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What does CHIP cover?

CHIP coverage can vary greatly from one state to the next. The Children’s Health Insurance Program (CHIP) is a federal medical assistance program that serves low-income communities. Some families earn too much to qualify for Medicaid but cannot afford private insurance for their kids. Therefore, they turn instead to CHIP health coverage. There are a few benefits that are offered in every state. This includes routine check-ups, immunizations and other basic medical services. However, each state can decide to offer additional services.

Based on the perceived needs of their communities, states can add CHIP benefits such as hospice care and medical transportation to their program. It is important to note that states that have a CHIP program with Medicaid can benefit from the same benefits offered in that program. In some cases, there are additional health coverage benefits for children. For an overview of the CHIP health coverage benefits, review the sections below.

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Learn About Standard CHIP Benefits in Every State

While each state creates its own process for CHIP coverage, there is some overlap in benefits across all states. By law, all states providing CHIP must offer the following services:

  • Routine checkups: These are tests that a primary care provider (PCP) will perform to check an individual’s overall health. Depending on the beneficiary’s age and previous medical history, the PCP may perform certain tests and discuss any changes in health.
  • Immunizations: To protect children against preventable infections and illnesses, states will provide free or low-cost vaccines for immunization.
  • Prescription drugs: Prescription medication can be very costly, especially for beneficiaries with chronic conditions. States are required to provide access to affordable prescription drugs.
  • Dental care: Oral health care is very important, as tooth decay is a chronic disease among children that is fully preventable. Dental CHIP benefits for children must include the restoration of teeth, dental health maintenance such as periodic teeth cleanings, relief of pain and treatment for infections.
  • Vision care: States must offer access to vision screenings to identify any issues with vision in beneficiaries. In addition to screenings, access to treatment is always necessary, such as eyeglasses.
  • Doctor visits: In addition to visits to PCPs, CHIP recipients must also have access to specialists for free or at low costs.

Inpatient and outpatient hospital care, along with emergency services, are additional CHIP benefits that are standard across all states. It is important to note that some states require beneficiaries to pay a small copayment for certain services. In some states, however, all services may be free. It depends on the state and the type of coverage for which the family is eligible.

Download our informative guide to find out more about the health coverage services in CHIP.

Understand Medicaid Expansion CHIP programs vs. Separate CHIP programs

Because CHIP is a federal program, states have the option to implement CHIP coverage in one of three ways. The first is by having the CHIP program as an extension of their Medicaid program. The second option is by having a separate CHIP program that is unrelated to the state’s Medicaid option. The third option is by combining these two options with a health insurance program for kids that runs semi-independently. This will affect the types of services that beneficiaries can expect in their states.

In states where CHIP is part of a Medicaid expansion, CHIP benefits include a plan called Early, Periodic, Screening, Diagnostic and Treatment (EPSDT). Early services are those that allow beneficiaries to receive medical attention to evaluate and identify medical issues early on. Periodic services are medical visits at specific time intervals to check for any new medical issues. Screening services include hearing, vision and developmental tests, among others, which screen beneficiaries for any medical issues. If the screenings reveal areas of concern, then treatment must follow. For instance, if a vision screening finds that a CHIP recipient has defects in her or his vision, the program may cover eyeglasses as appropriate treatment. Other services include physical exams, immunizations and lead screenings.

With health insurance coverage for children, diagnostic services are available to beneficiaries who are facing a potentially dangerous medical issue and require additional testing. States where CHIP works as a Medicaid expansion must ensure that beneficiaries receive appropriate care following an examination that indicates the need for follow-up work. This includes following up with referrals to ensure a diagnostic evaluation is complete and well-rounded care is available to the enrollees. Treatment services seek to remedy or control health issues. The purpose behind these types of services is to provide children with access to medical services during childhood in hopes of discovering and treating any health conditions before they worsen into adulthood.

 Are there additional CHIP benefits?

In addition to the comprehensive services offered by CHIP, some states offer additional CHIP benefits to their recipients. In most states, additional CHIP services include mental health services, substance abuse treatment and medical transportation. In states like Arizona, Colorado and Mississippi, the CHIP benefits include a 24/7 service where CHIP recipients gain direct access to trained and licensed nurses. Some states, such as Nevada, Oklahoma and Rhode Island have programs within their CHIP services to help individuals stop smoking.

For a detailed look at the benefits you can expect in every state as a CHIP beneficiary, download our comprehensive guide.

What is generally not covered under CHIP benefits?

CHIP coverage varies from one state to the next due to a variety of factors. There are some benefits that only certain states offer. However, it is important to keep in mind that there are some medical services that CHIP in most states does not cover. The program serves low-income communities and seeks to provide children with access to basic medical care. Therefore, the program does not have additional funding for elective procedures. While the following list does not include a full list of services, it does include a list of some services that are not covered by CHIP benefits:

  • Acupuncture
  • Cosmetic or plastic surgery
  • Fertility treatments
  • Physical exams for employment, insurance and more
  • Weight reduction programs
  • Experimental care
  • Herbal supplements