Understanding CHIP Health Coverage for Children

(DailyDig.com) – There’s no question that health care in the US is expensive, and out of reach for many families.  CHIP (Child Health Insurance Program) is a federal program that offers coverage to qualifying children under 19. Pregnant women are also eligible for CHIP health coverage.

General Qualifications

These are the guidelines that most states follow. Since the states also contribute to funding CHIP, they have some flexibility with setting the guidelines for each state.

  • Be younger than 19 and a resident of the state
  • Be a citizen of the US  or a qualified immigrant
  • Have no insurance
  • Qualify within the state’s income limits, and any other state-specific criteria
  • Some children are automatically ineligible for CHIP.
  • Inmates at public institutions, including mental health facilities
  • Ability to qualify for coverage with a state benefit plan, such as a parent’s job with a public agency

This healthcare is not necessarily free; there may be co-payments (you pay part, and Chip pays the rest)  for some services. Some states charge a monthly premium for CHIP, but that premium will not be more than 5% of your annual income.

Certain states also cover prenatal and delivery care for pregnant women. Check with your state to see what benefits are available for pregnant women. A child born to a mother covered under CHIP is automatically guaranteed benefits until they turn one.

Types of Benefit Programs

States can design their own CHIP benefits plan one of three ways—Medicaid expansion, a separate CHIP program, or a combination of both.

Medicaid Expansion

If your state participates in Medicaid expansion under the Affordable Care Act (ACA), CHIP benefits in your state are the same as Medicaid. This plan includes the Early and Periodic Screening, Diagnostic and Treatment services (EPSDT), which guarantees children in the program receive early diagnosis and care to avoid health problems later on. This includes routine check-ups, including vision care, and trips to the dentist.

Separate CHIP Benefits

If your state does not participate in Medicaid expansion, CHIP offers similar coverage, either benchmark or Secretary (Health and Human Services) approved benefits.


Benchmark coverage means that CHIP offers care that is equivalent to a government or private plan in that state.

Blue Cross Blue Shield provides health care coverage to federal employees, and the benchmark program is “substantially equal” to the BCBS plans. Some states base their coverage on the plans they offer state employees. The third option is a Health Maintenance Organization (HMO) plan through the largest commercial enrollment in that state.

Dental care follows those same guidelines; CHIP recipients get coverage based on an equivalent federal, state, or private plan.

Benchmark services must include the following services, regardless of whether the guideline plan includes them.

  • Routine physicals and doctor visits
  • Prescriptions and immunizations
  • Inpatient and outpatient care
  • Dental and vision care
  • Emergency, X-ray and lab services

Mental Health Care

CHIP falls under a federal program that prohibits discrimination that can limit coverage for mental health, substance abuse treatment, and behavioral care. This means that for payment and service use, these services are treated like a trip to the doctor for a sore throat. There are no limits on the following.

  • Copays, coinsurance, and out-of-pocket maximums
  • Limitations on services utilization, such as limits on the number of inpatient days or outpatient visits that are covered
  • The use of non-quantitative treatment limitations, such as care management tools, and criteria for medical necessity determinations

 How to Apply for CHIP

You can apply for CHIP at any time. Here’s how.


Log into the Health Insurance Marketplace at healthcare.gov (make sure it’s the .gov website; there are no fees to apply) and complete the application. If anyone in your family qualifies for CHIP, they forward your information to your state and they will get in touch about enrolling in CHIP.

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