D-110, General Policy

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Revision 26-1; Effective Jan. 1, 2026

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% of the federal poverty level (FPL). This is the applicable income limit for TA 84 (CHIP).

Children who do not qualify 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% of the FPL must 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 medical effective date (MED) 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 more than 198% of the FPL, the applicable income limit for Medicaid for Pregnant Women (TP 40), but whose household income is at or below 202% of the FPL, the applicable income limit for CHIP Perinatal (TA 85); or
Medicaid or CHIP due to immigration status if 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 eligibility from the month the eligibility determination is made. This 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-Emergency 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 programs above in the same month as CHIP perinatal. This is not considered dual coverage. Pregnant women may have concurrent CHIP perinatal and Medicaid for Pregnant Women – Emergency (TP 36) or Medically Needy with Spend Down – Emergency (TP 32) during their pregnancy if certain criteria are met. Follow the chart below to determine if concurrent coverage should be provided.

If	then
an application is received with a report of pregnancy and a Form H3038, Emergency Medical Services Certification, for an emergency event not related 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 12-month postpartum period; and certify CHIP perinatal.
an application is received for an active CHIP perinatal recipient with a Form H3038 for an emergency event not related 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 12-month postpartum period; and maintain the woman’s CHIP perinatal certification period.
an application is received with a report of a new pregnancy or a new pregnancy is reported as a change without an application for a TP 36 recipient in her postpartum period,	certify CHIP perinatal based on the new pregnancy; and maintain the woman’s existing TP 36 coverage through the initial 12-month postpartum period.

When a child is born to a CHIP perinatal mother whose household income is above the applicable income limit for Medicaid for Pregnant Women, 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 for 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 Medicaid for Pregnant Women, 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 termination month. The mother is eligible for two postpartum visits that may occur after her CHIP perinatal coverage ends.

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