CHIP Eligibility Basics: Understanding Income Guidelines and Age Rules

The Children’s Health Insurance Program (CHIP) is designed to help families who earn too much to qualify for Medicaid, but still struggle to afford private health coverage for their children. Knowing who qualifies, especially the income limits and age rules, can help you decide whether it’s worth applying through your state’s official channels.

HowToGetAssistance.org is an informational site only. This guide explains how CHIP typically works so you can better understand your options. To apply or get an official decision, you’ll need to use your state’s official benefits portal, CHIP/Medicaid agency, or local assistance office.

What Is CHIP and Who Is It For?

CHIP is a public health insurance program for children and, in many states, pregnant people and sometimes parents or caregivers. It generally:

• Helps cover doctor visits, checkups, vaccines, prescriptions, emergency care, and hospital stays
• Is managed by each state, often through the same agency that runs Medicaid
• Has no or low monthly premiums, and usually low copays, depending on income and state rules

Because CHIP is state-run, details like income limits, age cutoffs, and covered groups vary. However, most states follow similar basic eligibility ideas:

• The child must live in the state.
• The child must be under a certain age (commonly under 19).
• The family’s income must fall below a state-defined limit for CHIP.
• The child must not have other affordable health coverage that meets state criteria.

CHIP Age Rules: How Old Can a Child Be?

Most states design CHIP for uninsured children and teens, generally through high school age. Common patterns include:

Typical Age Limits

While specific ages can differ, many states use rules similar to:

• Children from birth up to age 19 (up to the day before their 19th birthday)
• Some states categorize age groups, for example:
  • 0–5 years
  • 6–18 years

Each age group may have slightly different income limits or cost-sharing rules, but they are usually all still considered CHIP children.

Special Age-Related Situations

In some states:

• Youth who were in foster care may qualify for extended coverage under Medicaid past age 18, but that is often handled outside of CHIP.
• A child who turns 19 will usually age out of CHIP and need to look at adult coverage options like Medicaid for adults, employer plans, or coverage through the federal Health Insurance Marketplace.

Because the exact cutoff and age-related rules vary, it’s important to:

• Check your state’s official CHIP or Medicaid website, or
• Call your state’s CHIP/Medicaid customer service line and ask:
  • “What is the maximum age for CHIP coverage in this state?”
  • “What happens when my child turns [18/19]?”

Income Guidelines: How Much Can You Make and Still Qualify?

CHIP is specifically aimed at families whose income is too high for Medicaid but still limited. Each state sets its own income ranges, and they’re usually based on a percentage of the Federal Poverty Level (FPL).

How CHIP Usually Looks at Income

States typically consider “household income”, which often includes:

• Wages from jobs (before most taxes, but after certain pre-tax deductions in some states)
• Self-employment income
• Some forms of unemployment, Social Security, or pensions
• Other regular income, like alimony or certain benefits, depending on state rules

Each state also defines who counts in your household, often including:

• The child or children
• Parents or legal guardians living with the child
• Sometimes a spouse or step-parent, depending on how the state defines a “household”

Income Limits Are Different in Every State

While the exact numbers differ, many states set CHIP income limits that go significantly above poverty level. That means some middle-income families still qualify for reduced-cost coverage for their children.

Because limits change over time and vary by state, the most reliable way to know is to:

1. Visit your state’s official CHIP or Medicaid website, or
2. Use your state’s official health coverage or benefits portal to do a pre-screening, or
3. Call your state’s CHIP/Medicaid hotline and ask:
   • “What are the current income limits for CHIP for a family of [your household size] in this state?”

You do not need exact numbers memorized ahead of time. Having a general estimate of your monthly or yearly income and household size is usually enough for staff to tell you whether it’s worth submitting an application.

Quick Reference: CHIP vs. Medicaid for Kids (Typical Patterns)

Specific rules vary, but many states follow a structure similar to the example below. This is not official for your state, only a simple illustration of how programs might be layered.

To find out exactly where your family fits, you will need to use:

• Your state’s official benefits portal, or
• Your local county or state health/Medicaid office, or
• Your state’s CHIP information line.

Other Common Eligibility Factors

In addition to income and age, states often use a few more conditions.

Residency and Citizenship / Immigration Status

Most states require that:

• The child lives in the state and
• Meets certain citizenship or immigration criteria, which can include:
  • U.S. citizens
  • Certain lawfully present immigrants (depending on state rules)

Immigration-related rules can be complex, so it is common for people to:

• Call their state’s Medicaid/CHIP office and ask about coverage options for non-citizen children or families.
• Use local legal aid or immigrant support organizations for more detailed guidance.

Existing Health Coverage

CHIP is for uninsured children in most states. That usually means:

• If a child already has comprehensive, affordable coverage through an employer plan or another government program, they may not qualify for CHIP.
• Some states have specific rules about dropping private coverage right before applying for CHIP, including possible waiting periods or other conditions.

Always tell the official caseworker or eligibility worker about any current insurance, even if you think it doesn’t fully cover your child’s needs. They can explain how it affects CHIP eligibility in your state.

Documents to Gather Before You Apply

Having documents ready can help prevent delays. Requirements differ, but many states commonly ask for:

1. Identity and age of the child:

• Birth certificate, passport, or other legal document
• Sometimes school or medical records, if accepted by the state

2. Proof of residency:

• A lease, rental agreement, or mortgage statement
• Utility bill with your name and address
• Official mail from a government agency

3. Proof of income for everyone in the household who works or earns money:

• Recent pay stubs (often last 4–6 weeks or last 30 days)
• Tax returns or W-2s (used sometimes as backup)
• Records of self-employment income or profit/loss statements
• Letters or statements for unemployment benefits, Social Security, or other income

4. Immigration or citizenship documents (if applicable):

• U.S. passport, naturalization certificate, or certificate of citizenship
• Permanent Resident Card (green card), or other immigration documents accepted by your state

5. Information about any current health insurance:

• Insurance ID cards
• Policy numbers
• Employer information, if the coverage is job-based

📝 Tip: When you contact your state’s office or hotline, you can ask directly:
“What documents should I bring or upload for a CHIP application in this state?”

How and Where to Apply for CHIP

HowToGetAssistance.org cannot accept applications or check application status. To actually apply, you need to go through official state or federal channels.

Typical ways to apply include:

1. Online Through an Official Portal

Most states allow you to apply:

• Through a state benefits website that handles Medicaid and CHIP, or
• Through the federal Health Insurance Marketplace, which can route information to your state’s Medicaid/CHIP office if your child appears eligible.

Look for websites that clearly identify themselves as an official state or federal government site, often with:

• A “.gov” web address, or
• A clear statement that it is the official state site for health coverage.

2. By Phone

Many states have:

• A toll-free CHIP or Medicaid hotline where you can start an application, ask questions, or request a paper form.
• Phone representatives who can walk you through income rules, age criteria, and required documents.

When calling, you might ask:

• “Can you tell me the income and age rules for children’s coverage in this state?”
• “Can I start a CHIP application over the phone?”

3. In Person

You may be able to apply at:

• Your county human services department
• A local Medicaid office
• A community health center that partners with the state program
• A family resource center or social services office

In-person help can be useful if:

• You have complex income, such as self-employment
• You are unsure which documents will count
• You prefer to hand over copies of documents directly

What Happens After You Apply

While timelines and procedures vary by state, the process commonly includes:

1. Application review

   • The agency checks your household size, income, age, and residency.
   • They may compare your information to federal or state data sources (with your permission) to verify details.

2. Requests for more information (if needed)

   • If something is missing or unclear, you might receive a letter, email, or portal message asking for:
     • Additional pay stubs
     • Proof of address
     • Clarification about existing insurance

3. Eligibility determination

   • You receive a written notice (by mail, portal, or both) telling you whether your child is:
     • Approved for Medicaid, or
     • Approved for CHIP, or
     • Found ineligible, with a reason listed

4. Enrollment and coverage start date

   • If approved, the notice will usually explain:
     • Which program the child is in (CHIP or Medicaid)
     • The start date of coverage
     • Any premiums or copays, if the state charges them
     • How to choose a health plan or doctor, if plans are part of your state’s system

If you don’t receive any communication within the timeframe the agency provided, you can:

• Call your state’s CHIP/Medicaid office
• Log into your official benefits account to check application status

Common Reasons CHIP Applications Are Delayed or Denied

Understanding common issues can help you avoid problems.

Frequent Causes of Delay

• Missing documents, such as pay stubs or proof of address
• Unreadable copies of documents (blurry photos, incomplete scans)
• Incomplete forms, including unanswered questions about income or household members
• Not responding quickly to requests for additional information

To reduce delays:

• Provide complete, clear copies of documents.
• Check mail, email, or your online account regularly for messages from the agency.
• Contact the office if you receive a notice you don’t understand.

Typical Reasons for Denial

Each decision should be explained in the official notice, but common reasons include:

• Income above the state limit for CHIP for your household size
• The child already has other qualifying health insurance
• The child is over the age limit for CHIP in your state
• The child doesn’t meet residency or citizenship/immigration criteria as defined by the program
• Incomplete application that was never finished, even after requests for more information

If you receive a denial and disagree, you usually have the right to an appeal or fair hearing.

How Appeals and Reviews Usually Work

If you think a decision was made in error, most state programs allow you to:

1. Request an appeal or fair hearing

   • Your notice should include instructions and a deadline (often 30, 60, or 90 days from the date on the letter).
   • You may be able to start an appeal by mail, online form, or phone.

2. Submit additional information

   • If the denial was due to missing or unclear income proof, you can often send better or updated documents.
   • Clearly label any appeal documents with your name, case number, and contact information.

3. Participate in a review or hearing

   • This might be a phone conference, video meeting, or in-person appointment, depending on your state.
   • You can explain your situation and present documents showing why you believe the decision was wrong.

If you feel overwhelmed, you may:

• Contact a local legal aid organization, community health center, or nonprofit that assists families with public benefits appeals.
• Ask the state’s customer service if there are any free assistance programs that help with appeals.

If You Don’t Qualify for CHIP: Other Options to Explore

If your child isn’t eligible for CHIP, there may still be alternatives.

1. Medicaid for children or pregnant people

• In some states, your income may be too high for CHIP but low enough for a different category, or vice versa.
• Ask the agency to confirm that they checked all possible categories, including Medicaid.

2. Health Insurance Marketplace plans

• Families who do not qualify for CHIP or Medicaid may be able to get private plans with subsidies through the federal Health Insurance Marketplace.
• Subsidies are usually based on household income and can significantly lower monthly premiums.

3. Employer-sponsored coverage

• If a parent or guardian has access to job-based insurance, adding a child to that plan may be another option, depending on cost and coverage.

4. Local low-cost or sliding-scale clinics

• Community health centers and free clinics may offer care on a sliding fee scale based on income, even without insurance.
• You can dial 211 in many areas to ask about local clinics and low-cost options.

Verifying You’re Using an Official Channel and Avoiding Scams

Because CHIP is a public program, you should not have to pay any company just to apply. To protect yourself:

• Look for .gov or clearly official state branding on websites where you enter personal information.
• Be cautious of sites that:
  • Charge a “processing fee” to submit a CHIP application
  • Guarantee “instant approval”
  • Ask for sensitive information without clearly being a state or federal agency
• When in doubt, you can:
  • Call your state’s Medicaid or CHIP information line and ask for the correct website or office address
  • Dial 211 to request help locating your official state CHIP/Medicaid office

You should not be required to:

• Pay a private service to “unlock” CHIP benefits
• Share bank passwords or unrelated financial details
• Sign up for unrelated products as a condition of applying

Key Takeaways to Help You Take the Next Step

• Age rules: CHIP usually covers children and teens up to around 19, but you must confirm the exact cutoff with your state’s program.
• Income guidelines: Each state sets its own income limits based on household size and income. Many families who don’t qualify for Medicaid may still qualify for CHIP.
• Other factors: Residency, immigration/citizenship status, and existing coverage can affect eligibility.
• Where to apply: You must apply through an official state or federal portal, by phone, or at a local government office, not through HowToGetAssistance.org.
• If denied: You can usually appeal or ask for a review, and you may have other coverage options such as Medicaid, Marketplace plans, or low-cost clinics.

If you believe your child might qualify, your most direct next step is to contact your state’s CHIP or Medicaid office or visit your state’s official benefits or health coverage website to review current income guidelines and age rules and start an application through the proper channel.