CHIP Premiums and Copays: A Practical Guide to What Families Might Pay

The Children’s Health Insurance Program (CHIP) helps many families get low-cost health coverage for their children. But “low-cost” doesn’t always mean completely free. Depending on your state and your household income, you may have to pay monthly premiums, copays, or small deductibles.

This guide explains, in plain language, what families might pay with CHIP, what affects those costs, and how to get exact details from your official state agency. HowToGetAssistance.org is an information-only resource and is not an application site or government office, but this overview can help you know what to expect before you reach out through official channels.

What Is CHIP and How Does Cost-Sharing Work?

CHIP is a public health coverage program for children (and in some states, pregnant people) in families who earn too much for full Medicaid but not enough to afford private insurance easily.

States have flexibility in how they design CHIP, but most share some common cost features:

• Some children pay no premiums or copays at all (very low income).
• Some families pay small premiums each month.
• Most CHIP programs have low copays for doctor visits, prescriptions, or emergency care.
• There are federal limits on how much a family can be asked to pay overall in a year, based on income.

The key point: Your state and your income level largely decide whether you pay anything and how much.

Do All Families Pay Premiums for CHIP?

No. Many children covered by CHIP do not have monthly premiums. Whether you pay a premium generally depends on:

• Your household income compared to the federal poverty level (FPL)
• Your state’s CHIP design (each state sets its own rules within federal guidelines)
• Whether your state runs CHIP as:
  • A Medicaid expansion program (often no premiums), or
  • A separate CHIP program (more likely to have premiums and copays for some families)

Common Premium Patterns

While every state is different, here’s what many families see:

• Lowest-income CHIP families
  • $0 premiums, $0–very low copays, sometimes no cost-sharing at all.
• Moderate-income CHIP families
  • Modest monthly premiums, often on a sliding scale (for example, one flat monthly amount per child or per family).
  • Low copays for services like doctor visits or prescriptions.
• Higher-income CHIP-eligible families (closer to the upper income limit)
  • May have slightly higher monthly premiums and higher copays, but usually still below typical private-plan costs.

To know exactly what your premium might be, you’ll need to contact your state’s CHIP or Medicaid office or visit your state benefits portal. They can give you current charts or tools showing premiums by income level.

What Are Copays and Deductibles in CHIP?

Copays and deductibles are types of “cost-sharing.”

• A copay is a set dollar amount you pay when your child receives a service (for example, $5 for a doctor visit).
• A deductible is an amount you may need to pay before the plan starts paying for certain services (though many CHIP programs have no deductibles, or only for certain services).

Typical CHIP Copays (Examples, Not Exact Amounts)

Amounts vary, but families often see:

• Primary care visits: low copays (sometimes around the cost of a few dollars to a small bill per visit)
• Specialist visits: slightly higher copays
• Prescriptions: low copays for generics; somewhat higher for brand-name drugs
• Non-emergency ER visits: higher copays, especially if the visit could have been handled in a clinic or urgent care

Some services are commonly free or almost free, such as:

• Well-child visits and routine checkups
• Vaccinations
• Certain preventive screenings

To see which services have copays and how much they are, look at:

• The benefits summary from your state CHIP office
• An official handbook mailed or given after you enroll
• The customer service line for the CHIP managed care plan that serves your area

How Much Can Families Be Charged in Total?

Federal rules limit how much a family can be asked to pay in CHIP:

• Total cost-sharing is capped at a small percentage of your annual income (often around 5%).
• That cap usually includes premiums + copays + deductibles for the year.

Once your family reaches that cost limit:

• The plan should not charge you more for covered services for the rest of the coverage period (often the rest of the year).

Because states track this differently, it is important to:

• Keep receipts or statements for copays and premiums.
• Call your plan or state agency if you think you’re near the limit, so they can confirm.

Quick Comparison: What Families Might Pay Under CHIP

The table below is a general pattern many states follow. The actual dollar amounts and income ranges will differ by state.

*FPL = Federal Poverty Level. States use income brackets based on this to set CHIP costs.

To get the exact numbers for your state and income:

• Contact your state Medicaid/CHIP agency.
• Visit your state’s official health coverage portal.
• Ask for the CHIP premium and copay schedule.

Who Typically Pays Little or Nothing in CHIP?

Many families who qualify for CHIP fall into very low or low-income brackets. In many states:

• Children whose family income is closer to Medicaid levels often:
  • Pay no premiums
  • Have no or very low copays
• Some children are covered under Medicaid-expansion CHIP, which often:
  • Follows Medicaid’s no-cost or very low-cost structure

Besides income, some states give extra protections to:

• Children with disabilities or special health needs
• Native American or Alaska Native children
• Children in foster care or certain guardianship situations

These children may face reduced or no cost-sharing. Your state agency or caseworker can explain if any special rules apply to your child.

How Your State’s CHIP Design Affects Costs

CHIP can look different from one state to another. There are three common structures:

1. Medicaid Expansion CHIP

• CHIP is basically an extension of Medicaid for slightly higher incomes.
• Costs usually match Medicaid rules, which often means:
  • No premiums
  • No or very low copays

2. Separate CHIP Program

• CHIP operates as a separate program from Medicaid.
• States have more flexibility to:
  • Charge income-based premiums
  • Set copays and possibly small deductibles
• The federal cost caps still apply, so costs are limited.

3. Combination Programs

• Some states use both models.
• Lower-income children may be in Medicaid or Medicaid-expansion CHIP, with no or minimal cost-sharing.
• Higher-income CHIP-eligible children may be in separate CHIP, with premiums and copays.

When you contact your state CHIP office, you can ask:

• “Is our CHIP coverage through Medicaid expansion or a separate CHIP plan?”
• “Do premiums apply at our income level?”
• “Can you send or explain the copay schedule for services?”

What Documents Affect Your CHIP Costs?

You do not submit documents just to set premiums or copays, but the same documents used for eligibility determine your income level, which then decides your cost-sharing.

Typical documents include:

• Proof of identity and relationship
  • Birth certificates for children
  • Photo ID for parent/guardian
• Proof of income
  • Recent pay stubs
  • A letter from an employer
  • Self-employment records if you work for yourself
  • Unemployment benefit letters, if applicable
• Proof of address
  • Utility bill, lease, or other official mail
• Immigration or citizenship documents (if required in your state)
• Social Security numbers, if available (some states request but do not require them for everyone)

Because income is what places you into a cost category:

• Make sure your income documentation is accurate and complete.
• If your income changes significantly, you should report it to your state agency, as it can affect:
  • Eligibility
  • Premium amounts
  • Copay levels

Your state’s official benefits portal, Medicaid/CHIP office, or local county office can provide a list of accepted documents.

How and Where to Find Exact CHIP Premiums and Copays

Since CHIP rules are state-specific, you will need to check official state sources for precise information.

You can typically find details by:

1. Using your state’s official benefits or health coverage portal

   • Look for sections labeled “CHIP,” “Children’s Health Insurance,” or similar.
   • Many states offer online premium calculators or charts by income.

2. Calling the state’s Medicaid/CHIP customer service or hotline

   • Ask specifically:
     • “At our household income, do we owe a monthly premium for CHIP?”
     • “What are the copays for doctor visits, prescriptions, urgent care, and ER?”
     • “Is there a deductible for any CHIP services?”

3. Visiting a local office

   • This may be your county human services department, Medicaid office, or family services office, depending on your state.
   • You can ask staff for:
     • A printed premium/cost-sharing chart
     • An explanation of maximum yearly out-of-pocket limits

HowToGetAssistance.org is not able to access your records or quote official costs, but the agencies above can.

What Happens to Costs After You Apply for CHIP?

While steps vary by state, a typical process looks like this:

1. Application Submitted

   • You apply through your state’s online portal, by mail, or in person at a local agency office.
   • You provide income and household information.

2. Eligibility Review

   • The state reviews:
     • Whether your child qualifies for Medicaid or CHIP.
     • Which income bracket your family falls into.
   • This bracket determines whether you owe premiums and what copay tier applies.

3. Approval and Plan Selection

   • If approved, you receive:
     • A notice explaining your child’s coverage.
     • Instructions on any monthly premiums.
     • Information on managed care plans, if your state uses them.
   • In many states, you choose a specific health plan that administers CHIP, but cost levels are set by the state.

4. Billing for Premiums (If Any)

   • If your family owes premiums, you may:
     • Receive a monthly bill.
     • Be asked to set up automatic payments (optional, depending on your state).
   • Some states will not fully start coverage until the first premium is paid, while others give an initial grace period. Check your approval notice.

5. Using Coverage

   • When you take your child to a provider:
     • Show your CHIP card or plan ID.
     • Pay the copay listed in your plan materials, if one applies.

6. Annual Renewal

   • Each year (or as your state schedules it), you must renew coverage.
   • Your premiums and copays may change if your income changed or if your state updated its CHIP rules.

Common Issues That Affect What You Pay

Some families run into problems that can change or interrupt their CHIP costs:

1. Missing or Incorrect Income Information

If your income is:

• Understated by mistake, the state may later:
  • Recalculate and bill higher premiums or
  • Reassess eligibility, which can be stressful.
• Overstated, you may be placed in a higher cost tier than necessary.

To avoid this:

• Provide complete, accurate income documents.
• Respond quickly to requests for additional information.

2. Late Premium Payments

In states that charge CHIP premiums:

• Late or missed payments can lead to:
  • Warning notices
  • Temporary suspension or termination of coverage after a grace period

If you know you will have trouble paying:

• Call your state CHIP office or plan customer service as soon as possible.
• Ask if there are:
  • Grace periods
  • Payment plans
  • Any temporary hardship options your state might allow

3. Not Noticing Changes After Renewal

After your yearly renewal, the state may:

• Move you to a different cost tier based on updated income.
• Adjust premiums and copays if state rules changed.

Always read your renewal decision notice closely to:

• Confirm your premium amount
• Note any new copays or changes in coverage

If You Disagree With the Premiums or Copays

Families sometimes believe their costs were calculated incorrectly. While exact procedures vary by state, you generally have options.

You can:

1. Ask for an informal review

   • Call your state Medicaid/CHIP agency.
   • Request that they recheck your income and cost tier.
   • Confirm they have the most recent income documents.

2. Request a fair hearing or appeal

   • Most states allow you to appeal eligibility and cost decisions.
   • Deadlines are time-limited, often 30–90 days from the date on the notice.
   • Follow the instructions on your official notice very carefully.

3. Get free local help

   • Some areas have:
     • Legal aid organizations
     • Health coverage navigators
     • Community health centers that help families understand decisions and appeals

Ask your local office, 211 information line, or community clinic about organizations that help with benefits appeals.

What If Your Family Doesn’t Qualify for CHIP?

If your income is too high or you don’t meet other CHIP requirements, you still may have options for your child’s coverage:

• Medicaid (if income is lower or situation changes)
• Marketplace health plans (through the federal or state health insurance marketplace)
  • Some families qualify for premium tax credits or cost-sharing reductions.
• Employer-sponsored coverage if a parent or guardian’s job offers it
• Community health centers
  • Often provide sliding-scale fees based on income, regardless of insurance.
• Local hospital financial assistance programs
  • Some hospitals offer charity care or discounts for uninsured children.

Contact:

• Your state health coverage marketplace or official help line.
• Local community health centers.
• The billing or financial assistance office at your regular hospital or clinic.

They can help you explore options beyond CHIP.

How to Make Sure You’re Using an Official CHIP Channel (Avoiding Scams)

Because benefits programs can be confusing, some unofficial websites or services try to collect fees or personal data by pretending they can enroll you or speed things up.

To protect yourself:

• Check the website address
  • Official state sites usually end in “.gov”.
• Avoid paying third-party fees to apply
  • CHIP and Medicaid applications are free.
• Do not share full Social Security numbers or bank details on:
  • Social media
  • Unsolicited emails
  • Texts from unknown senders
• Call your state agency directly
  • Use phone numbers found on:
    • State government websites
    • Printed materials from your local human services or Medicaid office
• If unsure, call 211
  • 211 operators can help direct you to official local agencies that handle CHIP and Medicaid.

Remember: HowToGetAssistance.org does not process applications, check case status, or approve benefits. Use it only as a guide before contacting your official state channels.

Understanding how CHIP premiums and copays work can help you plan for your child’s health care costs and avoid surprises. Your state’s Medicaid or CHIP office, official benefits portal, or local human services office can give you the exact premiums, copays, and rules that apply to your family today.