FAQ: Eligibility Criteria & Benefits

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How do I know if my child qualifies?*
Based on your family size and income, your child or teen may be eligible if he or she meets the following requirements:

  • Under 19 years of age
  • A U.S. Citizen, U.S. National or Qualified Alien
  • A resident of Pennsylvania
  • Uninsured and not eligible for Medical Assistance

You can also review the complete CHIP income guidelines to learn about all aspects of the program.

* All new applicants whose income falls in the low-cost and at-cost CHIP ranges must also show that the child(ren) has been uninsured for six months, unless the child is under the age of two, the child has lost health insurance because a parent lost their job or the child is moving from another public insurance program. At-cost CHIP families must also show that access to coverage is unavailable and affordable.

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What are the benefits?
With CHIP, your children are guaranteed to receive comprehensive insurance coverage, including:

  • Immunizations
  • Routine check-ups
  • Prescription drugs
  • Dental care
  • Maternity care
  • Mental health benefits
  • Up to 90 days hospitalization/year
  • Durable medical equipment
  • Substance abuse treatment
  • Partial hospitalization for mental health services
  • Rehabilitation therapies
  • Home health care

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What are the income guidelines for CHIP?
For many families, it's free. Families with higher incomes will pay low monthly premiums and co-pays for some services. Click here to see the income ranges, or Click here for rates by company.

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I live with my boyfriend - do I have to include his income? - OR - My baby and I live with my parents - do I have to include my parent's income?
The CHIP application requests all household members and income, which means you must provide information about everyone who lives with you and their income, if any. CHIP has rules that determine who is and is not included when determining eligibility. For example, even though you report income for your boyfriend, it would not be used to determine if you child is eligible, unless your boyfriend is the father of your child.

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What if my family's income changes? Can I be re-evaluated to see if I qualify for free CHIP?
If there is a change in family income, you may call your child's CHIP insurance company (at the phone number found on the back of your child's insurance card) and request a re-evaluation based on your new income to determine if your child is in the right CHIP group. If it is found that your child is now eligible for free CHIP, you can request that your child be moved to the free CHIP program effective the first month following the requested re-evaluation.

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Why is there a six-month period of going without insurance for the low-cost and at-cost CHIP programs? We cannot afford our private coverage, and our child is sick and needs to have the medical attention. Can't you waive the period of not having insurance?
We understand the hardship and uncertainty this may create for families in need; however, this period of going without insurance is written into law so that employers and or consumers would not drop health coverage to enroll in a public program. It cannot be waived. All new applicants must show that their child(ren) has been uninsured for six months unless: the child is under age two; the child has lost health benefits because a parent lost their job; or the child is moving from another public health insurance program.

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Why do my children have to wait six month for CHIP coverage?
Federal law requires that CHIP applicants whose income is over 200 percent of federal poverty guidelines (ex., a family of four making more than $47,100/year) be without insurance for six months before being enrolled - some exceptions apply, please continue reading. This requirement is part of the law and is used to prevent employers and/or consumers from dropping health coverage to enroll in a public program. CHIP is strictly for families with no other available health coverage. Exceptions to the six month rule include: the child is under age two; the child has lost health benefits because a parent lost their job; or the child is moving from another public health insurance program.

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Are children of state or public agency employees eligible for CHIP?
No, with a very few exceptions. Under federal law, a child eligible for or enrolled in a state-organized employees' health care benefits plan is not eligible for CHIP if the state or public agency for whom the employee works pays even a small portion of the benefit or premium cost. The Affordable Care Act allowed Pennsylvania CHIP to extend CHIP eligibility to some children of these employees who meet a hardship exception: the employee is not eligible to receive family full coverage benefits, or the employee works part-time and premiums and cost-sharing are more than 5% of the family's income during the year the child would be enrolled in CHIP. A child of a state or public agency employee who has been receiving CHIP benefits but who is not eligible for CHIP may have their benefits retroactively terminated.

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Are there any deductions when determining CHIP eligibility?
Yes, there are deductions for work and dependent care that are taken into consideration when determining a household's gross income. The standard income deduction is $120 per month for each member of the family who is working. Dependent care expenses are deducted from earned income when a family member is working and incurs an expense for child care for an incapacitated adult. The dependent care deduction is limited to actual cost up to a maximum of $175 per month for each child two years of age of older, or incapacitated adult; and/or $200 per month for each child under age two.

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What if I'm not legally living in the United States, but my child is?
Any child living in Pennsylvania can be enrolled if the child is a Pennsylvania resident, US citizen, a permanent legal alien or a refugee as determined by the US Immigration and Naturalization Services, is not eligible for Medical Assistance and meets the CHIP income guidelines.

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How long can my child be on CHIP?
Your child can remain on CHIP as long as he/she meets the eligibility requirements, up to age 19. Those enrolled in the program do have to renew CHIP on an annual basis to determine if they are still eligible.

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My child has CHIP health coverage. Will anything be changing with the new federal health care reform law?
Current CHIP enrollees will continue to receive coverage through CHIP. However, after 2014, there will be some changes in income eligibility for CHIP and for Medical Assistance for children 6 through 18 years of age. Some children who previously qualified for FREE CHIP will then qualify for Medical Assistance.

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I have a job - can my children still get CHIP?
Yes, CHIP is a program for working families! There is no income limit anymore. CHIP covers all uninsured kids and teens. Now, no family makes too much money for CHIP.

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I am pregnant. Can I apply for CHIP for me or my unborn child?
If you are under the age of 19, you can apply for CHIP for yourself, as long as you meet the eligibility criteria described above. If your unborn child needs insurance, you will need to wait until the child is born to apply for CHIP. But, we encourage you to start the application process prior to the birth. Depending on your income, your baby may be eligible for CHIP or Medical Assistance. If you have health insurance, your baby will be covered under your insurance policy for 31 days after it is born.

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When I applied, my child received Medical Assistance coverage, but I want them to be on CHIP - what can I do?
CHIP coverage is based on, among other things, household income. If your household income falls below CHIP income guidelines, your child will receive health insurance through Medical Assistance. If your child has one or more serious health conditions that require high-cost long term care, your child may be eligible for Medical Assistance. Medical Assistance provides a comprehensive benefits package to cover your child's medical needs. When you apply for either program, your application is sent to the appropriate program based on the information you provide.. You cannot choose one program over the other.

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My Medical Assistance benefits are going to end. Can I apply for CHIP?
If you no longer qualify for Medical Assistance because you make too much money, but you do not have other health insurance, your caseworker at the County Assistance Office (CAO) should automatically refer your case to CHIP. Please contact your CAO caseworker and confirm that they are referring your case to CHIP and ask them for the name and phone number of the CHIP provider they referred your case to so that you can check the status of your information. For a list of CHIP providers, click here.

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I just got a notice that my children aren't eligible for CHIP - what can I do?
If you do not agree with this decision, we encourage you to call the health plan first so that they can discuss their decision with you. You will find their toll-free number on the letter that you have received. After you talk to them, if you still do not agree with their decision, or if you choose not to call them to discuss the decision, you may submit a written request to them for an impartial review within 30 days from the date of the letter. You can send your written request to the address listed on your letter. Please submit:

- a written, dated request stating why you disagree with their decision
- a copy of the entire letter you received
- any additional documentation to support your case
- a phone number where you can be reached during the day

They may contact you for more information. If they cannot resolve your issue, they will forward your written request and any additional information to the Pennsylvania Insurance Department. You may also receive more detailed information from the Pennsylvania Insurance Department, including the time and date that a phone interview will be held, if needed.

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We are a family with three children. Two are eligible for CHIP, but one is eligible for Medical Assistance. How can this be?
The family income limit to qualify for Medical Assistance is higher for younger children than it is for older children. This is especially true for infants less than one year of age, but also may affect children less than six years of age. It is not unusual for a child less than age one to be enrolled in Medical Assistance while other older siblings are enrolled in CHIP.

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I have insurance but it does not cover dental, vision and/or prescriptions. Can I just get these benefits through CHIP?
CHIP is a complete health insurance package for children and teens up to age 19. Benefits, like dental and prescriptions, cannot be purchased separately. You may be able to find more information on accessing these types of services by checking out our health care services and programs page or visiting www.PAHealthOptions.com.

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Does CHIP cover braces?

Effective January 1, 2011, CHIP will cover medically necessary orthodontics up to a $5,200 lifetime maximum for dental problems that interfere with speaking, eating or breathing. Coverage for orthodontics is subject to prior authorization from the child's CHIP health plan.

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My child has a pre-existing condition. Will that affect our eligibility?
There are no exclusions for pre-existing conditions in CHIP or Medical Assistance. However, if your child has a serious medical condition or disability, he or she may be considered for Medical Assistance.

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I have more questions. What should I do?
Couldn't find the answer you're looking for? Maybe it's under another category in our FAQ section. Check it out.

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FREQUENTLY ASKED QUESTIONS

For questions about coverage and benefits, contact a CHIP health insurance company.

To find health insurance companies that offer CHIP in your area search by county.