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Learn About the different CHIP Insurance plans

Understanding CHIP Insurance and How It Can Help You

The Children’s Health Insurance Program, or CHIP insurance, is a federal health care program that provides low-income families with coverage for their children. This form of health insurance was established in 1997 and its main purpose remains the same. Generally, the program is meant to help families in which the parents or guardians do not qualify for Medicaid but cannot afford private coverage.

While the CHIP program is mainly intended for children, pregnant women may receive coverage in some states. States have control over how Medicaid and CHIP are connected and whether these programs are independent of one another. As a result, it is important to check the guidelines for CHIP established in your state. It is also important to learn how this form of insurance works, so that you will know how to navigate the program and what to expect.

What types of CHIP insurance exist in different states?

While Medicaid for children exists, CHIP is technically a different program in many states. This is because states have constructed their own programs while abiding by federal guidelines. Each state has chosen to either expand Medicaid, create a separate CHIP program or use a combination of both.

Note: Medicaid also offers coverage to low-income children, even if a state has separate CHIP and Medicaid programs. This occurs when an entire family qualifies for Medicaid.

If a state has chosen to expand its Medicaid program, it will provide qualifying children with a Medicaid benefits package that offers the same coverage as a CHIP package. Children and teens must have coverage for the following:

  • Early and periodic screenings
  • Diagnostic services
  • Treatment services

These services are often shortened to the EPSDT benefit. The EPSDT benefit helps ensure that each state gives low-income children routine check-ups and early detections, so that potential health problems are spotted more quickly and treated properly.

If your state offers a separate form of CHIP health insurance, it may implement one of three types of coverage: benchmark coverage, benchmark-equivalent coverage or secretary-approved coverage.

Benchmark coverage must provide health care that is equal to a federal employees health benefit plan, state employee plan or a Health Maintenance Organization (HMO). As a result, your state’s CHIP program will closely follow the requirements of federal health plans for employees.

Benchmark-equivalent coverage must meet certain benchmark qualifications and cover additional specified services. For instance, they must cover inpatient and outpatient hospital services, physician’s surgical and medical services, laboratory work and X-rays. Some states may have additional requirements for benchmark-equivalent plans.

Finally, CHIP for kids in the form of secretary-approved coverage is simply health care that has been approved by the state secretary. The secretary is responsible for designing appropriate coverage for low-income children that still follows federal guidelines. Oftentimes, secretary-approved coverage is equal to child health care under the Medicaid state plan.

Understanding how your state has designed its health insurance program for low-income children may help you complete the CHIP application process and gain a better understanding of the types of benefits your children may receive.

For more information about CHIP insurance, download our comprehensive guide.

What types of benefits do CHIP programs cover?

Your state’s CHIP healthcare program must abide by federal benefit guidelines, regardless of how it designed its state health care programs. Every state is required to offer qualifying low-income children the following types of coverage:

  • Well-baby and well-child care. These are routine checkups administered by a pediatrician or approved doctor. The purpose of these visits is to make sure that babies and children are up to date on their vaccinations and generally healthy. It may also cover federal early-detection requirements. Each state may choose when routine visits should take place.
  • Dental benefits. All children who have CHIP eligibility will receive dental coverage. According to federal guidelines, states that offer separate CHIP programs must cover dental visits that prevent disease, teach children about oral health, administer treatments and operate on oral emergencies.
  • Behavioral health care. According to the Mental Health Parity and Addiction Equity Act (MHPAEA), both Medicaid and CHIP programs must cover certain mental health and substance abuse treatments. A plan’s guidelines on copays, coinsurance or out-of-pocket maximums must abide by the MHPAEA. Thus, you or a child who has been denied behavioral health care may be protected under parity laws.
  • All forms of CHIP insurance must offer vaccine coverage for qualified children and teens. The vaccines offered must be age appropriate. If your state has a separate Children’s Health Insurance Program, it must fund vaccines using federal and state matching funds. Note that Medicaid operates differently, because it receives funding from the Vaccines for Children (VFC) program.
  • Qualifying children who require prescription medicine to treat or prevent certain symptoms or illnesses must be covered by CHIP for those prescriptions. This may include asthma medication, antibiotics, nasal spray and more.
  • Perinatal coverage. If you are pregnant, meet the CHIP income guidelines and your state offers perinatal coverage, you may receive coverage for health care that aids your unborn child. For instance, some states will cover prenatal visits, laboratory testing, prescription drug coverage that directly relates to pregnancy, hospital expenses for delivery and more.

To learn more about CHIP insurance coverage, download our comprehensive guide.

What happens if you are approved for CHIP insurance?

After you apply for the program, you will undergo the CHIP enrollment process. You must go through the same state enrollment process regardless of whether you applied through the Health Insurance Marketplace or your state’s Medicaid or CHIP agency. If you applied through the Health Insurance Marketplace, your information will be sent to your local agency.

If you or your children are approved for coverage, you will receive a notification from your state’s Medicaid or CHIP program. You will also be informed of how long your child’s coverage will last and what steps you need to take to complete your enrollment. Note that coverage typically lasts a full year, unless you move out of the state or your child becomes too old for the program.

Once you are approved for CHIP insurance, you usually need to select a primary care provider (PCV). In general, you may see a provider even if you do not have your health care card yet. In some states, you may also need to select a health plan after you are approved for coverage.