D-340, Children in State Hospitals

Revision 15-4; Effective October 1, 2015

CHIP, CHIP Perinatal

Children in state hospitals may be eligible as independent children for a 12-month period. In order to be admitted to a state hospital, the child must:

  • be under age 19;
  • be a U.S. citizen or Lawful Permanent Resident who entered the U.S. prior to Aug. 22, 1996;
  • be a ward of HHSC via court civil commitment; or
  • have or obtain a Social Security number (SSN).

A representative from the state hospital completes the application and attaches a cover sheet to specify the application is from the state hospital. In addition, the representative attaches copies of unpaid medical bills and, if applicable, Form H1113, Application for Prior Medicaid Coverage.

The application lists the:

  • independent child's name as the head of household;
  • SSN;
  • date of birth;
  • parents or UNKNOWN in other parent section;
  • income and resources (if any);

Note: Resources are not considered as a factor in determining eligibility for CHIP or CHIP perinatal.

  • insurance information;
  • dates of service may be in the month of the child's 19th birthday or sooner;
  • representative from the state hospital in the authorized representative section;
  • signature of the representative from the state hospital who completed the application; and
  • address of the state hospital in the residence and mailing address section, except for Terrell State Hospital (Terrell State Hospital lists the independent child's original residence address and the facility address in the mailing address).

If the independent child has no income, no other information is required to complete the application processing.


An institutionalized child is not eligible to apply for CHIP. Exception: When a child is currently enrolled in CHIP and enters a state mental health facility, the child remains enrolled in CHIP until the end of the child's current enrollment segment.