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FAQ: Eligibility & Benefits
Note: Click on the questions below to reveal the answers.
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 lawfully present person
- A resident of Pennsylvania
- Uninsured and not eligible for Medical Assistance
You can also review the CHIP income guidelines to help you determine if your child may qualify for the free or reduced cost CHIP benefits.
With CHIP, your children receive high quality comprehensive insurance coverage, including:
- 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
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. View CHIP income guidelines.
The CHIP application requires that you provide information including income for everyone who lives with you and 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.
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.
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. If it is found that your child is now eligible for free CHIP, you can request that your child be moved to that category effective the month following the requested re-evaluation.
No, with very few exceptions.
Under federal law, a child eligible for or enrolled in a state-organized employee 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 eligibility to some families who meet a hardship exception such as, 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.
Yes, tax deductions are taken into consideration when determining the household's adjusted gross incomeOpens In A New Window. These tax deductions are used to reduce the household's adjusted gross income based on IRS tax rules.
Any child living in Pennsylvania can be enrolled if the child is:
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.
Yes! CHIP is for working families!
If you are under the age of 19, you can apply for CHIP for yourself as long as you meet the eligibility criteria. If your unborn child needs insurance, the child may qualify for CHIP once they are born. We encourage you to start the application process prior to 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.
If your household income falls below CHIP income guidelines or if your child has one or more serious health conditions that require high-cost long-term care, your child will likely receive health insurance through Medical Assistance.
When you apply for CHIP or Medical Assistance, 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.
If you no longer qualify for Medical Assistance because you make too much money and you do not have any other health insurance, your county assistance office (CAO) caseworker should automatically refer your case to CHIP.
Contact your caseworker to confirm this 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.
If you do not agree with this decision, we encourage you to call the health plan directly so that they can discuss their decision with you. You will find their toll-free number on the letter that you 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 for an impartial review within 30 days of the date of the letter. Send your written request to the address listed on your letter and submit all of the following in your request:
- 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, visit the IRS website.
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 over 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
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.
Along with the other eligibility criteria, your children cannot be covered by any other insurance when you apply for CHIP. However, if your children are currently covered, but you are losing your health benefits in the near future, you may apply for CHIP. Be sure to note the end date of their insurance coverage on the application and apply prior to the loss of coverage to help prevent any break in insurance coverage.
CHIP will help you ensure your children are covered without a break in insurance coverage, as a break in coverage could cause a tax penalty from the federal government. For more information about tax penalties visit the IRS website.