What You Need Know About CHIP

What is CHIP?

The Children's Health Insurance Program (CHIP) provides insurance to kids whose families have an annual income that is too high for them to apply for Medicaid but still do not earn enough to purchase private insurance. There are co-pays and out-of-pocket costs for families enrolled in CHIP like other insurance plans. However, because CHIP is state-run, the fees and benefits differ in each state.

CHIP offers families access to a network of health care professionals and hospitals that specialize in care for children and teenagers. The benefits cover dental care, doctors’ visits, X-rays, hearing tests, vision care, vaccines, prescriptions and more. Furthermore, some states offer supplementary benefits to their residents. For example, CHIP Texas offers a 24-hour nurse help line, home visits for children with asthma and diabetes, and help with transportation to the doctor. Alternatively, CHIP Utah offers case management for special needs and mental health services.

CHIP Health Insurance Details

CHIP benefits vary from state to state, however there is an established minimum that the states are required to cover, and any additional coverage is enacted at the state’s discretion. The basic health coverage that all CHIP programs must provide are the following:

  • Doctors’ visits
  • Pharmacy service
  • Dental care
  • Laboratory services
  • X-rays
  • Scheduled check-ups
  • Emergency services
  • Immunizations
  • Vision care
  • Inpatient and outpatient care at a hospital or clinic

There are some services provided by CHIP, such as routine check-ups, at no cost to recipients. The amount charged for other services is determined by the state. Whether or not there will be premium fees for enrolling in CHIP is also left to the discretion of the states, but federal guidelines establish that a family cannot be charged any more than 5 percent of their annual income. The premium is also a flat amount, no matter how many children in the family are enrolled in CHIP.

Parents are not eligible to receive healthcare services through CHIP, but may still be qualified for health benefits through the Health Insurance Marketplace. Additionally, CHIP does not consider pre-existing conditions when determining which benefits to offer to an eligible child. There are also no pre-existing condition waiting lists or additional fees.

CHIP Requirements Details

Chip qualifications require that a family have a child who is younger than 19 years old, and the family income must be too high to qualify for Medicaid. But, a new eligibility group was added in 2010 under the Affordable Care Act. Children of public employees are now eligible to submit a CHIP Medicaid application provided that the family income falls within the eligibility income range. Additionally, children covered by CHIP must be legal residents or citizens who are currently covered by health insurance.

Each state has its own CHIP income guidelines. Forty-six states and the District of Columbia currently cover families up to 200 percent of the federal poverty guidelines, and 24 of those states cover families up to 250 percent of the poverty limit. The guidelines for federal poverty level and family size within the common CHIP income limits are as follows:

Family Size: 1 2 3 4 5 6 7
200% FPL $24,280 $32,920 $41,560 $50,200 $58,840 $67,480 $76,120
250% FPL $30,350 $41,150 $51,950 $62,750 $73,550 $84,350 $95,150
300% FPL $36,420 $49,380 $62,340 $75,300 $88,260 $101,220 $114,180

CHIPRA is federal permission for the states to expand CHIP to expecting women, not a demand that states open eligibility. Prenatal, delivery and postpartum care are available to low-income pregnant women through the CHIPRA act, or Children’s Health Insurance Reauthorization Act. The states that include pregnant women in the CHIP eligibility requirements are:

  • Colorado
  • Missouri
  • New Jersey
  • Rhode Island
  • Virginia

CHIP coverage is often more affordable than a plan purchased on the Marketplace. We must note that if your children qualify for CHIP, they are not eligible for savings on the Health Marketplace.

CHIP Application - What you need to know

Each state manages CHIP enrollment. There is no enrollment period that restricts when you are able to submit a CHIP or Medicaid form, and most states allow applications online or through the mail. In fact, if you apply to Medicaid coverage, you would be informed if your children are eligible for CHIP coverage. There is one application for both CHIP and Medicaid.

When applying for CHIP, download the state CHIP enrollment form which is the most direct way is to locate the CHIP agency in your state. In addition, on a national level, you may also:

Call the toll free CHIP number, 1-800-318-2596.

Submit an application to the Marketplace, at which point you will be notified if your family qualifies for CHIP benefits. The Health Marketplace will then send your information to the correct state agency in order to start the CHIP application process, and the state will contact you about enrollment.

To skip the middleman, go straight to the state. A CHIP online application is available from most states, and a state-specific toll-free number and a paper form are available on site. Applications can be downloaded, printed, and then mailed to the office.

Once you have submitted your application to the state office, you will hear a response in approximately 45 days. Documentation to prove the identity of all family members and proof of the family income will be required before your family can be cleared for benefits.

If you are approved for a CHIP plan, you are required to select a primary care doctor for all children who are covered. A doctor must be selected from the state network of hospitals, clinics and physicians who accept the state CHIP. For example, the Texas CHIP program includes roughly 700 doctors and 40 hospitals in 20 counties.

CHIP Waiting Lists

As of November 2016, only 15 states have waiting lists for CHIP insurance for kids. Due to a federal law passed in 2014, the waiting period cannot legally exceed 90 days. The same law also required that states adopt exemptions to their waiting periods and institute benefits preferences for families in need, but the terms of the exemptions were left to the discretion of the states.

Two common state exceptions to waiting periods are children who lost coverage due to a parent’s Medicaid lifetime limit. Lifetime limits exist on most health benefits offered by the government, and children who lose their health coverage because a parent or guardian reached this lifetime limit are frequently exempted from any CHIP waiting period.

Additionally, children who previously had coverage under the Consolidated Omnibus Budget Reconciliation Act (COBRA) health benefits provision are also exempted. COBRA is a health service that requires employers to continue to provide healthcare to group plans when coverage would otherwise be terminated. For example, a parent who loses employment due to company lay-offs may be entitled to continue coverage by COBRA. However, COBRA is a temporary benefit and may lapse before the family parent or guardian has acquired new health coverage. In this instance, many states exempt children who were previously covered by COBRA from the CHIP waiting list.

Of the 15 states that still use CHIP Medicaid waiting periods, 12 have a waiting period of 90 days, one has a waiting period of 2 months and the last two have a waiting period of 1 month. The waiting periods on the 15 states are:

  • Arizona = 90 days. The exceptions to this period in Arizona are newborns, Native Americans receiving service from a tribal organization, applicants who enrolled in Children’s Rehabilitative Services, and applicants who have reached their lifetime insurance limit.
  • Arkansas = 90 days. The only exception is unborn children.
  • Florida = 2 months. The exceptions to the CHIP waiting period in Florida are applicants who lost health coverage due to domestic violence and children who exhausted their coverage under COBRA. Additionally, Florida also exempts families who have health coverage that does not cover the health needs of the children and applicants who have reached their lifetime insurance limit.
  • Illinois = 90 days. There are exceptions for infants younger than 1 year of age and families who have an income above 209 percent of the federal poverty level.
  • Indiana = 90 days. There is an exemption to the waiting lists in CHIP for kids in families with an income below 158 percent of the federal poverty level.
  • Iowa = 1 month. The exceptions to the waiting list include children who are only eligible for dental coverage, children who are in families with an income below 181 percent of the federal poverty level and applicants who previously had health insurance through an individual plan. Further, the exemptions extend to children who lost coverage due to domestic violence, expiration of COBRA coverage, a lifetime insurance limit or disaster beyond the control of the parents, such as flood, fire or natural disaster.
  • Kansas = 90 days. Exceptions are made for applicants who have reached the lifetime insurance limit and children in families with an income below 219 percent of the federal poverty level.
  • Louisiana = 90 days. The exceptions are for unborn children, applicants with long-term illness or disability and those who have reached the lifetime insurance limit.
  • Maine = 90 days. No exemptions.
  • New Jersey = 90 days. CHIP medical exceptions are available to pregnant women, applicants who lost health coverage due to abuse, children in families with an income below 200 percent of the federal poverty level and children who were previously covered under an individual benefits plan or COBRA. Other exceptions include children who are covered by a network that is not accessible within 45 minutes of the family residence or children who lost insurance because they were previously covered under a parent’s employer who ceased operations in the state.
  • North Dakota = 90 days. The exception is if the family lives in an area declared a disaster zone by the president in the last 12 months.
  • Texas = 90 days. The exceptions are unborn children, applicants who lost coverage from the Employees Retirement System of Texas, children who were previously insured under COBRA and any applicant determined to have good cause by Texas Human and Health Services.
  • Utah = 90 days. The exceptions are applicants who voluntarily terminated COBRA coverage or who lost coverage due to the voluntary termination of health services by a non-custodial parent. Also exempt are those who voluntarily terminated a health network that did not provide coverage in Utah or voluntarily terminated a limited health insurance plan.