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What is CHIP?

Low-income people and families unable to afford health insurance may qualify for state Medicaid coverage based on income. Some states have expanded Medicaid coverage to serve low-income people whose income isn't otherwise low enough to qualify.

Children in the coverage gap (the "donut hole") also have options. The federal government established the Children's Health Insurance Program (CHIP) to address this public health matter by expanding coverage options for children. CHIP is a Medicaid program that ensures children and adolescents enjoy healthy childhoods.

This Findlaw article provides an overview of the Children's Health Insurance Program.

CHIP Basics

CHIP is a medical assistance program jointly funded by the U.S. Department of Health and Human Services (HHS) and individual states. CHIP provides health coverage to children through Medicaid and separate CHIP programs. Individual states administer CHIP following federal guidelines. CHIP eligibility and health coverage, therefore, varies by state. States must conform to federal guidelines for comprehensive children's health care services.

The Center for Medicaid Services and CHIP (CMSC), through the Children and Adults Health Programs Group (CAHPG), oversees all aspects of CHIP. The CMSC approves new initiatives and amendments to CHIP.

CHIP Coverage

Although CHIP coverage may vary from state to state, all states must provide eligible children with comprehensive health insurance coverage including, but not limited to:

  • Routine wellness visits
  • Preventive care, including immunizations
  • Prescription medication
  • Emergency medical care
  • Laboratory and X-ray services
  • Mental health care
  • Oral health benefits (pediatric dentistry)
  • Vision care
  • Inpatient and outpatient hospital care

There is no difference in health care quality or access to health care providers for CHIP beneficiaries. Under CHIP, children have access to the same quality of care and privacy protections as other children.

CHIP Costs

CHIP costs and premiums vary from state to state. Children can get wellness visits and dental visits for free. In some states, parents must satisfy a co-pay for some services. Although these health care costs may vary depending on the state, parents will not have to spend more than 5% of the family's annual income on CHIP expenses.

CHIP Eligibility

Although eligibility for the CHIP program varies by state, only those 18 and under can apply for CHIP. The federal Health Insurance Marketplace will send your information to your state agency if anyone in your household qualifies.

Generally, your household income (modified adjusted gross income, or MAGI) determines your eligibility according to the federal poverty guidelines. MAGI is your adjusted gross income plus any of the following:

  • Untaxed foreign income
  • Social Security benefits
  • Tax-exempt interest

Medicaid and CHIP eligibility is a percentage of the poverty level. For example, New York offers the best coverage for CHIP, at 400% of the poverty level, while North Dakota provides the least at 170%. Yet, it's essential to consider how the cost of living differs around the country relative to the federal poverty guidelines.

CHIP Benefits

As noted earlier, CHIP coverage varies by state within specific federal guidelines. Coverage also depends on whether your child has CHIP coverage through Medicaid expansion or separate CHIP coverage.

Medicaid Expansion CHIP Benefits

If state Medicaid expansion, under the Affordable Care Act (ACA), covers CHIP benefits, then they'll conform to the state's standard Medicaid benefit package. This includes the following medically necessary services:

  • Early and periodic screening services
  • Diagnostic services
  • Treatment services

Separate CHIP Benefits

If your child has separate (non-Medicaid) CHIP benefits, coverage will depend on whether your state provides benchmark, benchmark-equivalent, or secretary-approved coverage.

Benchmark coverage is based on either:

  • The Blue Cross/Blue Shield preferred provider option health plan offered to federal employees
  • The state employee's coverage plan
  • The HMO plan with the state's largest commercial, non-Medicaid enrollment

Benchmark-equivalent coverage is the literal equivalent of benchmark coverage that includes:

  • Inpatient/outpatient hospital services
  • Physician's services
  • Surgical and medical services
  • Lab and X-ray services
  • Well-baby and well-child care (including immunizations)

Secretary-approved coverage is any other type of health care coverage approved by the U.S. Health and Human Services secretary.

CHIP Dental Benefits

Medicaid expansion CHIP coverage must include dental services necessary to:

  • Prevent oral diseases
  • Promote oral health
  • Treat emergency conditions

Get Legal Help

If you or a loved one is experiencing difficulty applying for CHIP, a qualified health care attorney can help. They are experts in health care law and can help you through the process. Speak to an experienced healthcare attorney near you.

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