Getting Care under the Children’s
Health Insurance Program (CHIP)
A Guide for Parents and Families
If your child is newly enrolled in CHIP, here are some things you need to know.
What is CHIP?
CHIP is short for the Children's Health Insurance Program, Pennsylvania's program to
provide free or low-cost health insurance to uninsured children whose families earn too
much to qualify for MA but too little to afford private coverage. No family makes too much
money to get CHIP. For children in low-income families, CHIP is free. For children in
higher-income families, CHIP has a sliding scale monthly premium based on household
income and a requirement that the child has been without health insurance for at least six
months.
If your child is on CHIP, they get their coverage through private health insurance
companies that are licensed and regulated by the Pennsylvania Department of Insurance.
CHIP coverage comes from major insurance companies with large networks of physicians,
specialists and care facilities, so you may be able to enroll in CHIP without even changing
your child’s doctors.
CHIP provides children with comprehensive health care benefits, including:
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Immunizations
Routine Check-ups & Well Visits
Prescription Drugs
Dental, Vision, Hearing Services
Medically Necessary Orthodontia
Emergency Care
Mental Health Benefits
Hospitalization
Durable Medical Equipment
Substance Abuse Treatment
Partial Hospitalization for Mental Health Services
Rehabilitation Therapies
Home Health Care
Hospice and Palliative Services
Autism Spectrum Disorder and Related Services
Is CHIP the same as Medical Assistance?
No. Although Medicaid and CHIP both provide no-cost or low-cost health coverage for
eligible children in Pennsylvania, they are entirely separate programs. A child can qualify
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for either CHIP or MA; they cannot have both. Further, you cannot choose between MA and
CHIP. Rather, you must go into the program for which you qualify. One major difference
between the two programs is that children on MA can have other health insurance in
addition to MA, while children on CHIP must not have other health insurance in order to
qualify for CHIP.
If your child has a serious disability or medical condition that impairs his or her functioning
and is likely to last more than a year, it is likely that he or she should be enrolled in MA
instead of CHIP. If your child is in CHIP and it is determined that he or she is a better fit for
MA due to their medical condition or disability, your child should be referred to MA with no
break in their coverage while MA eligibility is determined. If your child experiences a
break in coverage switching between MA and CHIP, you should contact PHLP for
assistance.
Can I Choose between Medical Assistance and CHIP for my child?
No. Families cannot choose whether their child enrolls in CHIP or MA. When you apply for
either program, your application is sent to the appropriate program based on the
information you provide. You can only get the program available for your family's income
and your children's age. Some families may have one child in MA and another child in CHIP
because of their different ages.
How does my child get health care after we get CHIP insurance?
Your child will get care through the company that runs the CHIP insurance for your child.
You can find a list of CHIP insurance companies available in your county by visiting CHIP on
the web at www.chipcoverspakids.com. All counties have more than one company to
choose from, but all of the companies offer the same CHIP benefit package. Depending on
where you live, you will be able to choose from the following CHIP companies:
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Aetna (1-800-822-2447)
Capital BlueCross (1-800-543-7101)
First Priority Health (BCNEPA) (1-800-543-7199)
Geisinger Health Plan (1-866-621-5235)
Highmark Blue Shield (Central PA) (1-800-543-7105)
Keystone Health Plan West (1-800-543-7105)
Keystone Health Plan East (IBC) (1-800-464-5437)
KidzPartners (1-888-888-1211)
UnitedHealthPlan of Pennsylvania (1-800-414-9025)
UPMC for Kids (1-800-978-8762)
Getting Health Care in an Emergency: In an emergency, you should get care from the
closest hospital that can help you. The law requires providers offering these services to
examine you to determine if your medical condition is life threatening and provide you
with medical care until your life is no longer in danger.
Copyright January 2014
The Pennsylvania Health Law Project is a nonprofit legal services organization.
www.phlp.org ▪ 1-800-274-3258
How long is my child covered once they are enrolled in CHIP?
CHIP covers children in Pennsylvania up to age 19. Once enrolled, your child will remain
on CHIP so long as he or she remains eligible and you submit timely renewals. Families
must renew their coverage every year in order for coverage to continue. Renewal notices
are sent before benefits are going to end, and families must fill out and send the renewal
information back to their CHIP insurance company before the deadline in order for benefits
to continue.
To renew your child’s CHIP coverage, you will need the following information handy:
 Renewal Notice from your CHIP health plan
 Income amounts for your entire household before taxes.
 Social Security Numbers and birthdates for all applicants
 Commercial health insurance information (if you have or had private health
insurance in the last 90 days)
What if I have questions about CHIP coverage or experience a problem?
You should contact your CHIP health plan directly for most problems or questions. You can
also contact the CHIP through the Healthy Kids Helpline at 1-800-986-KIDS (5437).
Here are some examples of times when you should call your CHIP health plan:
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You didn’t get an enrollment card and are not sure if you are covered
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You can’t find a doctor in your area who will accept CHIP, or can’t get an
appointment
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You have questions about whether a service or product is covered
I haven’t received my enrollment card yet and I am not sure if I am
covered. What should I do if I need care?
If you received a letter telling you that you have been enrolled CHIP, but you haven’t
received an enrollment card yet, you should contact your CHIP insurance company to find
out how to get care. You may be able to get care in the meantime before your card arrives.
How do I find a provider in my area that accepts CHIP?
There are several things you can do to find a health care provider who accepts CHIP:
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Ask your current doctor or pharmacist if they accept CHIP. If you have been getting
care from a provider that doesn’t accept CHIP, you may be able to keep seeing that
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www.phlp.org ▪ 1-800-274-3258
provider for a short time until you can find another provider, but you need to ask
the CHIP program first.
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Call your CHIP insurance company for help. The phone number should be on your
eligibility letter or on the back of your enrollment card. This information should
also be available on your insurance company’s website or the CHIP website.
Be sure to let your provider know that you are enrolled in CHIP when you make an
appointment for care. If you are having trouble getting an appointment to see a doctor or
finding a doctor in your area, call CHIP or your insurance company for help.
What if CHIP refuses to cover services that my child’s doctor has
prescribed?
You can ask that the insurer reconsider its decision to deny a service that your child’s
doctor has prescribed. The CHIP website has information on how to file an appeal if a
service denial occurs, and this information will also be listed on your service denial notice.
Alternatively, you can call your CHIP insurance company at the number listed on the back
of your enrollment card to find out how to appeal a service denial.
What do I do if I find out my child’s CHIP insurance is being cancelled?
You should call your CHIP health plan immediately so that they can discuss their decision
with you. You will find the number on the letter that you received. You can also submit a
written request to your health plan for an impartial review within 30 days from the date on
your letter. You can send your written request to the address listed on your letter. When
you appeal, you must submit:
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A written, dated request stating why you disagree with the health plan’s decision
A copy of the letter you received
Any additional documentation to support your case (such as pay stubs)
A phone number where you can be reached during the day
Your health plan may contact you for more information once you file the appeal. If they
cannot resolve your issue, they will forward your written request and any additional
information you submitted to the Department of Insurance. You should then receive more
detailed information from the Department of Insurance, including the time and date that a
phone interview will be held if needed.
What if I have more questions about CHIP?
Contact the Pennsylvania Health Law Project Helpline at 1-800-274-3258.
Copyright January 2014
The Pennsylvania Health Law Project is a nonprofit legal services organization.
www.phlp.org ▪ 1-800-274-3258