D-110, General Policy

Revision 25-1; Effective Jan. 1, 2025

CHIP

The Children's Health Insurance Program (CHIP) provides health care coverage for children under 19 whose family income exceeds the Children's Medicaid income limit but is less than or equal to 201 percent of the federal poverty level (FPL). This is the applicable income limit for TA 84 (CHIP). Children who do not qualify for Medicaid and remain ineligible for Medicaid, are eligible to enroll in CHIP and receive up to 12 months of continuous coverage. Families with net income above 151 percent of the FPL are required to pay an enrollment fee. Most families also have copayments for doctor visits, prescription drugs and emergency care.

When an applicant requests children's health coverage, the child is first tested for Medicaid eligibility. If ineligible for Medicaid, the child is then tested for CHIP eligibility. When processing a change for a person certified for CHIP, the eligibility determination system automatically tests the person for Medicaid eligibility. A new application is not required.

CHIP eligibility is prospective. The effective date is based on if the Eligibility Determination Group (EDG) is disposed before or after cutoff and when the enrollment process is completed. The eligibility determination system provides the potential eligibility begin date, and Enrollment Broker provides the actual eligibility begin date.

CHIP Perinatal

CHIP perinatal provides services to unborn children of pregnant women, regardless of age. These pregnant women are ineligible for:

• Medicaid due to income exceeding 198 percent of the FPL, which is the applicable income limit for TP 40, but whose household income is at or below 202 percent of the FPL, which is the applicable income limit for TA 85 (CHIP Perinatal); or
• Medicaid or CHIP due to immigration status, since the pregnant woman is not a citizen or qualified alien.

When processing a change for a person certified for CHIP perinatal, the eligibility determination system automatically tests the person for Medicaid eligibility. A new application is not required.

The unborn children of pregnant women eligible for CHIP perinatal are granted 12 months of continuous enrollment from the month the eligibility determination is made. The 12-month period includes the months of CHIP perinatal coverage before and after birth. The mother receives CHIP coverage related to the birth only. She does not receive personal health care coverage.

Because CHIP perinatal only provides coverage for pregnancy-related services, women certified for CHIP perinatal must apply for Emergency Medicaid or Medically Needy (MN) with Spend Down to receive coverage for medical conditions not related to their pregnancy. Receiving CHIP perinatal does not affect the mother's eligibility for:

• MA-Pregnant Women – Emergency (TP 36);
• MA-Parents and Caretaker Relatives Medicaid – Emergency (TA 31);
• MA-MN with Spend Down – Emergency (TP 32); or
• MA-Children 6-18 – Emergency (TP 34).

Pregnant women may receive the program(s) above in the same month as CHIP perinatal. This is not considered dual coverage. Note: CHIP perinatal recipients cannot be certified for both CHIP perinatal and Medically Needy with Spend Down (TP 56) at the same time.

Concurrent CHIP perinatal and Emergency Medicaid (TP 32 or TP 36) coverage is allowed:

• when an application is received with a report of pregnancy along with a Form H3038, Emergency Medical Services Certification, for an emergency event unrelated to labor and delivery, then:
  • certify TP 36 or TP 32 once the spend down amount is met, effective the date of the emergency event through the pregnancy and 12-month postpartum period; and
  • certify CHIP-P coverage, if eligible.
• when an application is received for the CHIP-P recipient along with a Form H3038 for an emergency event unrelated to labor and delivery:
  • certify TP 36 or TP 32 once the spend down amount is met, effective the date of the emergency event through the pregnancy and 12-month postpartum period; and
  • maintain the current CHIP-P certification period.

When a child is born to a CHIP perinatal mother whose household income is above the applicable income limit for Pregnant Women Medicaid, the child's coverage begins on the date of birth and the mother's coverage is terminated on the last day of the month the birth occurs. The mother is eligible to receive two postpartum visits that may occur after the mother's CHIP perinatal coverage ends. At birth, the child receives perinatal coverage for the remainder of the 12-month eligibility period. The child's CHIP perinatal enrollment is terminated at the end of the 12-month period.

When a child is born to a CHIP perinatal mother whose household income is at or below the applicable income limit for Pregnant Women Medicaid and the mother receives Emergency Medicaid to cover the labor with delivery charges, enroll the child in TP 45 effective the child's date of birth. The mother's perinatal coverage ends the last day of the child's birth month or the pregnancy's termination month. The mother is eligible to receive two postpartum visits that may occur after her CHIP perinatal coverage ends.

Related Policy

Federal Poverty Level (FPL), C-131.1
Type Programs (TP) and Type Assistance (TA), C-1150
Adding a New Child, D-1433.1