CHIP Benefits

In a separate CHIP, states can choose to provide benchmark coverage, benchmark-equivalent coverage, or Secretary-approved coverage.

Benchmark coverage

Benchmark coverage offers health benefits that are substantially equal to the health benefits coverage in one of the following benefit plans:

• Federal Employees Health Benefit (FEHB) plan which is the standard Blue Cross/Blue Shield preferred provider option service benefit plan offered to federal employees
• State employee plan, a health benefits plan offered and generally available to state employees in the state
• Health Maintenance Organization (HMO) plan, a health insurance coverage plan:
  • Offered through an HMO, as defined in the Public Health Service Act
  • That has the largest insured commercial, non-Medicaid enrollment in the state

Benchmark-equivalent coverage

Benchmark-equivalent coverage has an aggregate actuarial value that’s at least actuarially equivalent to the coverage under 1 of the benchmark plans.

In addition to the mandatory coverage for all types of CHIP coverage, benchmark-equivalent health benefits coverage must include coverage for these services:

• Inpatient and outpatient hospital services
• Physicians' surgical and medical services
• Laboratory and X-ray services

There may be more coverage requirements depending on the specific benchmark package a state uses.

Secretary-approved coverage

Secretary-approved coverage are health benefits approved by the U.S. Health and Human Services Secretary who has found that they give the appropriate coverage for the targeted low-income children covered under the program. Secretary-approved coverage may include, but isn’t limited to, coverage that’s the same as the Medicaid state plan coverage.

No matter what type of benefit package a state chooses, it must provide certain benefits:

• Well-baby & well-child visits
• Dental
• Behavioral health
• Vaccines

Well-baby & well-child visits

States must provide well-baby and well-child visits, and have the flexibility to decide how often those visits should occur. Many states use the American Academy of Pediatrics recommended schedule, Bright Futures, while other states choose to use their own.

Dental benefits

Dental coverage in separate CHIP programs must include coverage "necessary to prevent disease and promote oral health, restore oral structures to health and function, and treat emergency conditions," as explained at 2103(a)(5) of the Act.

States with a separate CHIP program may choose from 2 options to give dental coverage:

1. A Secretary-approved package of dental benefits that meets the CHIP dental requirements
2. A benchmark dental benefit package

The benchmark dental package must be substantially equal to 1 of the following:

• The most popular federal employee dental plan for dependents
• The most popular plan selected for dependents in the state’s employee dental plan
• Dental coverage offered through the most popular commercial insurer in the state

For more information on children’s oral health care, find our Medicaid Dental Care page and our Dental Coverage in CHIP letter to State Health Officials.

On InsureKidsNow.gov, states must also post a list of benefit packages and all participating Medicaid and CHIP dental providers.

Behavioral health benefits

Separate CHIP programs are required to cover services to prevent, diagnose, and treat a broad range of mental health and substance use disorder conditions in a culturally and linguistically appropriate way. This includes mandatory coverage of:

• Tobacco cessation services
• Medication-assisted treatment for substance use

More information about mandatory mental health and substance use disorder services coverage is available in the SUPPORT for Patients and Communities Act in State Health Official letter # 20-001.

In addition, limitations applied to covered benefits for mental health and substance use disorder conditions must be no more restrictive than limitations on benefits for medical and surgical conditions.

Federal law requires Medicaid and CHIP programs to comply with mental health and substance use disorder parity requirements, which apply to:

• Copays, coinsurance, and out-of-pocket maximums
• Limitations on service utilization, like limits on the number of covered inpatient days or outpatient visits
• The use of non-quantitative treatment limitations, like care management tools, and criteria for medical necessity determinations

Please go to our Parity Resource page for more information on mental health parity requirements for Medicaid and CHIP.

Vaccines

CHIP programs must cover age-appropriate vaccines.

States with a separate CHIP program must buy vaccines for enrolled children only with CHIP federal and state matching funds.

Vaccines for the Medicaid program (including Medicaid expansion CHIP) and for uninsured children are paid for by the Vaccines for Children (VFC) program under section 317 of the Public Health Service Act. VFC funding may not be used to buy vaccines for children who have separate CHIP coverage.

States can buy vaccines for children enrolled in separate CHIP programs through:

• The Centers for Disease Control and Prevention’s (CDC) contract and distribution
• The private sector

Find out more about vaccines covered by CHIP and how they’re funded.

Find more information on:

Mandatory CHIP Coverage of Adult Vaccinations under the inflation Reduction Act in State Health Official letter #23-003.

The Centers for Medicare & Medicaid Services and the CDC issued a joint guidance letter to states explaining how to buy and claim vaccines for children enrolled in a separate CHIP program.

The guidance letter explains that states:

• Must pay for vaccines from the CDC when they’re ordered because states claim federal financial participation against their CHIP allotment based on the purchase invoices instead of individual provider claims
• Will use a reconciliation process to make sure future vaccine orders are adjusted on the outstanding credit for unused vaccines from an earlier order