may need to begin cost sharing again in the next quarter.
Calendar quarters are:
- January to March
- April to June
- July to September
- October to December
*MHS tracks cost sharing through your claim history.
Are There Any Exceptions?
Yes. There is no cost sharing for:
- Members who are pregnant
- Members of Native American descent
- Members who have already met their 5% cost sharing limit
- Maternity services
- Family planning services
- Preventive care services