FAQ: Eligibility Criteria & Benefits

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How do I know if my child qualifies?*
Based on your 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 Qualified Alien
  • A resident of Pennsylvania
  • Uninsured and not eligible for Medical Assistance

You can also review the complete CHIP guidelines to learn about all aspects of the program.

* All new applicants whose income falls in the low-cost and at-cost CHIP ranges must also show that the child(ren) has been uninsured for six months, unless the child is under the age of two, the child has lost health insurance because a parent lost their job or the child is moving from another public insurance program. At-cost CHIP families must also show that access to coverage is unavailable and affordable.

What are the benefits?
With CHIP, your children are guaranteed to receive comprehensive insurance coverage, including:

  • Immunizations
  • Routine check-ups
  • Prescription drugs
  • Dental 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

What are the income guidelines for CHIP?
For many families, it's free. Families with higher incomes will pay low monthly premiums and co-pays for some services. Click here to see the income ranges, or Click here for rates by company.

I live with my boyfriend - do I have to include his income? - OR - My baby and I live with my parents - do I have to include my parent's income?
The CHIP application requests all household members and income, which means you must provide information about everyone who lives with you and their income, if any. CHIP has rules that determine who is and is not included when determining eligibility. For example, even though you report income for your boyfriend, it would not be used to determine if you child is eligible, unless your boyfriend is the father of your child.

What if my family's income changes? Can I be re-evaluated to see if I qualify for free CHIP?
If there is a change in family income, you may 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 right CHIP group. If it is found that your child is now eligible for free CHIP, you can request that your child be moved to the free CHIP program effective the first month following the requested re-evaluation.

Why is there a six-month period of going without insurance for the low-cost and at-cost CHIP programs? We cannot afford our private coverage, and our child is sick and needs to have the medical attention. Can't you waive the period of not having insurance?
We understand the hardship and uncertainty this may create for families in need; however, this period of going without insurance is written into law so that employers and or consumers would not drop health coverage to enroll in a public program. It cannot be waived. All new applicants must show that their child(ren) has been uninsured for six months unless: the child is under age two; the child has lost health benefits because a parent lost their job; or the child is moving from another public health insurance program.

Why do my children have to wait six month for CHIP coverage?
Federal law requires that CHIP applicants whose income is over 200 percent of federal poverty guidelines (ex., a family of four making more than $41,300/year) have to be without insurance for six months before being enrolled - some exceptions apply, please continue reading. This requirement is part of the law and is used to prevent employers and or consumers would not drop health coverage to enroll in a public program. CHIP is strictly for families with no other available health coverage. Exceptions to the six month rule include: the child is under age two; the child has lost health benefits because a parent lost their job; or the child is moving from another public health insurance program.

Are there any deductions when determining CHIP eligibility?
Yes, there are deductions for work and dependent care that are taken into consideration when determining a household's gross income. The standard income deduction is $120 per month for each member of the family who is working. Dependent care expenses are deducted from earned income when a family member is working and incurs an expense for child care for an incapacitated adult. The dependent care deduction is limited to actual cost up to a maximum of $175 per month for each child two years of age of older, or incapacitated adult; and/or $200 per month for each child under age two.

What if I'm not legally living in the United States, but my child is?
Any child living in Pennsylvania can be enrolled if the child is a US citizen, a permanent legal alien or a refugee as determined by the US Immigration and Naturalization Services, is not eligible for Medical Assistance and meets the CHIP income guidelines.

How long can my child be on CHIP?
Your child can remain on CHIP as long as he/she meets the eligibility requirements, up to age 19. Those enrolled in the program do have to renew CHIP on an annual basis to determine if they are still eligible.

I have a job - can my children still get CHIP?
Yes, CHIP is a program for working families! There is no income limit anymore. CHIP covers all uninsured kids and teens. Now, no family makes too much money for CHIP.

I am pregnant. Can I apply for CHIP for me or my unborn child?
If you are under the age of 19, you can apply for CHIP for yourself, as long as you meet the eligibility criteria described above. If your unborn child needs insurance, you will need to wait until the child is born to apply for CHIP. But, we encourage you to start the application process prior to the birth. Depending on your income, your baby may be eligible for CHIP or Medical Assistance. If you have health insurance, your baby will be covered under your insurance policy for 31 days after it is born.

When I applied, my child received Medical Assistance coverage, but I want them to be on CHIP - what can I do?
CHIP coverage is determined by, among other things, household income. If your household income falls within the eligibility of Medical Assistance, your child will receive health insurance through Medical Assistance. Medical Assistance provides a comprehensive benefits package to cover your child's medical needs. When you apply for either program, your application is routed to the appropriate program based on your income. You cannot choose one program over the other

My Medical Assistance benefits are going to end. Can I apply for CHIP?
If you no longer qualify for Medical Assistance because you make too much money, but you do not have other health insurance, your caseworker at the County Assistance Office (CAO) should automatically refer your case to CHIP. Please contact your CAO caseworker and confirm that they are referring your case to CHIP 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 of your information. For a list of CHIP providers, click here.

I just got a notice that my children aren't eligible for CHIP - what can I do?
If you believe that your denial for CHIP benefits is not correct, you can file an appeal with the Insurance Department using the information located at the bottom of your CHIP denial notice. You must file this appeal within 30 days of the date of the notice or you will need to re-apply for CHIP benefits. The appeal can be sent to: Pennsylvania Insurance Department, CHIP Eligibility Review Unit, 333 Market Street, 2nd Floor Landing, Harrisburg, PA 17101.

Also you can contact your County Assistance Office or the Pennsylvania Helpline (1-800-986-KIDS) for other health care services and programs that are available.

We are a family with three children. Two are eligible for CHIP, but one is eligible for Medical Assistance. How can this be?
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 children less than six years of age. It is not unusual for a child less than age one to be enrolled in Medical Assistance while other older siblings are enrolled in CHIP.

I have insurance but it does not cover dental, vision and/or prescriptions. Can I just get these benefits through 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. You may be able to find more information on accessing these types of services by checking out our health care services and programs page.

Does CHIP cover braces?
CHIP, by law, does not cover orthodontia. Check out our health care services and programs page for information on dental services at a free or low cost rate.

My child has a pre-existing condition. Will that affect our eligibility?
No. Pre-existing conditions do not affect eligibility for the program.

I have more questions. Can I talk to someone about CHIP?
Couldn't find the answer you're looking for? Maybe it's under another category in our FAQ section. Check it out. If your question is still not answered, send us your question and someone will get back to you shortly. Figuring out insurance questions these days can be complicated, but applying for CHIP is simple. Knowledgeable, courteous counselors are available at 1-800-986-KIDS (TTY/TDD 1-800-451-5886) to assist you. A counselor will also help you sort through the information and can help you apply for CHIP and other social service programs.