FAQ: Eligibility Criteria & Benefits

How do I know if my child qualifies?
Regardless of 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 assist you in determining if your child may qualify for the free or reduced cost CHIP benefits.

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

 

  • Immunizations
  • Routine check-ups
  • Prescription drugs
  • Dental care
  • Vision and eye 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
  • Hospice and Palliative services
  • Medically necessary orthodontia
  • Autism spectrum disorder and related services 

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What are the income guidelines for CHIP?
For many families, it's free. However, even families with higher incomes can take advantage of quality insurance with low monthly premiums and co-pays for most services. Click here to see the income guidelines for CHIP, or Click here for rates by company.

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I live with my boyfriend or girlfriend - do I have to include their income?
The CHIP application requires that you provide information including income for everyone who lives with you as well as everyone who is expected to be included on your tax return -- even if they do not live with you. CHIP has rules that determine who is included and those that are not included when determining eligibility. 

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My baby and I live with my parents - do I have to include my parent's income?
Yes, the CHIP application requires that you provide information, including income, for everyone who lives with you as well as everyone who is expected to be included on your tax return even if they do not live with you. CHIP has rules that determine who is included and who is not included when determining eligibility. For example, your parent's income may be counted when determining eligibility for you and your child if you are claimed as a tax dependent on their tax return. 

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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 should 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 correct CHIP category based on your family’s current income. 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 month following the requested re-evaluation.

 

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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, tax deductions are taken into consideration when determining the household's adjusted gross income. These tax deductions are used to reduce the household's adjusted gross income based on IRS tax rules.

 

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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; a 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 must renew CHIP on an annual basis to determine if they are still eligible.

 

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I have a job - can my children still get CHIP?

Yes, CHIP is a program for working families! CHIP covers uninsured kids and teens.

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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, the child may qualify for CHIP once they are born and we encourage you to apply for them at that time.  However, we encourage you to start the application process prior to the birth as your baby may be eligible for CHIP or Medical Assistance. If you have health insurance, including CHIP, your baby may 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, household income, among other things. If your household income falls below CHIP income guidelines, your child will receive health insurance through Medical Assistance. In addition, 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 all available information and is subject to change if your income changes. You cannot choose one program over the other. However, if your income changes, you should provide documentation of that change to see if you qualify for a different program.

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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 may 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 all of the following promptly:

- 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 Department of Human Services. 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.

It is important that you provide this information and respond promptly to prevent any break in insurance coverage. If you have a break in insurance coverage, you may be assessed a tax penalty from the federal government.  For more information about tax penalties go to www.irs.gov for details.

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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 other children. It is not unusual for a child less than age one to be enrolled in Medical Assistance while older siblings are enrolled in CHIP.

Also, children with a severe medical condition or disability may qualify for Medical Assistance, while other children in the same family may not qualify for Medical Assistance.  Those children eligible for Medical Assistance may not receive CHIP coverage if eligible for Medical Assistance, while other children in the family may still qualify for CHIP coverage.

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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.

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Does CHIP cover braces?
CHIP will cover medically necessary orthodontics for dental problems if a child is diagnosed with a significant handicapping malocclusion that interferes with speaking, eating or breathing. Coverage for orthodontics is subject to prior authorization from the child's CHIP health plan and is not for cosmetic purposes.

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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 in these questions and answers? Perhaps your answer is located 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.