Children’s Health Insurance Plan, or CHIP

Meeting the ever-increasing costs of medical appointments, therapy sessions, and medications is a potential problem without easy solutions if a parent doesn’t carry employer-sponsored health insurance or qualify for Medicaid coverage. The Children’s Health Insurance Program is intended to make medical care affordable for families that are outside of those two categories.

What is CHIP?

When a family’s collective earnings are not enough to purchase health insurance on the private market, or are too much to apply for Medicaid, how can a parent of a child with disabilities make sure his or her child’s health care needs are being met?

That’s a question that is being asked by parents of children with Cerebral Palsy all of the time. This is especially true in circumstances are such that the family does not have employer-sponsored medical insurance.

In 1997, a program was created that can fill the earning gap that exists between the ability to afford private insurance and Medicaid eligibility. It’s called the Children’s Health Insurance Program, or CHIP. Sometimes referred to as the State Children’s Health Insurance Program – SCHIP for short – this program provides low-cost basic health care coverage to families that fall into that gap.

CHIP is similar to Medicaid in that qualification is mostly income-based. To parents that cannot qualify for Medicaid, it satisfies the single most important need of a family that includes a child with disabilities.

CHIP is designed to expand basic health services to children that meet income requirements, but do not qualify for Medicaid. Under the current version of the program, the program is jointly-funded by both federal dollars and state funds.

Administered by the U.S. Department of Health and Human Services at the federal level, and state health or human services departments locally, CHIP takes a couple of different forms.

States are given some leeway in terms of the scope and administration of their plans; most often, an approved applicant will need to select a private managed care provider. Some states use CHIP matching funds provided by the federal government to fund children’s health services through Medicaid, but others choose to administer entirely separate programs.

Also, depending on a person’s income – and where they live – the program can be free with the exception of copays, or, it may have a small monthly premium. Additionally, families with children covered by CHIP may be responsible for some specific services, but not for others.

At the inception of CHIP, it was considered to be a fairly large expansion of government-provided health services.

Why was CHIP created?

CHIP was created when lawmakers realized that, as health care insurance costs and premiums continued to escalate, the bar was set very low for Medicaid qualification. This fact alone left many families on their own in terms of paying for medical bills. The CHIP program offers a family alternatives that ensure children’s health through the crucial infant, childhood and teen years.

What does CHIP cover?

If a mother is pregnant and meets the income requirements for CHIP, her coverage can begin before a child is born. This provision was inacted to ensure that a mother and her baby receive all of the health care services needed to give the mother the best chance of having a healthy baby and an event –free birth.

Some states may have programs that help families with premiums, but these are far and few between. In some states, children may be covered under hybrid programs of CHIP and Medicaid, which may affect what is, or is not, covered by the program.

Generally, families are not expected to pay more than 5 percent of their income towards CHIP services.

Coverage under CHIP varies from state to state, but in general, the following services are covered:

• Physician’s appointments – Regular appointments to address conventional health care concerns; routine checkups.
• Hospitalization – Inpatient services covered include room fees, x-rays, laboratory services, and medication. Outpatient services include emergency room services, laboratory fees, x-rays, tests and drugs.
• Emergency services – Trips to the hospital or doctor’s office that are unexpected.
• Dental care – Covers conventional dental services including cleanings, fillings and extractions.
• Vision care – Pays for eye exams and eyeglasses.
• Preventative care – Services intended to prevent illness.
• Hearing care – Covers hearing tests and treatments.
• Diagnostic services – Covers tests and screening to treat medical conditions.
• Immunizations – Covers all immunizations available.
• Prescriptions – Covers the cost of prescription medication, but copays may still apply.

When a person seeks medical treatment under CHIP, what happens?

That depends on where a child and his or her family resides.

In some states, a CHIP recipient will be charged for only a handful of copays, and will not be charged a monthly premium. In other cases, a family may be charged a monthly premium. Under this scenario, a parent may also be responsible for copays.

What are the eligibility requirements for Medicaid?

Unlike other programs intended to treat children that are sick or disabled, CHIP eligibility hinges on two factors: How much a family earns, and how many children are in the home.

In general, federal poverty guidelines are used to determine CHIP eligibility. Generally, states will allow families with incomes of anywhere between 150 percent of the poverty level to 400 percent to enroll in CHIP. However, most states limit eligibility to 200 to 250 percent of the poverty level.

Some states have a two-tiered system of free CHIP, and low-cost CHIP. In these states, families that have an income at the higher level of the poverty spectrum will be charged a nominal monthly fee to maintain coverage. This fee is typically in the neighborhood of $35 to 50 per month.

Poverty levels are typically as follows: A family that earns about $22,000 per year with one child is considered at the poverty level. A family of four that earns $44,000 per year is also at the poverty level.

Beyond an applicant’s income level, there are other requirements, such as:

• Child must be 19 years old or younger
• A child must live in the state where he or she is seeking coverage
• Family must not be covered with any other health insurance programs
• Must not be Medicare-eligible

If a parent knows that he or she is losing employer-sponsored insurance coverage, he or she may be able to apply for CHIP early and get the application process moving.

Some states require that parents renew their CHIP benefits. If that occurs, a parent will need to confirm that their circumstances have not changed. If a family’s circumstances have changed, parents may be asked to provide information that proves the family still meets CHIP requirements.

Some circumstances that can determine eligibility include:

• If the family is receiving income from other government programs, like Temporary Assistance for Needy Families
• Whether one or both parents is eligible for insurance at work

What is the CHIP application process?

More often than not, a parent may apply for CHIP benefits online, but if he or she does not have access to a computer, they can visit their state’s human services office to fill out an application. Applications can also be mailed out, and then mailed back, to human services staff members.

An applicant will need to be able to provide information about their financial status, including:

• What his or her verifiable income is
• How much he or she pays for rent or a mortgage
• Whether he or she receives other government benefits
• How much he or she pays for utility bills

Documentation that human services caseworkers may ask for include:

• Pay stubs
• Tax forms
• Social Security numbers for each member of the family
• Rental leases
• Mortgage papers
• Utility bills

What happens if my application is denied

If in the event an application for CHIP coverage is denied, or benefits have been cancelled, a parent can ask that the decision be reversed.

For this to take place, a parent will need to be able to prove the application was denied in error. Once a parent receives a denial letter, there will likely be a toll-free phone number they can call to find out what the next step is.

In most states, the dispute process entails writing a letter to the state human services department indicating that a review of the file in question is needed. This letter must be received within 30 days of the date on the denial letter, in most cases.

In this request for review, an applicant must include the following information:

• The reason that the applicant believes the determination was made in error
• A copy of the denial letter
• Any additional information that may have erroneously omitted during the decision-making process
• Any additional information that supports the initial application for benefits

Is CHIP portable?

No. If a family moves, a parent will need to submit applications for CHIP benefits in the state where the family will reside. This is because states have varying requirements, and various parameters for statewide CHIP programs.