Who Qualifies for CHIP health insurance?

CHIP is a health coverage program for: 

• Uninsured children up to age 19 in families with incomes too high to qualify them for Medicaid 
• Low-income pregnant women and/or newborns (in some states) who do not qualify for Medicaid

Since CHIP varies by state, the exact benefits a particular state covers may differ from other states. However, all states must provide comprehensive coverage including:

• Routine checkups
• Immunizations
• Doctor visits
• Prescriptions
• Dental and vision care
• Inpatient and outpatient hospital care
• Laboratory and X-ray services
• Emergency services

These benefits are similar to Medicaid services offered to consumers.

Some states charge small premiums and/or copayments for CHIP coverage. Families with children enrolled in CHIP aren't required to pay more than 5 percent of their yearly income for CHIP coverage – including out-of-pocket costs – but most programs charge premiums that are far lower. Cost sharing (e.g., deductibles, copayments, and coinsurance) isn't allowed for certain preventive services like well-baby or well-child visits.

Some states also require that children be uninsured for up to 90 days before they can enroll in CHIP. Remember, MAGI is used to calculate consumers’ financial eligibility for CHIP. Each state’s CHIP program has its own rules about who qualifies for CHIP:

• Most states cover children in families with incomes up to at least 200 percent of the FPL.
  • Nearly half of these states offer coverage to children whose household income is at or above 250% of the FPL.
  • Other states allow children with higher income levels to pay higher premiums and buy into CHIP.

Remember, states also have the option to provide CHIP coverage to some low-income pregnant women. In a few states, CHIP provides coverage to women for the duration of their pregnancy. Infants born to women enrolled in Medicaid or CHIP are automatically eligible for Medicaid or CHIP up to one year of age. Under the Affordable Care Act, new mothers who lose access to healthcare services provided through unborn child CHIP coverage following the birth of their child may qualify for an SEP 60 days before or after their loss of coverage if they are otherwise eligible to enroll in a QHP through a Marketplace. The Affordable Care Act also gives states the option to extend CHIP eligibility to the children of state employees who were previously excluded from CHIP coverage.