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What is a CHIP (Children’s Health Insurance Plan)?

The Children’s Health Insurance Program (CHIP) offers medical care coverage for children in families that that would not be eligible for Medicaid. While the program is federally funded, each state is responsible for managing its own CHIP plan. The parents, grandparents, or guardians of children can apply for CHIP on their child’s behalf. Coverage under CHIP lasts from birth until a child’s 19th birthday, at which time they can apply for their own health insurance

How Does CHIP Work?

The funds for CHIP are provided by the federal government and equally distributed to states. States are then responsible for administering CHIP programs under their own Medicaid framework. Depending on your state, the program may have different names. For instance, it is called Child Health Plus in New York, Medi-Cal in California, and Nevada Check Up in Nevada.

Using CHIP is just like using Medicaid or private health insurance. Your plan comes with a list of in-network healthcare providers that offer CHIP-covered services. If there is no doctor available in your network to address a specific concern, your primary care physician can request permission from your state’s CHIP provider to extend coverage.

Services covered under CHIP include route check-ups, immunizations, dental and vision care, and emergency services. While some of these services — such as routine well child checkups — are entirely covered by CHIP, others may require copayments. States may also charge families a monthly premium for CHIP coverage, but the total amount paid cannot exceed 5% of the family’s income for the year. 

CHIP vs. Children’s Medicaid

CHIP and Children’s Medicaid are similar in that both provide health coverage for children via state governments through funding support from the federal government. In some cases, these programs fall under the same umbrella since states can choose to offer a stand-alone CHIP program or make it part of their larger Children’s Medicaid program.

Unlike adult programs, such as standard health insurance and Medicare, which have specific enrollment periods throughout the year, families can apply for CHIP and Children’s Medicaid at any time of the year. In total, more than 44 million children received coverage from either CHIP or Children’s Medicaid in 2020: 35 million were enrolled in Medicaid and 9 million were enrolled in CHIP.

CHIP Eligibility

CHIP eligibility is based on these factors: 

  • The age of the child
  • The income of the family
  • Current insurance status
  • Existing residence requirements

Children may be eligible for CHIP from birth to their 19th birthday, and any parent or guardian who lives with the child more than half the time may apply for CHIP on their behalf. 

Income eligibility amounts are based on total household size and total income per year. For example, a family of 4 must make less than $111,000 before taxes to qualify for CHIP. Meanwhile, a family of 6 must make less than $148,760. CHIP is also available to children of families that are uninsured, meaning they are not eligible for Medicaid and are not covered through a group health plan or other creditable insurance. In addition, CHIP recipients must either be U.S. citizens or meet the state’s immigration requirements for coverage. 

CHIP is designed to help families who aren’t below the federal poverty line (FPL) and therefore not eligible for Children’s Medicare, but who also can’t afford private health insurance. Some states also offer pregnant-women-in-medicaid-and-chip-2/” rel=”noreferrer noopener” target=”_blank”>CHIP coverage for pregnant people, unborn children, or both. For example, CHIP coverage for pregnant people is offered up to 260% of the FPL in Colorado, while  coverage is offered for the unborn child between 0% and 317% FPL in California. In Missouri, CHIP coverage is offered for both pregnant people and unborn children up to 300% FPL. The only other state to offer CHIP for both pregnant people and unborn children is Rhode Island, which offers coverage from 0% to 253% FPL.

Children’s Medicaid Eligibility

Children’s Medicaid eligibility is similar to that of CHIP, but is designed to provide coverage for lower-income families who are closer to — or below — state poverty lines. For example, in Alabama, the income eligibility cutoff for Children’s Medicaid is 141% FPL. However, in Arizona, the cutoff is 147% FPL for children between 0 and 1 year old, 141% FPL for children between 1 year old and 5 years old, and 133% FPL for children between 6 years old and 18 years old.

There are other nuances based on each state’s criteria. For example, in New York State, eligibility is assessed on a monthly income basis instead of annual. A family of 4 with a monthly income of $3,562 or less is eligible for Children’s Medicare for kids between 1 and 18 years old, while Medicaid coverage for children under 1 year old and pregnant women is available to families of 4 with a monthly income of less than $5,157.

What Does CHIP Cover?

CHIP covers common healthcare services, including:

  • Routine check-ups
  • Immunizations
  • Doctor’s visits
  • Prescriptions
  • Dental and vision care
  • Inpatient and outpatient hospital care
  • Laboratory and X-ray services
  • Emergency services

Some states may offer additional coverages. For example, Texas CHIP provides coverage for vision and hearing care along with the treatment of special health needs and preexisting conditions. It is worth consulting your state’s health website to see what they offer, what they cover, and how much they charge for CHIP premiums or co-payments. 

What Does CHIP Not Cover?

CHIP is designed to provide coverage for common healthcare services. As a result, there are some services that are not covered under state CHIP programs.

For example, CHIP does not cover home and personal care aides to help monitor your child’s daily health or child placements in hospitals for mental illness or nursing home care. There is also no CHIP support to have someone drive your child to their medical appointments. If any of these cases apply to you, it may be possible to apply for Children’s Medicaid in addition to CHIP, which provides coverage for these circumstances. Using what’s known as the Medicaid Buy-in for Children program, families with children who need more support than what is offered by CHIP can make monthly payments to add on Medicare coverage.

How to Enroll in CHIP

Unlike Medicare and other standard insurance plans, CHIP and Children’s Medicaid do not have enrollment periods. This means that you can apply for these programs at any time during the year as long as you meet the minimum requirements. As a result, it’s worth applying for CHIP or Medicaid coverage when you need it rather than waiting since there’s no penalty for applying at any time.

CHIP and Children’s Medicare have three types of eligibility:

Express Lane Eligibility

Express lane eligibility (ELE) is designed to help get kids enrolled as quickly as possible into CHIP and Children’s Medicare coverage. Originally introduced under the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA), ELE allows states to rely on specific findings to streamline health coverage. For example, states may use family income or household size along with data from other ELE-approved agencies, such as the Supplemental Nutrition Assistance Program (SNAP) or the National School Lunch Program (NSLP). Income tax data may also be used to establish ELE status rather than requiring families to submit income information. 

Continuous Eligibility

Continuous eligibility provides states with the option to offer 12 months of continuous health insurance for children under Medicaid or CHIP, even if their family experiences a change of income that would otherwise make them ineligible for CHIP. This approach allows children to remain with the same plan and see the same doctors for the entire year, after which families can find new coverage. Not only does this facilitate relationships between families and doctors, but it can help reduce the amount of paperwork required to insure and then uninsured children in the space of a few months.

States including Alabama, California, Florida, and Illinois offer continuous Medicaid and CHIP eligibility. 

Presumptive Eligibility

Presumptive eligibility programs can help children who are eligible for CHIP and Medicaid get enrolled faster. States are permitted to authorize qualified entities to screen children for CHIP eligibility and immediately enroll them before their application is fully processed. Examples of qualified entities include community organizations, primary health care providers, and schools.

States such as Connecticut, Colorado, Kansas, and New Jersey all offer presumptive enrollment programs. 

When it comes to applying for CHIP, there are several options. To learn more about your state’s specific CHIP plans, you can search for their program online via InsureKidsNow, or contact the agency by phone at 1-877-543-7669. Applications can be made using the federal government’s online application form or via your state’s CHIP agency. 

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