The Children's Health Insurance Program (CHIP) provides comprehensive benefits to children. Since states have flexibility to design their own program within Federal guidelines, benefits vary by state and by the type of CHIP program.
Medicaid Expansion Benefits
Medicaid Expansion CHIP programs provide the standard Medicaid benefit package, including Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services, which includes all medically necessary services like mental health and dental services.
Separate CHIP Benefits Options
States can choose to provide benchmark coverage, benchmark-equivalent coverage, or Secretary-approved coverage:
- Benchmark coverage based on one of the following:
- The standard Blue Cross/Blue Shield preferred provider option service benefit plan offered to Federal employees
- State employee's coverage plan
- HMO plan that has the largest commercial, non-Medicaid enrollment within the state
- Benchmark-Equivalent coverage must be actuarially equivalent and include:
- Inpatient and outpatient hospital services
- Physician's services
- Surgical and medical services
- Laboratory and x-ray services
- Well-baby and well-child care, including immunizations
- Secretary-approved coverage: Any other health coverage deemed appropriate and acceptable by the Secretary of the U.S. Department of Health and Human Services.
Separate CHIP Dental Benefits
States that provide CHIP coverage to children through a Medicaid expansion program are required to provide the EPSDT benefit. Dental coverage in separate CHIP programs is required to include coverage for dental services "necessary to prevent disease and promote oral health, restore oral structures to health and function, and treat emergency conditions." For more information see CHIP Dental Care Goals and related Federal Policy Guidance.
States with a separate CHIP program may choose from two options for providing dental coverage: a package of dental benefits that meets the CHIP requirements, or a benchmark dental benefit package. The benchmark dental package must be substantially equal to the (1) the most popular federal employee dental plan for dependents, (2) the most popular plan selected for dependants in the state’s employee dental plan, or (3) dental coverage offered through the most popular commercial insurer in the state.
States are also required to post a listing of all participating Medicaid and CHIP dental providers and benefit packages on www.insurekidsnow.gov.
Coverage for age-appropriate immunizations is required in CHIP. States with a separate CHIP program (including the separate portion of a combination program) must purchase vaccines to be administered to enrolled children using only CHIP federal and state matching funds. Vaccines for federally vaccine-eligible children (through the Vaccines For Children program) should not be used by children enrolled in separate CHIP programs, and funds available under section 317 of the Public Health Service Act are designated for the purchase of vaccines for the uninsured and may not be used to purchase vaccines for children who have separate CHIP coverage.
States have two options for purchasing vaccines for children enrolled in separate CHIP programs: (1) purchase vaccines using the CDC contract and distribution mechanism, or (2) purchase vaccines through the private sector.
The Centers for Medicare and Medicaid Services has worked with the Centers for Disease Control and Prevention (CDC) on issuing joint guidance for all states with a separate CHIP program on purchasing and claiming for vaccines administered to separate CHIP children. The guidance letter explains that, for states that purchase vaccines through the CDC, states are required to pay for vaccines at the time they are ordered. States claim federal financial participation against the CHIP allotment based on the purchase invoices rather than individual provider claims. The letter further explains that states will use a reconciliation process to ensure that future vaccine orders are adjusted based on the outstanding credit for unused vaccines from the previous order.
Find out more about the joint guidance letter on these policies.