Medicaid & CHIP Coverage

Medicaid and the Children’s Health Insurance Program (CHIP) offer free or low-cost health coverage to eligible individuals, including low-income people, families, children, pregnant women, the elderly, and people with disabilities. In some states, Medicaid has been expanded to cover all individuals below certain income thresholds.

Check Your Eligibility:

• Income-Based Qualification: Enter your household size and state to see if you qualify for Medicaid or savings on a Marketplace plan.
• Apply Even If Unsure: Even if you don’t qualify based on income, you should still apply. You may be eligible for your state's program, particularly if you have children, are pregnant, or have a disability.

How to Apply for Medicaid and CHIP:

1.Through the Marketplace:

1. • Complete a Marketplace application. If anyone in your household qualifies for Medicaid or CHIP, your information will be sent to your state agency, which will contact you about enrollment.
   • When you apply through the Marketplace, you’ll also learn if you qualify for cost savings on a Marketplace plan, which may be more affordable than you think.
   • Create an account to start your Marketplace application.
2. Directly Through Your State Medicaid Agency:
   • Select your state below to access your Medicaid agency’s contact information and apply directly.

Medicaid and CHIP applications are open year-round, so you can apply at any time.

Medicaid Expansion & What It Means for You

Medicaid Expansion Overview Some states have expanded their Medicaid programs to cover all individuals with incomes below a certain level, while others have not. Your eligibility for Medicaid depends partly on whether your state has expanded the program.

In All States:

• Eligibility Factors: Medicaid coverage is based on income, household size, disability, family status, and other factors. Each state has its own rules.

In States with Medicaid Expansion:

• Income-Based Eligibility: If your household income is below 138% of the federal poverty level (FPL), you qualify for Medicaid. Note that some states use slightly different income limits.

If Your State Has Not Expanded Medicaid:

• Income-Based Coverage: If your income is below the federal poverty level and you don't qualify for Medicaid under your state's rules, you won't qualify for Medicaid or savings on a Marketplace plan.

Check Your Eligibility:

• Find Out More: See if you qualify for Medicaid based on income alone and if you might qualify for savings on a Marketplace health insurance plan.

If You Don’t Qualify for Medicaid or Marketplace Savings:

• Community Health Centers: You can receive care at community health centers, which offer services on a sliding scale based on income.
• Catastrophic Plans: If you’re under 30, you may qualify for a "Catastrophic" plan. If you're 30 or older, you need to qualify for an exemption.
• Special Enrollment Period: If your income changes to between 100% and 400% of the FPL, you may be eligible for a Marketplace plan with premium tax credits. Income changes above 400% FPL might still qualify for savings.

Apply for Medicaid:

• Even if Uncertain: Apply for Medicaid even if your state hasn’t expanded the program, especially if you have children, are pregnant, or have a disability. Detailed income information might reveal eligibility for savings.

If Your Income Changes:

• Special Enrollment: If your income increases to qualify for Marketplace plans or tax credits, you may qualify for a Special Enrollment Period. Contact the Marketplace Call Center within 60 days of the income change to check your eligibility.

The Children's Health Insurance Program (CHIP)

Overview If your children need health coverage, they may qualify for the Children's Health Insurance Program (CHIP). CHIP offers affordable health insurance to children in families that earn too much to qualify for Medicaid but still need assistance. In some states, CHIP also covers pregnant women.

How to Check Eligibility and Apply:

• Eligibility Rules: Each state has its own CHIP rules. Apply anytime of the year to find out if your children qualify.
• Application Process:
  1. Call: Reach out to 1-800-318-2596 (TTY: 1-855-889-4325).
  2. Online: Submit an application through the Health Insurance Marketplace®. If it looks like anyone in your household qualifies for Medicaid or CHIP, your information will be sent to your state agency for enrollment. You can also check if you qualify for savings on an individual insurance plan.

Application Timing:

• No Enrollment Period: You can apply for Medicaid or CHIP any time of the year. If you qualify, coverage can start immediately.

What CHIP Covers: CHIP benefits vary by state but generally include:

• Routine check-ups
• Immunizations
• Doctor visits
• Prescriptions
• Dental and vision care
• Inpatient and outpatient hospital care
• Laboratory and X-ray services
• Emergency services

For more details on what’s covered in your state, contact your state CHIP program.

Using Your Medicaid or CHIP Coverage

Getting Help and Information:

• Contact Information: For most questions, reach out to your state Medicaid or CHIP agency. If you have a health plan through Medicaid or CHIP, use the member services phone number on your eligibility letter or enrollment card. This number is also available on the websites of your health plan or Medicaid/CHIP agency.
• Doctor or Pharmacist: Your doctor or pharmacist may be able to answer questions about what services are covered.

Emergency Services:

• In an Emergency: Go to the nearest hospital that can help you. Providers must assess your condition and provide care if your life is at risk.

When to Contact Your State Medicaid or CHIP Agency:

• Enrollment Issues: If you didn’t receive an enrollment card and aren’t sure about your coverage.
• Finding Providers: If you can't find a doctor who accepts Medicaid or CHIP or if you can’t get an appointment.
• Coverage Questions: If you’re unsure whether a service or product is covered.

• Life Changes: Report changes like a new job affecting your income, a dependent aging out of coverage, or changes in marital status.

Filling Prescriptions:

• Without a Card: If you need to fill a prescription and don’t have your enrollment card yet, check if your pharmacy accepts Medicaid, CHIP, or your health plan. Bring your eligibility letter and prescription to the pharmacy. They may be able to fill it based on your letter.
• Temporary Medication: If there isn’t enough information, pharmacies can usually provide a 3-day supply. Contact your Medicaid or CHIP agency or health plan for help with the rest of your medication.
• Finding a Pharmacy: If your pharmacy doesn’t accept Medicaid, CHIP, or your health plan, call the number on your eligibility letter or check your state Medicaid or CHIP agency website for a list of approved pharmacies.

Cancelling Your Marketplace Plan After Getting Medicaid or CHIP

When to Cancel:

• Eligibility: If you qualify for Medicaid or CHIP, which provides essential health coverage, you must cancel your Marketplace plan with financial help.
• Immediate Action: Cancel the Marketplace plan with premium tax credits as soon as you’re eligible for Medicaid or CHIP.

If You Want to Keep a Marketplace Plan:

• Full Price: If you keep a Marketplace plan after qualifying for Medicaid or CHIP, you will have to pay the full price without any financial help.

Important Points:

• Check Coverage: Most Medicaid and CHIP programs count as qualifying health coverage. If not, you might still get Marketplace savings based on your income.
• Don’t Cancel Early: Wait for a final decision on Medicaid or CHIP eligibility before cancelling your Marketplace plan. If you are later found ineligible for Medicaid or CHIP, you may not be able to re-enroll in a Marketplace plan without a Special Enrollment Period.

Receiving a Notice:

• Dual Coverage: You might get a notice if you're enrolled in both Medicaid or CHIP and a Marketplace plan. Follow the instructions in the notice.

What to Do:

• Within 30 Days: Update your Marketplace application or cancel your Marketplace coverage with financial help within 30 days of receiving a notice.
• If You Don’t Act: If you don’t take action, you’ll lose financial help and will be responsible for the full cost of the Marketplace plan.

For Help:

• Medicaid: Contact your state Medicaid office.
• CHIP: Visit InsureKidsNow.gov or call 1-877-543-7669.

If Keeping Full Price Coverage:

• Maintaining Both: You can have both Medicaid or CHIP and a Marketplace plan, but you’ll pay full price for the Marketplace plan.
• Steps:
  • Cancel the Marketplace plan with financial help.
  • Apply for Marketplace coverage without financial help.
  • Notify your state Medicaid or CHIP agency.

Ending Your Marketplace Plan:

• Instructions: Follow the steps to cancel your Marketplace plan with premium tax credits and savings.

Getting Marketplace Coverage After Losing or Being Denied Medicaid or CHIP

Steps to Take:

1.Apply for Marketplace Coverage:

1. • Log in or create a Marketplace account to start your application for health coverage.

1. • Stay Informed:
     • Update your contact information with your state.
     • Watch for mail from your state regarding your Medicaid or CHIP status.
     • Complete and submit any required forms promptly.

2.Stay Informed:

• Update your contact information with your state.
• Watch for mail from your state regarding your Medicaid or CHIP status.
• Complete and submit any required forms promptly.

3. If You Lose Medicaid or CHIP:

• • You may qualify for Marketplace coverage with savings if:
    • You had Medicaid or CHIP but lost it.
    • You currently have Medicaid or CHIP but will lose it soon.
    • Your state denied your Medicaid or CHIP application.
  • Apply for Marketplace coverage right away to avoid a gap in coverage.

Marketplace Notifications:

• If you lose Medicaid or CHIP, your state may send your contact info to the Marketplace. The Marketplace might contact you by mail, phone, text, or email to inform you about coverage options.
• Local assisters may also reach out to help you enroll.

Beware of Scams:

• Marketplace assisters will never ask for payment or sensitive information like your Social Security Number. Report any suspicious contacts to the Federal Trade Commission and your local police.

Submitting Your Marketplace Application:

• Log in or create an account, start a new application, or update an existing one.
• Include your state’s Medicaid or CHIP decision, your current income, and household details.
• Submit your application to receive eligibility results immediately.

Special Considerations:

• If you’re a member of a federally recognized tribe or an Alaska Native Claims Settlement Act (ANCSA) Corporation shareholder, you may qualify for additional savings on Marketplace plans.

Getting Your Results:

• Your eligibility results will tell you if you qualify for Marketplace savings, additional actions needed, and enrollment deadlines.
• If you or someone in your household lost or will lose Medicaid or CHIP, you may qualify for a Special Enrollment Period to enroll outside of the Open Enrollment Period.