The Children's Health Insurance Program (CHIP) is a joint federal and state program that provides health insurance for uninsured children in families whose income is too high to qualify for Medicaid but too low to afford private health insurance be able. Please take a look...Annual Child Registration Reportsfor more information on current and historical registrations. Upper eligibility limits in separate CHIPs range from 170% of the federal poverty line (FPL) to 400% of the FPL and vary by state. The authorization levels of CHIP and Medicaid can be viewed atMedicaid and CHIPE Eligibility LevelsSide.
CHIP was originally enacted under the Balanced Budget Act 1997 and more recently through Federal Fiscal Year 2027 under the Helping to Protect Access for Hopeful Littles, Children and Young People Act while maintaining a stable benefit (HEALTHY CHILDREN Act) and the Advancement of the extends chronic care, counseling and social service law (right of access).
The Affordable Care Act established a consistent method of determining income eligibility based on modified adjusted gross income (MAGI). MAGI is used to determine financial eligibility for CHIP, Medicaid, and the health insurance market. Using a set of income counting rules and a single cross-program application aims to make it easier for people to sign up and enroll in the relevant program.
The MAGI-based methodology considers taxable income and tax codes to determine financial eligibility for CHIP. This method does not allow for income neglect, which varies by state or stakeholder, and does not allow for asset or means testing.More information on the MAGI-based methodology.
Federal law gives states the option to cover low-income children and low-income pregnant women under a separate CHIP. In addition, states may provide coverage to certain groups historically excluded from CHIP, e.g. See below for descriptions of these options.
Targeted low-income children
To be eligible for CHIP, a child must:
- under 19 years,
- Uninsured (determined that they are not eligible for Medicaid and are not covered by a group health plan or credible health insurance),
- Be a citizen or meet immigration requirements,
- citizen and
- Eligible within the state CHIP income bracket based on household income and other rules established by the state in the state CHIP plan.
The following children may not be eligible for CHIP:
- The inmates of a public institution,
- Patients in a mental health facility
- Children who are eligible for sickness benefit coverage under a state health insurance plan because of a family member's employment with a government agency (unless a state qualifies for the Department of Support Contribution or the Hardship Exception described below).
Within these guidelines, states have the flexibility to adopt their own licensing standards. For example, some states have created programs for specific geographic areas or for children with disabilities. However, states are prohibited from setting certain types of eligibility criteria, such as: B. Discrimination based on diagnosis.
Eligibility criteria for a low-income target child are described in Section 2110(b) of the Social Security Act.
Targeted low-income pregnant women
States have the ability to provide benefits such as prenatal care, midwifery, and postpartum care to low-income pregnant women without health insurance under the state CHIP plan. States must comply with different types of conditions to cover pregnant women, such as:
- Cover children under the age of 19 on Medicaid or CHIP up to at least 200 percent of the FPL and
- Cover pregnant women on Medicaid up to at least 185 percent of the FPL.
This is not an exhaustive list of conditions states must meet to insure pregnant women under CHIP.
Babies born to pregnant women in CHIP should automatically be considered eligible for Medicaid or CHIP without filing an application or other determination of eligibility. These babies are insured until the child is one year old. States also have the option of granting an assumed entitlement to a child born to a mother who is insured as a target low-income child under CHIP at the time of the child's birth.
For guidance in this area see Section 2112 of the Social Security Act andLetter from State Health Officer (SHO) No. 09-006.
Low-income children and legally resident pregnant women
States have the ability to provide CHIP and Medicaid coverage to children and pregnant women lawfully residing in the United States who are eligible for coverage, including those within the first five years of obtaining specific legal status. If states don't embrace this option, federal law requires a 5-year waiting period before many legal immigrants can apply for Medicaid and CHIP. Learn more about the provision of health insurance for legally resident children and pregnant women in 2107(e)(1)(N) of the Social Security Act and atSHO# 10-006🇧🇷 ONEstate listProvide Medicaid and CHIP coverage for legally resident children and/or pregnant women.
Targeted treatment of low-income children with access to government employee insurance coverage
States have the option to cover children of civil servants if the state can demonstrate that it meets one of the following two conditions:
- Retaining the Agency Contribution Condition: To meet this condition, states must demonstrate that they have continuously contributed to workers' insurance costs since 1997, compounded by increases in inflation.
- Hardship Condition: In order for this condition to be met, States must demonstrate that the coverage currently available through the public employee system creates financial hardship for families. In a hardship determination, states would assess whether the total annual premiums and co-payments imposed by the state health insurance plan would exceed 5% of household income during the year the child is enrolled in CHIP.
See Section 2110(b)(6) of the Social Security Act for more information on this provision.
The subscription strategy
Federal law gives states the ability to implement a variety of registration strategies, including express lane eligibility, continuous eligibility, and presumptive CHIP eligibility. These provisions are described below.
Express Range Eligibility
States have the option to implement Express Band Eligibility (ELE), which is a streamlined eligibility determination and redetermination process for CHIP and Medicaid. States using the ELE may rely on determinations of income, family size, or other eligibility factors from another program, called the Highway Authority, to facilitate enrollment in those programs. Expressway agencies may include: Supplemental Nutrition Assistance Program, Temporary Assistance for Families in Need, Head Start, National School Lunch Program and Women, Infants and Children. The ELE was funded through FY2027 under the Helping Secure Access for Hopeful Little Ones, Children and Youth Act, Maintaining Stable Insurance Delivery (HEALTHY CHILDREN Act) and Chronic Care Advancement, Extenders and Services Act Social ’ (Access Act) extended. For more information on ELE's expansion through the HEALTHY KIDS and ACCESS Acts, visitSHO# 18-010🇧🇷 For more information on this provision, see Section 2107(e)(1)(H) of the Social Security Act andSHO# 10-003.
States have the option to provide children with 12 months of uninterrupted coverage under CHIP and Medicaid, even if the family experiences a change in income during the year. Continuing eligibility is a valuable tool that helps states ensure that children remain covered by the health insurance to which they are entitled and that they have ongoing access to the health services they need. For more information on this provision, see Section 2105(a)(4)(A) of the Social Security Act. A list of states that are biddingcontinuing eligibilityin Medicaid and CHIP.
States have the option to implement a presumptive eligibility in CHIP or Medicaid. Under this option, States may use Title XXI funds to pay for the cost of CHIP coverage during a period of presumptive eligibility pending the completion of the review process and a final determination of eligibility. For more information on this provision, see Section 2107(e)(1)(P) of the Social Security Act. A list of states that are biddingpresumed suitabilityin Medicaid and CHIP.
sustaining the effort
As a condition of receiving federal Medicaid funding, states must maintain Medicaid and CHIP eligibility standards, policies, and procedures for children no more restrictive than those in effect on March 23, 2010. This Effort Maintenance Provision (MOE) applies to states with eligibility levels that do not exceed 300 percent of the FPL. States with eligibility levels above 300% of the FPL have the option to maintain the coverage level or reduce it to 300% of the FPL. The MOE Medicaid and CHIP regulations have been extended through the 2027 federal tax year under the HEALTHY KIDS and ACCESS Acts and are included in Sections 2105(d)(3), 1902(a)(74), and 1902(gg)(2 ) to find ) of the Social Security Act. For more information on the MOE extension, seeSHO# 18-010.
CHIP cover exchange follow-up
States must include in their state plans a description of the procedures used to ensure that CHIP coverage does not replace group health insurance plan coverage. States use various procedures to prevent substitution of coverage, such as: For example, monitoring survey data or private insurance databases, or enforcing a grace period for people who are no longer enrolled in private coverage. This requirement is found in Section 2102(b)(3)(C) of the Social Security Act.Additional information on country-specific CHIP waiting time guidelines.
Disclaimers and Explanations
States may apply to CMS for section 1115 demonstration authority if they are interested in waiving Title XXI rules applicable to a population in the state CHIP plan.
Third Party Liability (TPL)
States must take all reasonable steps to determine the legal liability of third parties under both CHIP and Medicaid. Although children do not need to be insured to qualify for CHIP, there may be situations where other types of third parties may be responsible for some healthcare costs, e.g. B. Car insurance after a car accident. States should identify potentially liable third parties, determine third-party liability, avoid payment of third-party claims and, where appropriate, seek recovery from third parties. In states with continued eligibility, purchasing another health plan after initial eligibility determination will not affect eligibility until annual renewal; However, states are required to implement TPL policies.
The application of the TPL to the CHIP came into force on February 9, 2018. Section 53102(d) of the Balanced Budget Act (BBA) of 2018 amended Section 2107(e)(1)(B) of the Social Security Act to apply the Medicaid TPL requirements in Section 1902(a)(25) of the CHIP Act. For more information, seeJuni 2018 CMCS-1-Newsletter.