What CHIP and Medicaid Actually Cover for Children

What CHIP and Medicaid are, and who they serve

Medicaid is a joint federal-state program that provides health coverage to low-income individuals and families, including children. The Children's Health Insurance Program (CHIP) extends that coverage to children in families who earn too much to qualify for Medicaid but still cannot afford private insurance. Together, these two programs cover roughly one in three children in the United States, according to the Centers for Medicare and Medicaid Services (CMS).

The programs share a common application in most states, so families do not need to determine which program applies before they apply. A state eligibility worker makes that determination based on household income and family size.

CHIP is sometimes called SCHIP or carries a state-specific name. In California it is called Healthy Families; in Pennsylvania it is CHIP; in Texas it is CHIP as well. The underlying federal rules are the same regardless of what the program is called locally.

Income thresholds and eligibility rules

Medicaid covers children in families with incomes up to 138 percent of the Federal Poverty Level (FPL) in states that have expanded Medicaid, though many states set their children's Medicaid threshold considerably higher, often between 200 and 300 percent FPL. CHIP typically covers children in families with incomes between the top of the Medicaid threshold and 200 to 300 percent FPL, depending on the state.

Because each state sets its own income limits within federal minimums, the exact cutoffs vary. CMS publishes current state-by-state income thresholds at medicaid.gov. As a practical check, a family of four with an annual income around $60,000 to $70,000 may qualify for CHIP in many states.

Children must be U.S. citizens or meet specific immigration status requirements. Most states require children to be state residents. There is no asset test for CHIP at the federal level, though a small number of states add one. For children under age 19, coverage is available regardless of pre-existing conditions.

What the programs cover

Both Medicaid and CHIP must cover a defined set of services for children under a federal standard called Early and Periodic Screening, Diagnostic and Treatment (EPSDT). EPSDT is broader than the standard adult Medicaid benefit and is one reason coverage for children is generally more comprehensive than for adults on these programs.

Covered services under EPSDT include:

• Well-child visits and developmental screenings at scheduled intervals
• Vaccinations, as recommended by the Advisory Committee on Immunization Practices
• Vision exams and corrective lenses
• Dental care, including cleanings, X-rays, and restorative treatment
• Hearing screenings and hearing aids when medically necessary
• Mental health and behavioral health services, including therapy
• Prescription drugs
• Laboratory tests and imaging
• Inpatient and outpatient hospital care
• Physical, occupational, and speech therapy

CHIP benefits must be at least as good as a benchmark plan, such as a standard Blue Cross Blue Shield plan or a plan offered to state employees. In practice, most CHIP programs cover all of the services listed above, though co-pays, cost-sharing limits, and prior authorization requirements differ by state.

Families already comparing plan types may find the open enrollment overview for families useful for understanding how CHIP and Medicaid benefits compare to commercial coverage.

How to apply

The fastest way to apply is through your state's Medicaid or CHIP agency. You can find the direct link at insurekidsnow.gov, a CMS-run resource, or call 1-800-318-2596 (the federal marketplace line) to be connected to your state program.

Many states also accept applications through healthcare.gov. If a child is determined ineligible for Marketplace subsidies, the system automatically screens for CHIP eligibility and can transfer the application.

Documents typically needed at application include proof of income (pay stubs, tax returns, or employer letters), proof of the child's age and citizenship or immigration status, and proof of state residency. Some states offer a simplified mail-in or phone application for families with very low incomes.

Enrollment in Medicaid and CHIP is open year-round. There is no open enrollment window. A child can apply at any time, including after an income change, a birth, or a loss of other coverage. For families also managing employer or marketplace coverage decisions, the guide to open enrollment covers how qualifying life events interact with other coverage timelines.

This article is for informational purposes only and does not constitute medical, legal, or financial advice. Program rules, income thresholds, and covered services change over time and vary by state. Consult your state Medicaid or CHIP office for current eligibility requirements and benefit details specific to your household.