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What to Do After Applying for CHIP

After you submit your application to get benefits from the Children’s Health Insurance Program (CHIP), you have to complete the next steps in the process. This includes negotiating with the agency about procedures and sometimes appealing a denial of benefits. However, it also includes communicating with your state’s agency or changing your CHIP plan when necessary. Navigating those changes and communications can be a challenge for inexperienced parents. Therefore, it is important to learn how CHIP operates and what steps are required to claim or change benefits.

More than 9 million children each year are covered by the CHIP program, making it a vital insurance provider for low-income families. Even more receive coverage through a Medicaid-CHIP combined program. However, if you do not know how to navigate the program, you may have difficulty using your benefits. Therefore, you should familiarize yourself with the process of claiming benefits within CHIP after enrolling. The sections below describe how to handle CHIP denials, how to communicate with CHIP agencies and how to change your child’s plan.

How to Navigate CHIP Agencies

When you apply for benefits through the CHIP program, you begin a relationship with your state’s CHIP agency. Throughout your time in the program, you will need to contact your the agency regularly. For example, when you are seeking a new doctor, you should call to receive recommendations for in-network doctors and to help book an appointment. Additionally, if you have questions about your benefits or coverage, you should contact your agency to find out what options are available.

Sometimes, the CHIP program may deny you access to benefits you believe are included in your coverage. You can appeal a rejection for a particular benefit if you think it was denied erroneously. To do so, you would contact the CHIP agency and speak to a representative over the phone. In other cases, you may be required to seek approval or permission before obtaining a particular treatment. Many state programs allow you to seek basic medical care without permission but require prior approval for more advanced or expensive procedures.

It is important to familiarize yourself with the contact information to access your children’s healthcare benefits. When you enroll in CHIP for your children, you should review your enrollment card or benefits handbook. The handbook or card will have instructions on who to contact in various situations. You may have different contact numbers for different types of services. Therefore, you should keep track of the book or card you are presented when you sign up. The contact information included in the card or book is critical for you to gain full access to your child’s CHIP health plan.

To learn more about how to navigate your CHIP agency, download our informative guide on CHIP.

Understand CHIP Denials and Appeals

Sometimes when you apply for the CHIP program, your application is denied. This may happen if you do not meet the eligibility requirements for coverage. For example, children must be 19 years of age or younger to qualify and live in a household with an income that is somewhere within a certain percentage of the Federal Poverty Level (FPL). If you believe you were incorrectly denied entry into the program, you may be able to appeal the decision.

When you are enrolled in the CHIP program, you must sometimes request permission to obtain particular services. Basic services may be obtained without previous arrangement. However, more complex or expensive procedures commonly require prior approval. In some cases, when you request that CHIP covers a particular expense, you may receive a CHIP denial letter instead. The letter will describe why you were denied benefits and may also include information on how to appeal the decision. In that case, you may have to file an appeal for services to get the request re-examined and approved. Typically, your denial letter will describe the process for filing an appeal. You may be able to send in a written notice or call the CHIP agency to report that you want to appeal the denial.

The procedures for appealing a CHIP denial letter can vary from state to state. You may have anywhere between 10 and 180 days to challenge a denial of benefits and request an appeal. If you receive a CHIP denial letter, read the details carefully to ensure you appeal the decision correctly.

If you believe you were denied services erroneously, you should submit your appeal for CHIP benefits. After you submit your appeal, the state will consider your request and whether it should reconsider the decision. You may be able to appeal the decision again. Your final option is to request that your service request be considered by an independent review organization (IRO). The IRO will review your request and make a final decision regarding your medical services.

Download our comprehensive guide to learn more about navigating within CHIP.

How to Change Your CHIP Health Plan

Depending on how a state funds and organizes its CHIP program, you may have several CHIP plans to choose from. These plans may be arranged to offer benefits at different cost levels or offer different sets of benefits, depending on the state. For example, the state of Utah has three separate CHIP health plans. The plans differ based on the income of the eligible applicants, with different levels of payment plans available. The state of Texas also has different plans available for CHIP enrollees. Texas’s plans have  different benefits between them, and they may be available only within particular counties. For example, the UnitedHealthcare CHIP health plan allows children to stay on the plan up to age 20 and includes value-added services. However, it is limited to residents in particular counties of Texas.

In some cases, your state agency may allow you to change your CHIP health plan if a situation has arisen requiring a new plan. For example, if your child has developed a new medical condition and requires new treatment, or your income has changed, you may need a different plan. Additionally, if you move, you may be required to subscribe to a new plan. Not all states offer a variety of plans, instead offering a single streamlined plan for enrollees. You should contact your state’s agency to explore options and determine if you can switch your child’s plans. You should renew your child’s enrollment annually. You may be able to complete the switch when you renew your child’s enrollment in the program for the year.