The Children’s Health Insurance Program (CHIP) is a joint federal and state program that provides health coverage to uninsured children in families with incomes too high to qualify for Medicaid, but too low to afford private or group health plan coverage.
Learn more about Medicaid and CHIP eligibility levels , which vary by state and can range from as low as 170% up to 400% of the Federal poverty level (FPL).
- There are two different populations in CHIP: children and pregnant women
- Eligibility for the populations is based on financial and non-financial information
- States have several options to expand eligibility within the two populations
- There are also different enrollment strategies states can use, like express lane eligibility, continuous eligibility, and presumptive eligibility
Who is eligible?
States have the option to cover two populations:
- Targeted low-income children and
- Targeted low-income pregnant women under a separate CHIP.
- Targeted low-income children
There are eligibility criteria for targeted low-income children. To be eligible for CHIP, children must be:
- Under 19 years of age
- Uninsured (determined ineligible for Medicaid, and not covered through a group health plan or creditable health insurance)
- U.S. citizens or meet immigration requirements
- Residents of the state
- Eligible in the state’s CHIP income range, based on family income, and any other state specified rules in the CHIP state plan
The following children generally cannot be eligible for CHIP:
- Inmates of a public institution,
- Patients in an institution for mental diseases, and
- Children who are eligible for health benefits coverage under a State health benefits plan due to a family member's employment with a public agency (unless a state qualifies for either the maintenance of agency contribution, or hardship exception described below).
Within these guidelines, states have the flexibility to adopt their own eligibility standards. For example, some states have programs for specific geographic areas, or for children with a disability status.
States can’t establish certain types of eligibility criteria, like discriminating because of a diagnosis.
- Targeted low-income pregnant women
Under their CHIP state plans, states can cover prenatal, delivery, and postpartum care to targeted low-income, uninsured pregnant women. To offer this coverage, states have to meet several conditions, including requirements to cover:
- Children under 19 years of age under Medicaid or CHIP, up to at least 200% of the FPL
- Pregnant women under Medicaid up to at least 185% of the FPL
This isn’t a complete list of conditions that states must meet to cover pregnant women in CHIP. See Section 2112 of the Social Security Act (the Act) and State Health Official (SHO) letter #09-006 for more information.
Infants born to targeted low-income pregnant women must automatically deemed eligible for Medicaid or CHIP, without an application or further determination of eligibility. These infants are covered until the child turns one year of age […]. For more guidance regarding deemed newborns, please see SHO #09-009.
States can also provide deemed eligibility to children born to mothers who, on the date of the child’s birth, are covered as targeted low-income children under CHIP.
How do states determine eligibility?
Children and pregnant women must meet financial and non-financial criteria to be eligible for CHIP. Financial eligibility, or income eligibility, is based on Modified Adjusted Gross Income (MAGI). MAGI is used to determine financial eligibility for Medicaid, CHIP, and premium tax credits and cost sharing reductions available through the health insurance marketplace. By using one set of income counting rules and a single application across programs, the Affordable Care Act made it easier for people to apply and enroll in the appropriate program. To be eligible for CHIP, individuals must also meet certain non-financial eligibility criteria. CHIP beneficiaries generally must be residents of the state in which they are receiving CHIP. They must be either citizens of the United States or certain qualified non-citizens, such as lawful permanent residents. In addition, some eligibility groups are limited by age, or by pregnancy status.
What options do states have for expanding eligibility?
The CHIP statute and regulations specify that eligibility is limited to the higher of 200 percent of the Federal poverty level (FPL) or 50 percentage points above the Medicaid applicable income level (the upper Medicaid eligibility level in place in 1997 before the creation of CHIP).
Many states have exceeded the maximum for expansion of children’s eligibility with title XXI funds, for most - if not all - age ranges of children under age 19.
States that have exceeded the maximum have two options for expanding eligibility. States also have the following options for expanding eligibility:
- Lawfully present targeted low-income children & pregnant women
States can provide CHIP and Medicaid coverage to children and pregnant women who are:
- Lawfully present in the U.S.
- Otherwise eligible for coverage, including those within their first 5 years of having certain legal status
See a list of states providing Medicaid and CHIP coverage to lawfully residing children and pregnant women.
If states don’t offer this option, federal law requires a 5-year waiting period before many legal immigrants can enroll in Medicaid and CHIP.
Learn more about providing health coverage to lawfully present children and pregnant women at 2107(e)(1)(N) of the Act and in the July 10, 2010 SHO Letter (# 10-006).
- Extended postpartum coverage
States have the option to provide 12 months of extended postpartum coverage to pregnant individuals enrolled in Medicaid and CHIP. If states adopt this option in Medicaid, they must also adopt it in CHIP.
See a list of states providing extended postpartum coverage.
- State employee coverage
States can cover children of state employees if the states can show they meet 1 of these 2 conditions:
- Maintenance of agency contribution where states must show they’ve been consistently contributing to the cost of employee coverage, with increases for inflation, since 1997.
- Hardship where states must show the coverage currently available through the public employee system could be a financial hardship for families. To determine a hardship, states would assess whether the annual aggregate premiums and cost-sharing required by the state health benefits plan would be more than 5% of a family’s income during the year the child would be enrolled in CHIP.
Learn more from section 2110(b)(6) of the Act.
- Other Eligibility Topics
Maintenance of effort
To receive federal Medicaid funding, states must maintain Medicaid and CHIP eligibility standards, methodologies, and procedures that aren’t any more restrictive than those that went into effect on March 23, 2010.
This maintenance of effort (MOE) provision applies to states with eligibility levels that don’t exceed 300% of the FPL.
States with eligibility levels above 300% of the FPL can maintain coverage levels or reduce them to 300% FPL.
The MOE provisions in Medicaid and CHIP were extended through federal FY 2027 under the HEALTHY KIDS and ACCESS Acts, and can be found at sections 2105(d)(3), 1902(a)(74), and 1902(gg)(2) of the Act. Learn more about the MOE extension in the October 5, 2018 SHO letter (# 18-010).