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Types ofCHIP ProgramsThere are three types of CHIP programs. Each state or territory utilizes one of the three options: CHIP as an expansion of Medicaid Separate CHIP Combination of separate CHIP MedicaidWhen CHIP is administered as an expansion of Medicaid, states can offer different levels of coverage based onthe child’s age or the family’s income. States must adhere to federal guidelines for costs of services.When CHIP is offered as a separate program, states are given the freedom to design benefit packages that lookmore like commercial insurance programs. States also get to determine how much beneficiaries will pay formedical services.12

Most states offer CHIP as a combination of the two options listed above. Combination plans adhere to Medicaidcost-shares and income eligibility requirements, but states can design packages for families with different levelsof income.The chart below shows how each state and territory administers CHIP as of 2020:LocationCHIP as an Expansion ofMedicaidSeparate CHIPAlabamaAlaskaCombination CHIP Arizona Arkansas California Colorado Connecticut DelawareDistrict of Columbia Florida Georgia Hawaii Idaho Illinois 13

LocationCHIP as an Expansion ofMedicaidSeparate CHIPCombination CHIPIndiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New JerseyNew MexicoNew York 14

LocationCHIP as an Expansion ofMedicaidSeparate CHIPCombination CHIPNorth Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode IslandSouth Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands VirginiaWashington West Virginia Wisconsin Wyoming 15

CHIPEligibility RequirementsEach state or territory sets its own CHIP eligibilityguidelines. Some requirements are standard across thecountry, while others vary by location. Before submittingyour application, review your state’s requirements andincome limits to make sure you qualify. Routine checkups Immunizations (shots) Prescription drugs Dental care Vision careSee the section called “CHIP Income Guidelines byLocation” on page 17 of this guide for informationabout specific income limits.NationwideRequirements Doctor visits Emergency services Inpatient and outpatient hospital care “Inpatient” is when an individual is admittedinto the hospital. “Outpatient” is when an individual continuesto receive care once they have left thehospital.There are nationwide eligibility requirements that alllocations adhere to. To qualify for CHIP, you must have: A child who is 18 years of age or younger. U.S. citizenship or approved immigration status. Proof of your legal status, such as a passport ora permanent resident card.Nationwide CHIP BenefitsThe following list encompasses the standard CHIPbenefits administered in each state or territory:16

Location-SpecificRequirementsSince CHIP is administered at the state/territory level,there are state-specific requirements that applicantsmust meet before they receive benefits. Applicantsmust meet both their state’s requirements and thenational requirements listed above.person income limit amount for each additionalfamily member. You can use this figure to find thetotal income limit for your larger household using thesteps below:01Locate your state or territory in the chartbelow.02Find the highest income limit listed foryour state.To qualify for your local CHIP program, you must: Some states list income limitsfor up to 12 members whileother states stop at six. Meet your location’s established incomeguidelines. Have proof of state residency, such as a driver’slicense or utility bill.03 Adhere to your state-specific CHIP waitingperiod. If your state lists the incomelimits for up to eight householdmembers, but there are 10members in your household, youhave two additional members.CHIP Income Guidelines by LocationCHIP income limits are different in every location.Income limits may change each year. It is commonfor a family to qualify one year and become ineligiblethe next due to a state’s changes to its income limitsor due to a change in the family’s income.Each state or territory determines income limitsbased on the size of the household. Household sizeis calculated by adding up the total number of familymembers living in the home.Most states list income limits for households withup to eight members. For families with more thaneight household members, states provide a per-Determine how many additionalhousehold members you have.04Multiply the number of additionalmembers by the dollar amount locatedin the “additional” column of the table.05Add the answer you get in step four tothe highest income limit listed for yourstate.In the chart below, you will find the 2020 incomelimits for every state, including those for the U.S.Virgin Islands and Puerto Rico, based on the size ofthe household.17

A single asterisk (*) means that the income limit for that state is listed annually.Double asterisks (**) signify that the income limit varies depending on the Federal Poverty Level (FPL).Triple asterisks (***) signify that the information was intended to be included but was not available.No asterisks mean that the income limit for that state is listed monthly.Note: Certain states may have lower limits for infants or varying income limits based on the age of the child.Household Size1AL234567892,644 -3,189 -3,734 -4,279 -4,824 -5,369 ,6204,3675,1145,860///////AR2,196.51 2,972.99 3,751.58 4,528.06 5,304.54 6,083.13 6,859.61 7,636.09 3,32564,37575,42586,47597,525108,575 ////11,050CT*25,104 - 33,989 - 42,873 - 51,757 - 60,641 - 69,525 - /////////////CT*31,724 - 42,951 - 54,178 - 65,405 - 76,631 - 87,858 - /(HUSKY BLEVEL2)54,17865,40576,631/Addtl2,099 -42,951/123,37131,724/111,554 -(HUSKY BLEVEL1)/10583 25DC*38,28051,72065,16078,60092,040105,480 118,920 132,360 145,800 159,240 172,680 186,120 70FL*/** 16,980 - 22,932 - 28,896 - 34,848 - 40,812 - 46,764 - 52,728 - 58,680 - 64,644 - 70,608 - 492,07288,248/97,200/106,16418

Household Size1234567GA*29,352HIDetermine your eligibility by going to: 8585,567IL**1,530 -2,071 -2,613 -3,154 -3,696 l102,061 ////10,3876,2776,986////709////////////////21,310 - 28,792 - 36,273 - 43,755-51,237 - 58,718 - 66,200 - 73,681 - /////38,53552,06565,59479,12492,654106,183 119,713 ,308 -3,118 -3,928 -4,738 -5,548 -6,359 -7,169 -7,979 3 -2,328 -2,933 -3,537 -4,142-///////605 -2,2653,0613,8564,6515,446ME39,7398796MDHousehold income must fall below 322% of the Federal Poverty Level (FPL), but in some cases, it must be below 211% of the FPL.MA*37,47050,73063,99077,25090,510103,770 117,030 130,290 122107,277 119,432 69////781MO**1,595 -2,155 -2,715 -3,275 -3,835 -4,395 -4,955-5,515 -6,075 -6,635 -7,195 -7,755 47597,525108,575 ////MT*86,86011,05019

Household 34069,18078,02086,860////8,840NH**2,085 -2,816 -3,548 -4,280 -5,012 -5,743 -6,475 -7,207 564 -2,112 -2,661 -3,210 -3,759 -4,308 -//////549 -3,7755,1016,4267,7519,07710,4021,064 -1,437 -1,810 -2,184 -2,557 -2,930 -3,1904,3115,4306,5507,6718,7901,638 -2,213 -2,788 -3,363 -3,938 -4,2545,7477,2408,73410,227/1,875 -2,365 -2,854 -3,344 //////4,513 -5,088 -5,663 -////575 OR3,2444,3825,5216,6607,7988,937///////PA*20,034 -27,067 -34,101 -41,134 -48,168 -55,202 -62,235 -69,269 -76,302 - 83,336 - ,537152,604 166,672PR1,1001,3001,5001,700//////200RIHousehold income must be up to 261% of the Federal Poverty Level (FPL) for children 18 years of age or younger. For pregnant women,//income must be at 253% of the FPL.SC2,211.73 2,988.26 3,764.80 4,541.33 5,317.86 6,094.40 6,870.93 7,647.46 ////20

Household ,391/////USVI548.40739.19929.981,120.77 71.20 4,554.85 5,738.50 6,921.20 8,104.85 9,288.50 10,472.20 11,655.85 /766WA2,233 -3,017 -3,801 -4,585 -5,369 -6,153 -///////3,3184,4835,6486,8127,9779,142/2,155 -2,715 -3,275 -3,835 -4,395 -4,955 -//////4,3105,4306,5507,6708,7909,910/373.33 -WVWI**10111,063.33 1,436.67 1,810 -2,183.33 2,556.67 2,930 -3,303.33 3,676.67 4,050 -4,423.33 /-----5,4303,189.99 4,310.01WY5,02892,1272,874-8,7906,549.99 7,670.013,6204,3675,114-12,1509,909.99 1008,847///If you are a Native American or Alaska Native, you are held to the same income guidelines for the state in whichyour tribe is located. Use the table above to see if you qualify for CHIP benefits. For more information or to contactyour state’s CHIP department, refer to page 8 of this guide.21

Location-Specific CHIP BenefitsBeyond the nationwide standard coverage, local agencies may choose to provide additional covered servicesthrough CHIP. In the chart below, you will find a list of additional medical services provided by each state or territory.Note: Some of these services may require referrals from primary care physicians. A referral is a notice of approvalfor medical services not provided by a primary care physician.TherapyMedicalEquipmentand cesPregnancyand /orPostpartumcare Alaska Arizona Arkansas California Colorado Connecticut Delaware District ofColumbia Florida MentalHealthServicesAlabamaLocationGeorgia FamilyPlanning Hawaii Idaho 22

TherapyMedicalEquipmentand cesPregnancyand /orPostpartumcareFamilyPlanning Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada NewHampshire New Jersey MentalHealthServicesIllinoisLocation 23

MentalHealthServicesNew MexicoPregnancyand /orPostpartumcareTherapyMedicalEquipmentand SuppliesSubstanceAbuseTreatment New York NorthCarolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington LocationTransportationServicesFamilyPlanning 24

MentalHealthServicesTherapyMedicalEquipmentand SuppliesSubstanceAbuseTreatmentWest Virginia Wisconsin Wyoming LocationTransportationServicesPregnancy and/or PostpartumcareFamilyPlanning CHIPWaiting PeriodsSome states require children to be uninsured for a period of time before they are eligible for CHIP coverage. By law,the state-specific waiting period can be no longer than 90 days. See the chart below for the list of states that haveCHIP waiting periods, including the duration of each waiting period and any exceptions to this rule. States that arenot listed below do not have waiting periods.StateWaiting PeriodExceptionsArizona90 days Newborns Anyone enrolled in Children’s RehabilitationServices Native Americans receiving services from IHSor a 638 Tribal Facility Anyone who reached their lifetime insurance limitArkansas90 days Unborn childrenFlorida2 months Anyone who reached their lifetime insurance limit Victims of domestic violence Children who have exhausted coverage underCOBRA Children with special health care needsIllinois90 days Babies younger than 1 year of age Families at or above 209% of the FederalPoverty Level (FPL)Indiana90 days Families at or below 158% of the FederalPoverty Level (FPL)25

StateWaiting PeriodExceptionsIowa30 days Families at or below 181% of the FederalPoverty Level (FPL) Children who are only eligible for dentalcoverage Anyone who reached their lifetime insurance limit Children who have exhausted coverage underCOBRALouisiana90 days Unborn children Anyone who reached their lifetime insurancelimit Children with long-term disabilitiesMaine90 days NoneNew Jersey90 days Pregnant women Families at or below 200% of the FederalPoverty Level (FPL) Applicants who lost their insurance coveragedue to abuse Children who have exhausted coverage underCOBRASouth Dakota90 days NoneTexas90 days Unborn children Children who have exhausted coverage underCOBRA Loss of coverage in the Texas EmployeeRetirement SystemUtah90 days Applicants who voluntarily terminated theirCOBRA coverage Non-custodial parents who voluntarily terminatedtheir coverage Applicants who voluntarily terminated insuranceoutside of Utah Applicants who voluntarily terminated a limitedhealth insurance planWyoming1 month None26

CHIP Medical Funding Requestsfor Denied ServicesCHIP children who require special medical attentionor need extensive treatment may not be automaticallycovered for certain services they need through theirstate’s program, even if they have already beenaccepted into CHIP.If you receive a CHIP coverage denial for certainmedical services to treat your child’s special medicalcondition, you need to submit an appeal and requestfunding to get those specific services covered byCHIP.Appealing a Medical Service DenialYou can appeal a medical service funding denialon behalf of your child for any service or treatmentnot considered “medically necessary” by your state.States and territories determine which services arereasonable and necessary for the treatment of anygiven condition. More complicated or expensiveprocedures may be initially rejected for coverage bythe CHIP program. If you disagree with your state’sdecision, you can file an appeal to have CHIP coverthose medical expenses. Appeals are not guaranteedand may be denied by the CHIP agency.If you are denied CHIP coverage for your child’smedical services, you will receive a denial letter inthe mail. It will include a deadline for appealing thedecision as well as the specific steps you must taketo begin the appeal.After submitting an appeal, your local CHIP agencywill send you an acknowledgement letter statingthat the denial will be reviewed. Most appeals arereviewed and processed within 30 days of the datethat the original appeal was received.During the appeal process, you must remainenrolled in your CHIP coverage plan. If you do notstay enrolled or fail to pay your premiums, you willlose your CHIP health coverage. You may not be ableto re-enroll in CHIP immediately after the appeal,even if your appeal is granted. For more informationabout paying CHIP premiums, please refer to thesection called “CHIP Premiums in U.S. States andTerritories” on page 45 of this guide.While your appeal is being reviewed by your localCHIP agency, you should start gathering anydocuments that prove your child’s medical servicesand treatment are necessary for his or her healthcondition. These include: Written authorizationsproviders.fromhealthcare Dates of medical care provided. Prescription notices.Your local CHIP agency will evaluate these medicaldocuments to reconsider the initial decision. Oncethe CHIP agency has come to a final decision, you willeither receive a notice of approval or another denialletter.27

How toApply for CHIPYou can apply to CHIP year-round. Also, if you apply to Medicaid, your Medicaid application is automaticallyexamined to identify whether your children are eligible for CHIP coverage.The application process varies from location to location.Information andDocumentsWhen applying to CHIP, you must provide extensive personal and financial information as well as documents toprove that you qualify: Proof of full name Social Security card, driver’s license or U.S. passport Proof of date of birth Birth certificate Proof of citizenship Passport, Permanent Resident Card, Certificate of Naturalization or Certificate of Citizenship28

Proof of residency Utility bill, property tax, rent receipt or mortgage documents Proof of income Pay stubs, bank statement, tax return, W-2 or 1099 forms Proof of employment Pay stubs, signed and dated letter from employer on company letterhead Proof of relation Adoption papers or marriage recordsNote that applicants must provide all sources of income, including earned income (such as a salary) andunearned income. Unearned income is money that is received but that is not payment for work, such as: Inheritance Unemployment benefits Social Security benefits Alimony Child support Pensions29

Applying inU.S. States and TerritoriesBecause each location sets its own regulations for managing CHIP, the application process can vary greatly fromone location to the next. Your local CHIP agency may or may not accept applications online, in person or by mail.To find out how to submit an application, review the applicable section below.01Alab

MassHealth MinnesotaCare MO HealthNet for Kids MIChild CHIP Healthy Montana Kids (HMK) 1 (800) 841-2900 1 (800) 657-3629 1 (855) 373-9994 1 (888) 988-6300 1 (800) 421-2408 1 (888) 706-1535 District of Columbia Healthy Families Insurance 1 (800) 620-7802 Location Program Name Office Phone Number