CHIP Health Insurance Program: How Children’s Coverage Usually Works

The Children’s Health Insurance Program (CHIP) is a public health insurance program that helps many families cover medical and dental care for their children at low cost or no cost. It is run by each state, following federal rules, so specifics vary by state, but the basic idea is the same almost everywhere.

This guide from HowToGetAssistance.org explains how CHIP normally works, who may qualify, what to expect when you apply, and how to move forward through official channels. This site is not a government agency and does not process applications—it simply helps you understand the usual steps.

What Is the CHIP Health Insurance Program?

CHIP is a state-run health insurance program for children (and in some states, pregnant people) in families that:

• Earn too much to qualify for Medicaid, but
• Cannot afford private health insurance or employer coverage

In many states, CHIP is combined with children’s Medicaid under a single children’s coverage program. You might see names like:

• “[Your State] CHIP”
• “[Your State] Children’s Health Insurance Program”
• “[Your State] Healthy Kids” or similar

CHIP generally covers essential health benefits for children, such as:

• Doctor visits and checkups
• Vaccines and immunizations
• Emergency room care
• Hospital stays and surgeries
• Mental and behavioral health services
• Prescription medicines
• Vision and dental care for children in most states

Exact coverage, copays, and provider networks depend on your state’s version of CHIP and, in some states, the managed care plan assigned to your child.

Who Usually Qualifies for CHIP?

Because CHIP is a state-based program, eligibility rules differ. However, most states use several main criteria:

1. Age

CHIP generally covers:

• Children under age 19

Some states cover:

• Pregnant individuals (sometimes under a special CHIP-funded program)
• Unborn children (coverage for prenatal care)

2. Income

CHIP is aimed at low- and moderate-income families. Typical patterns:

• Families below a certain income limit based on the Federal Poverty Level (FPL) may qualify for Medicaid instead of CHIP.
• Families above Medicaid income limits but below higher CHIP limits may qualify for CHIP.
• Families significantly above CHIP income limits usually do not qualify.

Income rules vary widely. A few clues:

• Income limits are based on household size and countable income (wages, some benefits, etc.).
• Some states consider deductions (like some childcare costs or certain premiums), but not all.
• In many states, higher income families may pay modest premiums or copays, while lower-income CHIP families might have no premiums.

To find your exact income range:

• Check your state’s official Medicaid/CHIP website or
• Call your state’s Medicaid/CHIP customer service line.

3. Residency and Citizenship/Immigration Status

In most states, a child must:

• Live in the state where you apply
• Be a U.S. citizen, U.S. national, or certain eligible noncitizen status
  (such as some lawful permanent residents or other qualified statuses)

Some states offer state-funded programs for children regardless of immigration status. These are often administered alongside CHIP or Medicaid.

4. Other Coverage Rules

Common additional requirements:

• The child must not have other comprehensive health insurance (like a private employer plan), or if they do, they may not qualify for CHIP.
• Some states may have waiting periods if a child recently lost private coverage, but these rules have changed in many places—your state office can confirm.

What CHIP Usually Covers

While details differ, CHIP often includes:

• Preventive care: well-child visits, routine checkups, immunizations
• Doctor and specialist visits
• Emergency room / urgent care
• Hospitalization: inpatient, outpatient surgery
• Lab tests and X-rays
• Mental health and substance use disorder treatment
• Prescription drugs
• Dental and vision care (very common, but check your state’s rules)
• Some therapies like physical, occupational, and speech therapy when medically necessary

Costs may include:

• No monthly premium for many low-income families
• Modest monthly premiums or copays for higher-income CHIP families
• Annual cost caps: many states limit total out-of-pocket costs to a small percentage of family income

To know exactly what’s covered:

• Review plan materials sent by your state agency or
• Call the number on your child’s CHIP ID card once enrolled.

CHIP vs. Medicaid vs. Marketplace Plans

Here’s a simplified comparison to help you see where CHIP usually fits.

In many states, one combined application checks for both Medicaid and CHIP, and sometimes also screens for Marketplace eligibility.

Documents to Gather Before You Apply

Having the right documents ready can reduce delays. States differ, but families usually need:

1. Identity and Age

• Birth certificate for each child (or other official proof of birth)
• Photo ID for the adult applying (driver’s license, state ID, passport, etc.)

2. Social Security and Immigration Documents

• Social Security numbers for each person applying (if they have one)
• Immigration documents, if applicable (e.g., permanent resident card, work permit, or other official documents for eligible noncitizens)

3. Proof of Income

Typical documents (for all working adults in the household):

• Recent pay stubs (often last 4 weeks or last month)
• Most recent tax return (especially if self-employed)
• Proof of unemployment benefits
• Proof of Social Security income, pensions, or other regular income

4. Address and Residency

• A utility bill, lease, or official letter showing your name and address
• Sometimes school records or other documents confirming the child lives in the state

5. Insurance Information (if any)

• Information about any current health insurance (policy numbers, coverage dates)
• Documents about loss of coverage, if the child recently lost insurance (like a letter from an employer or insurer)

If you are unsure which documents count in your area, contact your local Medicaid/CHIP office or check your state’s official benefits portal.

How to Apply for CHIP Through Official Channels

You cannot apply through HowToGetAssistance.org. Applications must go through official state or federal systems. Typically, you have several options:

1. Apply Online

Many states offer an online benefits portal where you can:

• Create an account
• Fill out a single application for Medicaid, CHIP, and sometimes other programs
• Upload, fax, or mail supporting documents

To find the correct portal:

• Search for “[Your State] Medicaid CHIP official website” or
• Visit your state’s health or human services agency website and look for “Apply for Benefits” or “Health Coverage for Children.”

2. Apply by Phone

Most states allow you to:

• Call a state Medicaid/CHIP hotline
• Request an application by mail
• Get help filling it out by phone or find out about local help

Look for phrases like:

• “State Medicaid Customer Service”
• “[Your State] CHIP Hotline”
• “Health Coverage Call Center”

3. Apply In Person

You can often apply at:

• Local county human services offices
• Medicaid offices
• Sometimes at community health centers or hospitals that help with applications

Call ahead or check the state agency website for:

• Office locations
• Hours
• Whether you need an appointment

4. Apply Through the Health Insurance Marketplace

In many states, you can:

• Go to the federal or state Health Insurance Marketplace online or by phone.
• Complete one application that checks for Medicaid, CHIP, and Marketplace eligibility.
• If your kids appear eligible for CHIP, their information is usually sent to your state Medicaid/CHIP agency.

When using the Marketplace, be sure you are on the official site or phone line (see the scam-avoidance section below).

What Happens After You Apply?

Processing times vary by state, but here’s the usual progression:

1. Application Review

Your state agency:

• Reviews the information on your application
• Confirms identity, income, and residency
• Checks for Medicaid vs. CHIP eligibility

They may contact you if:

• Something is missing
• They need extra documents
• Information is unclear or inconsistent

2. Determination Notice

You typically receive a notice by mail, online portal, or both stating:

• Whether your child is approved, denied, or needs additional information
• Whether your child qualifies for Medicaid or CHIP
• Any premiums or copays you may be responsible for
• Next steps, such as picking a managed care plan if required

Keep this notice and any ID cards that follow.

3. Picking a Health Plan (If Required)

In many states, children get coverage through managed care plans. You may need to:

• Review a list of plan options
• Check which doctors and hospitals are in each plan’s network
• Choose a plan by a set deadline

If you do not choose, the state may assign one automatically. You can often change it later within a specified time window.

4. Coverage Start Date

Your approval notice or plan materials will state:

• When coverage starts
• Whether there is retroactive coverage (coverage going back to a certain date)

In some states, coverage may:

• Start on the first day of the month you applied, or
• Be effective from a specific approval date

Call your plan or state Medicaid/CHIP office if you are not sure.

Common Reasons Applications Are Delayed or Denied

Knowing typical issues can help you avoid them.

Frequent Delays

• Missing documents (no proof of income or residency)
• Unclear or inconsistent information (income on the application doesn’t match pay stubs)
• Not responding to requests for more information by the stated deadline
• Unreadable uploads or faxes, or documents sent to the wrong office

To reduce delays:

• Double-check that all required fields are filled
• Use legible copies of documents
• Keep your case number and any confirmation numbers
• Watch your mail, portal messages, and voicemail for follow-up requests

Common Denial Reasons

• Income too high for both Medicaid and CHIP
• The child does not live in the state
• The child is over the age limit
• The child already has other eligible comprehensive coverage
• Immigration or citizenship status does not meet the program’s rules in that state
• Application was not completed or requested information was never provided

If you’re denied, the notice should explain the specific reason and tell you about your right to appeal.

How Appeals and Reviews Usually Work

If you disagree with a CHIP decision, you typically have the right to request a fair hearing or appeal.

Key Steps in an Appeal (Typical)

1. Read the denial or closure notice carefully

   • It should explain why you were denied and
   • The deadline to request an appeal (often 30–90 days, depending on the state)

2. Submit an appeal request in writing or by phone

   • Follow the instructions in the notice
   • Include your name, case number, and a brief statement of why you disagree

3. Gather supporting documents

   • Updated income information
   • Proof of residency
   • Any letters or notices related to your coverage

4. Attend the hearing (if scheduled)

   • Hearings may occur by phone, video, or in person
   • You can usually present your side and bring additional documents

During the process, some states may allow your child to keep temporary coverage if you appeal by a certain date. The notice will explain if this applies.

If you need help:

• Ask your state legal aid office
• Look for health coverage navigators or community-based organizations that assist with appeals

If You Don’t Qualify for CHIP

If your child does not qualify for CHIP, there may be other options:

1. Medicaid

If your income is lower than you thought, or your situation changes:

• Your child might qualify for Medicaid instead.
• Many states have higher income thresholds for children than for adults.

You can:

• Recheck your situation with your state Medicaid agency
• Report changes in income, household size, or job status

2. Health Insurance Marketplace Plans

If your income is too high for CHIP:

• You may qualify for subsidized private coverage through the Health Insurance Marketplace.
• Families often get tax credits and sometimes cost-sharing reductions, which can make premiums and out-of-pocket costs lower.

You must use the official Marketplace website or phone number for your state.

3. Employer-Sponsored Coverage

If anyone in the household has access to employer health insurance:

• Review whether dependents (children) can be added.
• Compare:
  • Monthly premiums
  • Deductibles and copays
  • Provider networks

4. Community Health Clinics and Sliding-Scale Care

If none of the insurance options work:

• Community health centers, free clinics, and some hospital charity care programs may provide:
  • Low-cost or sliding-scale visits
  • Vaccines and basic care

You can dial 211 in many areas to locate local options.

How to Make Sure You’re Using an Official Channel (Scam-Avoidance Tips)

Because CHIP involves sensitive information, it is important to confirm you’re dealing with legitimate agencies.

Consider these tips:

• Check for .gov domains
  Many official state health and human services websites have “.gov” in the address.
• Use known phone numbers
  Find contact numbers from:
  • State government directories
  • Official Medicaid/CHIP or health department websites
• Be cautious of fees
  Applying for CHIP through official state or federal channels is typically free. Be cautious of:
  • Websites or individuals who charge a fee just to apply
• Protect your information
  Only share:
  • Social Security numbers
  • Immigration documents
  • Bank details (if paying a small official premium)
    with trusted, official offices or portals.
• Avoid giving information through random links
  If you get a text, email, or social media message:
  • Go directly to your state’s official site by typing the address, or
  • Call the number listed on your state agency’s known contact page.

If you’re uncertain:

• Call your state Medicaid/CHIP hotline directly and ask if a website, letter, or call you received is legitimate.

Key Takeaways and Next Steps

• CHIP is a state-run health insurance program that helps cover children (and sometimes pregnant people) in families that earn too much for Medicaid but struggle with private insurance costs.
• To see if your family qualifies, you typically need to provide proof of income, residency, identity, and Social Security or immigration documents.
• Applications are handled through official state Medicaid/CHIP offices, online benefit portals, the Health Insurance Marketplace, or local offices—not through HowToGetAssistance.org.
• If you are denied, you usually have a right to appeal and to submit updated or additional information.
• If CHIP is not an option, consider Medicaid, Marketplace coverage, employer plans, or community health centers as alternatives.

Your most reliable next step is to contact your state’s Medicaid or CHIP office or visit your state’s official benefits portal to review eligibility and start an application through the proper channels.