CHIP Coverage Explained: What It Pays For And How The Program Works

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 insurance for their children. It typically offers low-cost or no-cost health coverage for kids, and in some states, for pregnant people as well.

This guide from HowToGetAssistance.org explains what CHIP usually covers, how it works, and what to expect when you go through the official application and enrollment process. This site is not a government office or an application portal, but it can help you understand the next steps to take with your state’s official CHIP or Medicaid agency.

What Is CHIP, In Plain Language?

CHIP (Children’s Health Insurance Program) is a public health coverage program that:

• Is run by each state (often together with Medicaid)
• Helps cover children up to age 19 in many states
• May also cover pregnant people in some states
• Is aimed at families with low to moderate incomes

States have flexibility in how they design their CHIP programs, so:

• Names can vary (for example, some states use a state-specific name instead of “CHIP”).
• Rules and benefits can differ from state to state.
• Some states run CHIP as a Medicaid expansion, while others run it as a separate CHIP program, or a blend of both.

Even though details differ, the goal is the same: affordable health coverage for children.

What Does CHIP Typically Cover?

CHIP is meant to provide comprehensive health coverage for kids. The exact benefits depend on your state, but most CHIP plans include:

Core Medical Services

Most CHIP programs cover:

• Doctor visits, including routine and sick visits
• Well-child checkups and physical exams
• Immunizations (vaccines)
• Hospital care (inpatient and often outpatient)
• Emergency room visits
• Urgent care visits
• Specialist care (such as cardiologists, dermatologists, etc.)

These services are usually similar to what you’d see in a standard health insurance plan for children, but often at a much lower cost.

Preventive and Routine Care

Preventive care is a major focus. CHIP commonly covers:

• Routine well-child visits
• Growth and developmental screenings
• Vision and hearing screenings
• Behavioral and mental health screenings
• Lead tests and other recommended childhood screenings

Copays for preventive visits are often low or $0, but this varies by state.

Prescription Drugs

Most CHIP plans include coverage for:

• Prescription medications
• Some over-the-counter drugs when prescribed

Your state’s CHIP program usually has a preferred drug list or formulary, and may require:

• Small copayments for certain medications
• Prior authorization for some higher-cost drugs

Dental and Vision Care

Many families turn to CHIP specifically for help with dental and vision costs. These benefits often include:

Dental:

• Routine dental checkups and cleanings
• X-rays
• Fillings and other basic restorative care
• Some level of emergency dental treatment

Vision:

• Eye exams
• Glasses or contact lenses, usually with limits on how often they can be replaced

The scope of dental and vision coverage can differ by state, so it’s useful to check the official materials from your state’s CHIP program for details.

Mental and Behavioral Health Services

Many CHIP programs cover:

• Mental health evaluations
• Counseling or therapy
• Substance use treatment services for adolescents (when medically appropriate)
• In some cases, inpatient or intensive outpatient mental health treatment

Exact services and limits depend heavily on the state and the plan.

Other Services That May Be Covered

Depending on the state and the child’s needs, CHIP may also cover:

• Physical, occupational, and speech therapy
• Medical equipment (like wheelchairs or inhalers)
• Home health care for certain conditions
• Rehabilitation services after surgery or injury
• Lab tests and imaging (like blood tests, X-rays, MRIs)

Some services may require:

• A referral from a primary care provider
• Prior authorization from the plan

What CHIP Usually Does Not Cover

While coverage is broad, there are typical exclusions or limits. These can vary, but often include:

• Cosmetic procedures not medically necessary
• Certain experimental or investigational treatments
• Some brand-name drugs if there’s a covered generic alternative
• Services from providers who are not in the CHIP network, except in emergencies (varies by plan)
• Certain elective services not considered essential for a child’s health

To know for sure, you would need to:

• Review your plan’s Summary of Benefits, or
• Contact the member services number listed on the CHIP card or plan paperwork

How Much Does CHIP Cost?

CHIP is designed to be affordable, but costs differ widely from state to state and may depend on your income.

Common Cost Features

Many CHIP programs use a mix of:

• No monthly premium or a low monthly premium
• Small copayments for doctor visits, prescriptions, or emergency care
• Annual caps on how much a family has to pay out-of-pocket

Families with lower incomes often pay no premiums and very low copays. Families with higher incomes within CHIP’s range may pay slightly more.

There are usually protections so that total costs stay limited compared with private insurance.

Quick Comparison: Medicaid vs. CHIP vs. Marketplace Plans

Below is a simple, general comparison. Details can vary by state and family situation.

This table is meant as a general guide. For your specific situation, you would need to check:

• Your state Medicaid/CHIP office, and
• The official health insurance marketplace, if you are comparing private plans

Who Typically Qualifies for CHIP?

Eligibility is set by each state, but some patterns are common.

General Eligibility Factors

States usually look at:

• Child’s age

  • Most states cover children up to age 19 (up to 18 in some cases)

• Household income

  • Families who earn too much for Medicaid, but still under a certain limit, may qualify for CHIP

• State residency

  • You must generally live in the state where you are applying

• Citizenship or immigration status

  • States may have different rules; some cover lawfully present immigrant children
  • Verification is usually required through official documents

• Other coverage

  • In many cases, a child must not already have other comprehensive health insurance, though there can be exceptions

Some states also extend CHIP or similar coverage to pregnant people, sometimes with different income limits.

What Documents to Gather Before You Apply

Requirements differ, but having certain information ready can make the process smoother. Commonly requested documents include:

• Proof of identity for the child

  • Birth certificate, passport, or other official document

• Proof of identity for the parent or guardian

  • Driver’s license, state ID, or other government ID

• Proof of income for the household

  • Recent pay stubs
  • Tax returns
  • Employer statement or letter
  • Documentation of self-employment income

• Proof of residency

  • Utility bill, lease, or other document showing your current address

• Social Security numbers (if available)

  • For the child and sometimes for other household members

• Immigration documents, if applicable

  • Such as permanent resident cards, visas, or other official documentation

Your state’s official CHIP or Medicaid website or hotline typically provides a list of accepted documents. If you’re unsure, you can call the state agency or local office before applying.

How to Apply for CHIP Through Official Channels

You cannot apply through HowToGetAssistance.org, but you can use this overview to understand the typical process before you contact official offices.

Step 1: Find the Correct State Office or Portal

Because CHIP is state-run, the first step is identifying the right official contact:

• Look up your state’s Medicaid or CHIP agency by name.
• Use your state’s official health benefits website or the federal health insurance marketplace.
• You can also call 211 in many areas and ask for help locating the official CHIP or Medicaid agency.

Make sure you are on an official government website (often ending in “.gov”), or speaking with a recognized state or county benefits office.

Step 2: Choose How You Want to Apply

Most states offer one or more of the following:

• Online application through an official state benefits portal
• Phone application through a state or county call center
• Paper application submitted by mail or fax
• In-person application at a local county social services office or Medicaid office

Ask your state agency what methods they support and which is fastest in your area.

Step 3: Complete the Application

During the application, you can expect to:

• Provide household information (names, ages, relationships)
• List income sources and amounts
• Provide details on any current health coverage
• Share Social Security numbers or other identifiers, when available
• Answer questions about residency and citizenship or immigration status

Being as accurate and complete as possible helps avoid delays.

Step 4: Submit Required Documents

Depending on your state, you may:

• Upload scanned copies or photos through the online portal
• Mail or fax copies to a processing center
• Bring documents in person to a local office

Missing or hard-to-read documents are a common reason for delays, so it helps to:

• Submit all requested items
• Double-check that names and dates are clear and match the application

Step 5: Wait for a Decision

Processing times vary, but many states:

• Provide an initial decision within several weeks
• Send a notice by mail, and sometimes by email or through an online account

In some situations (such as emergencies or pregnancy), states may have provisions for faster processing or temporary coverage. Ask your state office what options exist in urgent cases.

What Happens After Your Child Is Approved

If your child is approved for CHIP, a few common steps follow:

Enrollment in a Health Plan

In many states, children are enrolled in:

• A managed care plan or
• A specific health insurance company contracted with the state

You may be:

• Assigned a plan automatically, or
• Asked to choose from a list of plans that operate in your area

The plan’s member handbook or benefit summary usually explains:

• Covered services
• Copays and cost-sharing
• How to find in-network doctors and hospitals

Getting a Member ID Card

You typically receive:

• A CHIP or health plan ID card for your child
• Instructions on how to use the card at doctor’s offices, pharmacies, and hospitals

Keep this card in a safe but accessible place and bring it to every medical visit.

Choosing a Primary Care Provider (PCP)

Some plans require you to choose a primary care provider (PCP) for your child, such as:

• A pediatrician
• A family doctor

The PCP often:

• Coordinates your child’s care
• Provides referrals to specialists, when needed

Renewal and Ongoing Responsibilities

CHIP coverage is not always permanent. Many states require annual renewal (also called redetermination).

Renewal Process

Each year (or at another set interval), you may need to:

1. Confirm household information (family members, address, etc.).
2. Update income information.
3. Provide new proof of income or residency, if requested.

States typically send a renewal notice by mail, email, or through an online account. Missing this notice is a frequent cause of coverage ending unexpectedly, so it helps to:

• Keep your mailing address and phone number updated with the agency.
• Check your online account regularly if you applied online.

Changes You Should Report

You are usually required to report certain changes to the CHIP or Medicaid agency within a specific timeframe, such as:

• Changes in income
• Changes in family size (birth, adoption, someone moving in or out)
• Moves to a new address or a new state
• Your child gaining other health coverage

Failure to report changes can lead to:

• Incorrect benefits
• Possible overpayments that may need to be repaid
• Coverage gaps when changes are discovered later

Common Reasons for Delays or Denials

Understanding common issues can help you avoid problems.

Application Delays

Applications are often delayed due to:

• Missing documents (such as proof of income or residency)
• Incomplete application questions left blank
• Mismatched information, such as names or dates differing from official documents
• Unreadable document copies (blurry photos or faded faxes)

If you receive a notice asking for more information, it’s usually important to respond by the stated deadline.

Denials

Common reasons a child might be denied CHIP include:

• Household income is above the program’s limit for that state
• The child does not meet the age or residency requirements
• The child already has other comprehensive health insurance (depending on state rules)
• Citizenship or immigration documentation could not be verified, and no follow-up information was provided

If you receive a denial and believe it’s incorrect, read the notice carefully to understand:

• Why your application was denied
• How to appeal or request a review
• Any deadlines for filing an appeal

How Appeals and Reviews Usually Work

If you disagree with a denial or a decision that affects your child’s coverage, most states provide a formal appeal process.

While details differ, appeals commonly involve:

1. Written request

   • You submit a letter or form explaining that you are appealing and why.

2. Time limits

   • There is usually a strict deadline (for example, 30, 60, or 90 days after the notice date).

3. Review or hearing

   • Your case may be reviewed by a different staff member or an independent hearing officer.
   • Some states offer an in-person, phone, or video hearing.

4. Decision notice

   • You will receive a written decision explaining the outcome.

The appeal instructions are typically included in the denial or termination letter. If you are unsure how to proceed, you can:

• Call the number listed on the notice, or
• Ask a local legal aid organization or community health navigator for help understanding the process

If Your Child Doesn’t Qualify for CHIP

If your child is denied CHIP, there may still be other options to explore.

Other Health Coverage Paths

Depending on your situation, you might look into:

• Medicaid

  • If your income or circumstances change, your child might become eligible.

• Health insurance marketplace plans

  • You may qualify for premium tax credits or cost-sharing reductions to lower the cost of private insurance.

• Employer-sponsored coverage

  • If available, review dependent coverage options through a family member’s job.

• Local or community health programs

  • Some communities have sliding-scale clinics or charity care programs that offer reduced-cost care for children.

For help understanding your choices, you can:

• Contact your state’s health insurance marketplace call center
• Reach out to a local health navigator or community health center
• Call 211 to ask for referrals to official health coverage resources

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

Because CHIP is a public program, there are sometimes unofficial websites or services that may mislead consumers into thinking they are applying for official coverage.

To protect yourself:

• Check the web address

  • Official state sites are often “.gov” or are clearly linked from a state government portal.

• Be cautious about fees

  • Applying for CHIP through the official state agency is typically free. Be wary of anyone asking for a charge just to submit an application.

• Verify phone numbers

  • Confirm phone numbers through your state’s main government website, or call 211 and ask to be connected to the official CHIP or Medicaid office.

• Never share full information with unverified callers

  • If someone calls you claiming to be from the state, you can hang up and call back using the number from the official website or your state benefits letter.

If anything seems unclear, you can always contact:

• Your state Medicaid/CHIP agency directly, or
• A trusted local source like a community health center or legal aid office, and ask them to confirm you are on the correct official site or phone line.

By understanding what CHIP covers and how it works, you can be more prepared when you contact your state’s official CHIP or Medicaid office to explore coverage options for your child.