US Healthcare · System Basics
CHIP Eligibility Basics
Who qualifies for the Children's Health Insurance Program — income limits by state, age rules, enrollment timing, and how CHIP differs from Medicaid for families whose income is too high for Medicaid but too low for affordable private insurance.
Parents and guardians whose children may not qualify for Medicaid but cannot easily afford private health insurance, or whose children have aged out of Medicaid and are looking for alternatives.
The Children’s Health Insurance Program (CHIP) fills a gap between Medicaid and private insurance for millions of American families. If your income is too high for your children to qualify for Medicaid but you cannot easily afford private coverage, CHIP may be an option. This guide explains who qualifies, how income limits work, what the program covers, and how to apply. For the broader picture of public coverage options, see the Medicaid and CHIP guide.
What CHIP is designed to do
CHIP was created in 1997 to extend coverage to children who fell in the gap between Medicaid and private insurance. Both the federal government and each state fund the program, though the federal government contributes at a higher rate than it does for Medicaid. States have flexibility to design CHIP within federal guidelines, which is why benefit packages, income limits, and cost-sharing requirements differ across states.
CHIP covers children up to age 19. In about half of states, CHIP also covers pregnant women.
Income eligibility: the FPL system
CHIP eligibility is tied to the federal poverty level (FPL) — a federal measure updated annually. Most states set their CHIP income limit well above the Medicaid limit, creating a band of income in which children qualify for CHIP but not Medicaid.
Typical income bands (examples)
| Income relative to FPL | Likely eligibility |
|---|---|
| Below Medicaid limit (typically 100–138% FPL) | Medicaid |
| Between Medicaid limit and CHIP limit (varies by state) | CHIP |
| Above CHIP limit | May qualify for Marketplace plan with or without a premium tax credit |
Most states set their CHIP upper limit between 200% and 300% of FPL. Several states have higher limits. For example:
- A state with a CHIP limit of 200% FPL would cover children in a family of four earning up to roughly $62,000 per year at current federal poverty guidelines.
- A state at 300% FPL would cover the same family up to roughly $93,000 per year.
- Some states go higher — a few cover children at 400% FPL or above.
Because these numbers change annually when the FPL is updated, and because states can adjust their own limits, you should verify your state’s current income threshold through InsureKidsNow.gov or your state Medicaid agency.
How CHIP is structured: separate CHIP vs. Medicaid expansion CHIP
States implement CHIP in one of two ways, and the structure affects how coverage works in practice.
Separate CHIP programs operate independently from Medicaid. They have their own rules, benefit packages, and cost-sharing. A child on a separate CHIP program is enrolled in that program, not Medicaid. Separate CHIP programs can impose premiums and copayments (within federal limits) that Medicaid cannot.
Medicaid expansion CHIP delivers CHIP coverage through the state’s Medicaid program using CHIP federal funding. Children enrolled this way receive coverage under Medicaid rules, which generally means lower cost-sharing and a broader benefit framework.
Whether your state uses separate CHIP, Medicaid expansion CHIP, or a combination affects what copayments your child may face and which providers they can see.
What CHIP covers
Federal law requires CHIP to cover a comprehensive set of benefits:
Documents and terms you’ll see with CHIP coverage
- Summary of Benefits and Coverage (SBC) — a standardized document describing what a plan covers and what you will pay. See summary of benefits and coverage in the glossary.
- Cost-sharing — the portion of healthcare costs a family pays directly, including premiums, copayments, and deductibles. Federal law limits how much CHIP can require in cost-sharing. See cost-sharing in the glossary.
- Network — the group of doctors, hospitals, and other providers contracted with a health plan. Children on CHIP are generally limited to in-network providers except in emergencies. See network in the glossary.
Required CHIP benefits include:
- Well-child checkups and immunizations
- Doctor visits for illness and injury
- Hospitalization (inpatient and outpatient)
- Prescription drugs
- Emergency services
- Dental care
- Vision care, including glasses
- Laboratory tests and X-rays
- Mental health and substance use services (parity required)
States may add benefits beyond this floor. Dental and vision are notable inclusions — many private plans do not cover these for children without a separate premium, while CHIP typically does.
Enrollment: year-round, no waiting period in most states
Unlike Marketplace plans, CHIP does not have an annual open enrollment window. You can apply for a child at any time during the year. Federal law prohibits most states from imposing a waiting period before coverage begins, although some states may have had approved waiting periods in the past. Check with your state.
Coverage usually begins on the first day of the month following approval, though some states can make coverage effective immediately or retroactively to the date of application.
What CHIP costs families
CHIP is designed to be affordable. Federal law caps the total cost-sharing a CHIP family can be required to pay at 5% of annual family income. Within that cap, states may charge:
- Premiums: monthly fees to maintain coverage; many states charge nothing for families at lower income levels
- Copayments: flat fees at the time of service (e.g., $5 for a doctor visit)
- Deductibles: annual amounts that must be paid before the plan contributes (less common in CHIP)
For families at the lower end of the CHIP income band, premiums are often zero or a few dollars per month.
When a child turns 19
CHIP covers children up to but not including age 19. When a child ages out of CHIP, the family should explore:
- Medicaid — if the young adult’s income is within the Medicaid limit (especially in Medicaid expansion states).
- A parent’s employer plan — if a parent has employer coverage, the young adult can typically join or remain on the plan through age 26 under federal law.
- Marketplace plan — aging out of CHIP is a qualifying event that opens a 60-day special enrollment window; the young adult can enroll in a Marketplace plan, possibly with a premium tax credit based on their income.
Plan ahead for this transition. Contact your state CHIP program or healthcare.gov before the child’s 19th birthday to understand options and avoid a gap in coverage.
How to apply
Applications are accepted through healthcare.gov, your state’s Medicaid or CHIP agency, or in person at a social services office. When you apply through healthcare.gov, the system screens for both Medicaid and CHIP eligibility and routes the application appropriately. You will typically need to provide proof of the child’s age, household income, and residency.
Key terms
| Term | Plain meaning | Glossary |
|---|---|---|
| CHIP | Children's Health Insurance Program — provides low-cost health coverage to children in families above Medicaid income limits | → |
| Federal Poverty Level (FPL) | A federal income measure used to determine eligibility for many government assistance programs including CHIP and Medicaid | → |
| Separate CHIP | A CHIP program that a state runs independently from Medicaid, with its own rules and cost-sharing | → |
| Medicaid expansion CHIP | CHIP coverage delivered through the state Medicaid program using CHIP funding for children above Medicaid income limits | → |
| Premium | A monthly payment required to maintain health insurance coverage | → |
Common questions
- What is CHIP and who does it cover?
- CHIP is the Children's Health Insurance Program. It provides low-cost or no-cost health insurance to children up to age 19 in families whose income is above the Medicaid limit but below the CHIP income limit set by their state. In many states, CHIP also covers pregnant women.
- What is the income limit for CHIP?
- Income limits vary by state, but most states cover children in families earning between 200% and 400% of the federal poverty level (FPL). Some states have limits as high as 400% FPL or even higher. There is no single national limit — you must check your state's specific threshold.
- Does CHIP cost anything?
- CHIP is designed to be affordable. Many states charge little or no premium for CHIP coverage, especially for lower-income families. Copayments may apply for some services. Federal law caps the total cost-sharing that CHIP programs can impose on families.
- Can I enroll my child in CHIP at any time?
- Yes. CHIP does not have an open enrollment period. You can apply for a child at any time during the year, and if the child is eligible, coverage can begin quickly.
- What does CHIP cover?
- CHIP must cover a defined set of benefits including routine checkups, immunizations, doctor visits, prescriptions, dental care, vision care, inpatient and outpatient hospital care, lab services, and X-rays. The exact benefit package varies by state.
- What happens when a child turns 19?
- CHIP covers children up to age 19. After that, they may qualify for Medicaid (if income is within the limit), a parent's employer plan if the parent has one, or a Marketplace plan. Losing CHIP at age 19 is a qualifying event that opens a special enrollment period.
- Can undocumented children get CHIP?
- Federal CHIP funds generally cannot be used for undocumented children. However, some states use state funds to provide coverage to children regardless of immigration status. Emergency Medicaid is available to all children for acute medical conditions regardless of status.
- Is CHIP the same as Medicaid?
- They are related but separate programs. Medicaid covers a broader population across all ages. CHIP specifically covers children (and in some states, pregnant women) whose income is too high for Medicaid. CHIP is funded jointly by federal and state governments, with a different federal matching rate than Medicaid.
Sources
Last reviewed: September 2026