Children’s Health Insurance Program (CHIP)

Quick Facts

• Coverage scope: Comprehensive health insurance for children and, in many states, pregnant women, including doctor visits, immunizations, hospital care, mental health services, dental care, and vision benefits.
• Cost structure: Low or no premiums and minimal cost-sharing. States may charge modest enrollment fees or copayments based on income.
• Eligibility: Families with incomes too high for Medicaid but too low to afford private coverage. Each state sets its own income thresholds, generally between 170% and 400% of the federal poverty level (FPL).
• Enrollment: Open year-round. Applicants can enroll online, by phone, by mail, or in person via state Medicaid/CHIP agencies or HealthCare.gov.
• Administration: Joint federal-state program funded through capped allotments; states design their own CHIP or Medicaid expansion CHIP plans within federal guidelines.

Program Overview

Established in 1997, CHIP fills the coverage gap for millions of children who lack employer-sponsored or affordable private insurance. The program operates alongside Medicaid, with states choosing between a stand-alone CHIP plan, a Medicaid expansion model, or a combination. Regardless of structure, CHIP emphasizes preventive care, early treatment, and access to specialists. Federal law mandates a robust benefits package, and states may exceed minimum standards to address local health priorities.

Eligibility Basics

• Income thresholds: Each state publishes income charts based on household size. Many states cover children up to at least 200% FPL, while some extend eligibility beyond 300% FPL. Pregnant women may qualify at even higher income levels.
• Age and residency: Coverage typically extends to children under age 19 who are U.S. citizens or qualified noncitizens and residents of the state administering the program.
• Other requirements: Applicants must be uninsured and may need to show that employer-sponsored coverage is unavailable or unaffordable. Some states impose waiting periods before enrollment if a child recently had private coverage, though federal rules limit these waiting periods.
• Pregnancy coverage: 35 states and DC cover pregnant women through CHIP, offering prenatal visits, labor and delivery, and postpartum care. Babies born to mothers enrolled in CHIP are automatically eligible for one year of coverage.

Benefits and Services

CHIP benefits emphasize preventive and primary care:

• Medical services: Doctor visits, well-child checkups, immunizations, hospital care, lab tests, and emergency services.
• Dental coverage: Required for all stand-alone CHIP programs, covering checkups, cleanings, fillings, and medically necessary orthodontia in some states.
• Vision and hearing: Exams, glasses, hearing tests, and hearing aids when medically necessary.
• Behavioral health: Mental health and substance use disorder services, including counseling and inpatient treatment.
• Prescription drugs: Comprehensive coverage subject to state formularies.
• Special services: Some states cover transportation to medical appointments, case management, or nutrition counseling.

States may offer enhanced benefits such as autism services, telehealth, or disease management programs tailored to local needs.

Costs to Families

• Premiums: Many states charge no premiums. Others use a sliding scale based on income. Premiums are capped at 5% of household income annually.
• Copayments: Nominal copayments may apply for non-preventive visits, prescriptions, or emergency room use. Preventive services like well-child visits and vaccines must be provided without cost-sharing.
• Annual limits: Federal law caps total cost-sharing at 5% of family income. Families can request reviews if they believe they have reached the cap.

Enrollment Process

1. Check eligibility: Use state websites or HealthCare.gov to review income limits and required documents.
2. Prepare documentation: Gather proof of identity, citizenship, residency, household income (pay stubs, tax returns), and immigration status for noncitizen applicants.
3. Submit application: Apply online through the state Medicaid portal or HealthCare.gov, by calling the state’s Medicaid/CHIP hotline, mailing a paper application, or visiting a local agency or community assister.
4. Receive determination: States must process applications promptly—often within 45 days (15 days for pregnant women). Families receive written notices detailing coverage start dates and managed care plan options.
5. Choose a health plan: Many states use managed care organizations (MCOs). Review provider directories to ensure your preferred doctors and hospitals are in-network.

Coverage generally begins the month after approval, though some states offer retroactive coverage for recent medical bills.

Renewal and Reporting Changes

• Annual renewals: States conduct yearly eligibility reviews. Respond to renewal notices promptly to avoid gaps in coverage.
• Change reporting: Notify the agency if income, household size, or address changes. Many states allow updates online or via mobile apps.
• Continuous eligibility: Federal rules encourage 12-month continuous coverage for children, meaning they remain enrolled even if income fluctuates slightly during the year.

Interaction with Other Programs

• Medicaid: Children who qualify for Medicaid are enrolled in Medicaid rather than CHIP. Families can apply through the same portal; the agency determines the appropriate program.
• Marketplace coverage: CHIP-eligible children cannot receive premium tax credits on the Marketplace. However, parents and older siblings may qualify for Marketplace plans while younger children enroll in CHIP.
• Supplemental Nutrition Assistance Program (SNAP) and WIC: State agencies often coordinate outreach, allowing families to apply for multiple benefits simultaneously.
• School-based services: Many CHIP plans cover services delivered in schools, such as vision screenings and behavioral counseling.

Best Practices for Families

• Keep documents handy: Store income and identity documents in a secure folder for easy renewal.
• Use preventive services: Schedule regular checkups and vaccinations; CHIP covers these without copays.
• Choose a medical home: Select a primary care provider who coordinates care and referrals.
• Explore additional resources: Many states offer dental sealant programs, asthma education, or telehealth mental health visits. Ask the health plan about available extras.
• Monitor notices: Managed care plans send updates about provider network changes and prior authorization rules. Reading these communications prevents surprise bills.

Frequently Asked Questions

Can parents be covered through CHIP? CHIP primarily covers children and pregnant women. Some states provide limited coverage to parents through Medicaid waivers or state-funded programs, but CHIP funds cannot be used for nonpregnant adults.

What if my income increases? Report changes promptly. If income rises above CHIP limits, the child may transition to Marketplace coverage with premium tax credits. Continuous eligibility rules may allow coverage to continue until renewal.

Are undocumented children eligible? Federal CHIP funds cannot cover undocumented children, but some states use state-only funds to offer similar coverage. Check local programs for options.

Does CHIP cover behavioral health? Yes. Plans must cover mental health and substance use disorder services, often including therapy, psychiatric visits, and inpatient care when medically necessary.

How does CHIP work with employer insurance? If employer coverage is unaffordable or does not meet minimum value, children may still qualify for CHIP. Provide documentation of employer premiums when applying.

References

• Medicaid and CHIP overview – Medicaid.gov
• HealthCare.gov CHIP resource
• CHIP State Program Information
• CHIP Income Eligibility by State (KFF)

Insider Tips to Win Children’s Health Insurance Program (CHIP)

• Mirror U.S. Centers for Medicare & Medicaid Services’ priority language. Pull phrasing from the latest call documents when you describe healthcare, children, insurance, and related priorities, so panelists immediately recognize strategic fit.
• Control your timeline. Even though the opportunity accepts rolling submissions, set quarterly internal checkpoints so drafts stay audit-ready and stakeholder letters remain current.
• Prove execution capacity. Pair your narrative with data from United States and letters or MOUs that show you already have partners, facilities, and governance to deliver on the workplan.