The Children’s Health Insurance Program (CHIP) provides health insurance to qualifying children and pregnant women within the U.S. in order to ensure that these individuals have access to adequate healthcare. Funded by both the federal government and states, the CHIP program is administered on a state level within federal guidelines.

Qualifying children and pregnant women can receive CHIP insurance at little to no cost. Families who participate in CHIP may have a small premium fee, coinsurance costs or co-payment based upon the state program and the participating family’s income. However, costs generally do not exceed five percent of a family’s annual income.

Who qualifies for CHIP Insurance?

It is important to review CHIP eligibility requirements before submitting an application to determine whether you or your child may qualify for CHIP benefits. If you are a pregnant woman, you may be eligible for benefits depending on how long into your pregnancy you are.

These requirements primarily pertain to age, income and other forms of insurance. However, state programs may include additional eligibility requirements that are important to be aware of.

Age-Related CHIP Guidelines

Unless you are a pregnant woman, age-related guidelines must be met to receive CHIP benefits. The CHIP program offers health insurance to qualifying children who are 18 years of age or younger. Once a teen reaches 19 years of age, he or she will no longer be qualified for CHIP benefits.

Income-Related CHIP Guidelines

CHIP insurance is designed to assist low- to medium-income families who make too much to qualify for Medicaid but not enough to afford private health insurance. In most states, CHIP is available to qualifying pregnant women and children with income levels that are at or above 200 percent of the Federal Poverty Level (FPL). In 24 of the 50 states, income can be as high as 250 percent of the current FPL.

Insurance-Related CHIP Guidelines

Applicants may qualify for the CHIP program if otherwise uninsured. Applicants who have another form of insurance, including Medicaid, employer-provided or private insurance, will not be eligible to receive CHIP benefits.

Other Requirements for the CHIP Program

Depending on your state program, you may experience additional eligibility requirements. For example, some states require families to be able to meet minimum premium (or other costs) requirements. However, total out-of-pocket costs are generally capped at five percent based on federal guidelines. You will need to check with your state program to learn if there are any other eligibility requirements that must be met in order to qualify for benefits.

How do you apply for CHIP insurance?

You can apply for the CHIP program in several different ways, including by mail, over the phone, online or in person at your local office. An online application is generally considered to be the fastest application method as well as the most convenient.

Perhaps the easiest way to apply for CHIP is by completing an application through the Health Insurance Marketplace. If anyone within your family qualifies for CHIP, the Marketplace will inform you of such and automatically send your information to your local state agency. Alternatively, most state agencies allow you to apply for CHIP online directly through the agency’s website.

If you would rather apply for CHIP insurance over the phone, you can do so by calling (800) 318-2596. Alternatively, you may also request an application from your local office. A paper application can either be provided to your office directly or submitted by mail.

Information and Documentation to Provide When Applying for the CHIP Program

When completing an application for CHIP insurance, you must provide personal information about yourself and each of your household members, including any children that are living within the home. Personal information that you must provide include:

  • Full names and date of births.
  • Social Security Numbers.
  • Income and employer information.

Your state agency may ask you to provide documentation in order to process your application. The most commonly requested documentation is proof of income for any household members that have an income.

When proof of income is required, you can satisfy this requirement by submitting copies of your most recent paystubs to your local office. However, it is essential that you provide any documentation that you are requested to provide in a timely manner. Failing to provide necessary documentation could result in your application being delayed or denied entirely.

Understanding Waiting Periods for the CHIP Program

You may experience a waiting period when applying for the CHIP program depending on the state that you reside in. However, 21 states have eliminated their waiting periods as of November of 2016. Most state programs that do include waiting periods are only 90 days while other waiting periods are considerably shorter.

Your local office will inform you as to whether or not there is a waiting period in your state. If a waiting period is in place, you will be informed of the length of this period.

What does CHIP perinatal cover?

The CHIP program provides health insurance for medical care to the unborn children of pregnant women who meet CHIP eligibility requirements. Once the child is born, the child will either receive Medicaid or CHIP benefits for a set period based upon family income. CHIP benefits include coverage for medical services such as:

  • Prenatal visits.
  • Certain laboratory testing, planning and educational services.
  • Certain prescription drugs, such as prenatal vitamins.
  • Services and care related to the delivery.
  • A certain number of postpartum visits for the mother after the child is born.

While the child will typically receive either CHIP or Medicaid benefits following his or her birth, the mother will only be entitled to services and care related to her delivery as well as a specified number of postpartum visits following the birth of the child. After these visits have concluded, the mother will no longer be eligible to receive benefits from CHIP.

What does CHIP perinatal not cover?

If you are receiving CHIP insurance benefits as a pregnant woman, it is crucial that you understand the medical services that the program will not cover. Services that are not covered include:

  • Inpatient care for the mother that is not related to labor with delivery.
  • Medical services that are not related to pregnancy.
  • Most outpatient specialty services, including mental health or substance abuse treatment.
  • Labor without the delivery of the baby, such as false or premature labor.

Other Differences Between the CHIP Program and CHIP Perinatal

Depending on your state program, you may not experience a waiting period after you submit an application. Additionally, you may not be subject to the same enrollment fees or copayments.

Understanding Your Right to an Appeal

If your CHIP office makes any decision on your case that you do not agree with, you have the right to an appeal. The most common reason to submit an appeal request is after being denied benefits based upon eligibility.

While an appeal does not guarantee that a different decision will be determined, it does ensure that a second look is given to your case. If the decision made on your case or application was made correctly, the decision will stand. If a new decision is reached, the new decision will take precedence over the old one.

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