Benefit | Copay if income is 0%-99% of poverty | Copay if income is 100%-199% of poverty | Copay if income is 200% of poverty or greater |
Hospital emergency room use for non-emergency services (waived if admitted) | $0 | $10 | $50 |
Primary care provider services other than preventive care | $0 | $5 | $15 |
Community Mental Health Agency services other than preventive care | $0 | $5 | $15 |
Physician specialists and dentists | $0 | $5 | $20 |
Prescription or refill | $0 | $3 for covered branded prescriptions and $1.50 for covered generic prescriptions | $3 for covered branded prescriptions and $1.50 for covered generic prescriptions |
Inpatient hospital admission | $0 | $5 | $100 |
Income Bands | Poverty levels | Standardized Annual Aggregate Cap |
1 | 0% - 99% | Not applicable |
2 | 100% - 149% | 5% of the amount that corresponds to 100% FPL |
3 | 150% - 199% | 5% of the amount that corresponds to 150% FPL |
4 | 200% - 249% | 5% of the amount that corresponds to 200% FPL |
5 | 250% - 299% | 5% of the amount that corresponds to 250% FPL |
6 | 300% - 349% | 5% of the amount that corresponds to 300% FPL |
7 | 350% - 399% | 5% of the amount that corresponds to 350% FPL |
8 | 400% - 499% | 5% of the amount that corresponds to 400% FPL |
9 | 500% - 599% | 5% of the amount that corresponds to 500% FPL |
10 | 600% and over | 5% of the amount that corresponds to 600% FPL |
Tenn. Comp. R. & Regs. 1200-13-14-.05
Authority: T.C.A. §§ 4-5-202, 4-5-208, 4-5-209, 71-5-105, 71-5-109, Executive Order No. 23.