Medicaid and CHIP: Health Coverage Available Year-Round

Last updated 1 month ago. Our resources are updated regularly but please keep in mind that links, programs, policies, and contact information do change.

Finding affordable health insurance is crucial for staying healthy. Medicaid and the Children’s Health Insurance Program (CHIP) are two important government-sponsored programs that provide free or low-cost health coverage to millions of eligible Americans. One of their most significant features is that you can apply for them at any time during the year if you meet eligibility requirements. There’s no need to wait for a special “Open Enrollment” period.

This article provides essential information about Medicaid and CHIP, including who they serve, how to determine eligibility, and how to apply throughout the year.

Understanding Medicaid and CHIP

While often discussed together, Medicaid and CHIP are distinct programs that share the goal of providing health coverage to specific populations.

What is Medicaid?

Medicaid serves as the cornerstone of the nation’s health safety net, providing vital health coverage to millions of Americans. It is specifically designed for eligible low-income adults, children, pregnant women, elderly adults, and people with disabilities. In fact, Medicaid is the single largest source of health coverage in the United States, demonstrating its critical role.

The program operates as a partnership between the federal government and individual state governments. States administer their own Medicaid programs according to federal requirements, receiving funding from both state and federal governments to cover costs. Federal law mandates that states participating in Medicaid must cover certain groups, often referred to as “mandatory populations.” These typically include specific low-income families, qualified pregnant women and children, and individuals receiving Supplemental Security Income (SSI) due to disability or age.

Within broad federal guidelines, each state establishes and manages its own program. This means states have considerable flexibility in determining the exact type, amount, duration, and scope of services offered beyond the federally mandated minimums. States can also choose to cover “optional” populations beyond the mandatory groups, such as individuals receiving home and community-based long-term care services or certain children in foster care.

Under the Affordable Care Act (ACA), states were given the option to expand Medicaid eligibility to cover nearly all low-income adults below a certain income threshold (typically 133% of the Federal Poverty Level). Some states have adopted this expansion, while others have not, leading to significant differences in adult eligibility across the country. This federal-state partnership structure, combining federal standards with state operational control and options, is why Medicaid programs can look quite different depending on where you live. States may also choose different ways to deliver services, with some paying providers directly and others using private managed care insurance companies to provide Medicaid coverage.

What is the Children’s Health Insurance Program (CHIP)?

The Children’s Health Insurance Program (CHIP) specifically targets children in families who have incomes too high to qualify for Medicaid but often struggle to afford private health insurance. CHIP aims to bridge this gap, ensuring that children in lower- and middle-income working families have access to necessary health care. In some states, CHIP also provides coverage for pregnant women.

Similar to Medicaid, CHIP is a collaborative effort between federal and state governments. States manage their CHIP programs according to federal rules, and the program is funded jointly by state and federal dollars. To actively encourage states to cover children, the federal government offers an “enhanced” federal matching rate (known as E-FMAP) for CHIP. This enhanced rate is typically about 15 percentage points higher than the state’s regular Medicaid matching rate (FMAP), making it financially advantageous for states to invest in children’s coverage through CHIP. This higher federal contribution signals a strong policy commitment to reducing the number of uninsured children. However, unlike Medicaid, federal funding for CHIP is capped, meaning each state receives a specific annual funding allotment.

States also have flexibility in how they structure their CHIP programs. Some states run CHIP as an expansion of their Medicaid program, using the same administrative structures. Others operate CHIP as a completely separate program with potentially different rules and benefit packages. A third option is a combination approach, using both Medicaid expansion and a separate program component. Because of this flexibility, the specific rules about who qualifies for CHIP can vary from state to state. The program is designed to fit between Medicaid and the private market, targeting a specific income range above Medicaid levels but generally below where families can easily afford private plans.

Apply Anytime: Medicaid and CHIP Offer Year-Round Enrollment

Perhaps the most important feature for potential applicants to understand is the enrollment timing for Medicaid and CHIP.

No Need to Wait for Open Enrollment

Unlike many other types of health insurance, Medicaid and CHIP feature year-round enrollment. This means you can apply for these programs at any time during the year. There is no limited Open Enrollment Period that restricts when you can apply. If you or your family members are found to be eligible after applying, coverage can often begin immediately or very soon after approval. You generally do not have to wait months for your health benefits to start.

How This Differs from Other Insurance

This continuous availability stands in stark contrast to how enrollment works for most private health insurance plans, including those purchased through the Health Insurance Marketplace. Marketplace plans typically have a specific Open Enrollment Period once a year, usually lasting from November 1 to January 15, during which most people can enroll in or change their plans.

Outside of this annual Open Enrollment window, enrolling in or changing a Marketplace plan generally requires a Qualifying Life Event. These are specific circumstances like losing other health coverage (including losing Medicaid or CHIP), getting married, having a baby, adopting a child, or moving. These events trigger a Special Enrollment Period, a limited time window to enroll.

Medicaid and CHIP, however, do not require a Qualifying Life Event to apply for the first time. Their year-round availability provides a crucial, continuous safety net. This is particularly beneficial for individuals and families who experience sudden changes in income, job loss, or other circumstances that might make them newly eligible for coverage, allowing them to apply and get covered when they need it most, regardless of the time of year.

Could You Be Eligible? Checking Medicaid and CHIP Requirements

Eligibility rules for Medicaid and CHIP are complex and vary significantly from state to state. Because states administer the programs, they set many of the specific criteria within federal guidelines. However, several key factors are generally considered across all states:

Key Factors States Consider

Income: This is a primary factor. For most applicants, eligibility is based on the household’s Modified Adjusted Gross Income (MAGI). Income limits are often compared to the Federal Poverty Level (FPL).

Household Size: The number of people counted in your household (usually based on tax filing status) affects income limits.

Age: Programs target specific age groups, including children (generally under 19 for CHIP), pregnant individuals, adults (eligibility often depends on whether the state expanded Medicaid), and seniors (age 65 and older). Former foster youth may be eligible up to age 26.

Disability Status: Individuals who meet federal criteria for blindness or disability often have specific eligibility pathways, which may differ from income-based pathways.

Citizenship and Immigration Status: Applicants generally must be U.S. citizens or qualified non-citizens (such as lawful permanent residents, refugees, asylees). Federal rules often require a 5-year waiting period for many lawfully present immigrants to become eligible, but states have the option to waive this waiting period for children and pregnant women. Some CHIP coverage options may be available for the unborn children of pregnant individuals regardless of the pregnant person’s immigration status.

State Residency: Applicants must live in the state where they are applying for coverage.

Insurance Status (Primarily for CHIP): To be eligible for CHIP, children must generally be uninsured. This means they aren’t eligible for Medicaid and don’t have coverage through a parent’s job or another private health plan.

Income Rules: Understanding MAGI and the Federal Poverty Level (FPL)

Income is a critical piece of the eligibility puzzle. The Affordable Care Act introduced Modified Adjusted Gross Income (MAGI) as the standard method for calculating income eligibility for most Medicaid and CHIP applicants, as well as for Marketplace subsidies. MAGI uses income definitions based on tax rules (like adjusted gross income plus certain deductions added back) and considers tax filing relationships to determine household size and income. The goal was to create a more uniform system across different health coverage programs. Importantly, MAGI-based eligibility generally does not consider assets or resources; eligibility is based solely on income. This applies to most children, pregnant women, parents/caretaker relatives, and adults eligible under Medicaid expansion.

However, MAGI rules do not apply to everyone seeking Medicaid. Individuals whose eligibility is based on being age 65 or older, blind, or disabled are typically exempt from MAGI. For these groups, states generally use income counting rules similar to those used by the Supplemental Security Income (SSI) program. These non-MAGI rules can be different, potentially allowing for certain income disregards but also potentially including asset or resource tests, which MAGI rules prohibit. Some states, known as 209(b) states, use eligibility criteria that are even more restrictive than standard SSI rules. This distinction between MAGI and non-MAGI pathways is crucial because it means the application process, required documentation (proof of income only vs. proof of income and assets), and financial limits can differ significantly depending on the basis for eligibility.

Income limits themselves are usually expressed as a percentage of the Federal Poverty Level (FPL). The FPL is an income measure updated annually by the U.S. Department of Health and Human Services (HHS) that varies by household size. (Separate guidelines exist for Alaska and Hawaii). States set their Medicaid and CHIP income limits based on these FPL figures. For example:

• Medicaid eligibility for children must reach at least 133% FPL in all states, though most states cover children at higher income levels.
• States that expanded Medicaid typically cover adults with incomes up to 133% FPL.
• CHIP eligibility typically covers children in families with incomes above Medicaid limits, with upper limits varying by state, potentially ranging from 170% FPL up to 400% FPL.
• If a state covers pregnant women through CHIP, eligibility must extend up to at least 200% FPL.

Knowing the FPL guidelines helps make these percentages meaningful. Here are the 2025 FPL figures for the 48 contiguous states and the District of Columbia:

2025 Federal Poverty Level (FPL) Guidelines (48 Contiguous States & DC)

Source: U.S. Department of Health and Human Services (HHS) Poverty Guidelines for 2025. For families/households with more than 8 persons, add $5,500 for each additional person.

By comparing your household size and estimated annual income to this table, you can get a better sense of whether you might fall within the eligibility range for Medicaid or CHIP in your state.

Quick Check: Using Online Screening Tools

To get a quick, preliminary idea of potential eligibility based on income, you can use online screening tools. The Health Insurance Marketplace website offers a tool where you can enter your state, household size, and estimated annual income. The tool will indicate whether you or your family members may qualify for Medicaid, CHIP, or savings on a Marketplace plan. You can find this screener at HealthCare.gov/medicaid-chip or HealthCare.gov/screener.

It is very important to remember that these screening tools provide only an estimate. They cannot account for all state-specific rules or non-income eligibility factors. The only way to know for sure if you qualify for Medicaid or CHIP is to complete and submit an official application. Even if a screening tool suggests you might not qualify based purely on income, you should still apply if you think you might be eligible due to other factors like pregnancy, disability, age, or because you are caring for children.

How to Apply for Medicaid and CHIP

Reflecting the year-round enrollment policy, you can submit an application for Medicaid or CHIP through several channels at any time:

Through the Health Insurance Marketplace

One common way to apply, especially if you’re unsure whether you qualify for Medicaid, CHIP, or Marketplace subsidies, is through HealthCare.gov. You can create an account (or log into an existing one) and fill out a single application. Based on the information you provide:

• The system checks eligibility for all relevant programs: Medicaid, CHIP, and subsidized Marketplace coverage.
• If it appears anyone in your household is eligible for Medicaid or CHIP, HealthCare.gov will securely transfer your application information to the appropriate state agency.
• The state agency will then contact you directly regarding enrollment and any further steps needed.
• If you are not eligible for Medicaid or CHIP, the same application will determine if you qualify for financial assistance (premium tax credits and cost-sharing reductions) to lower the cost of a private health plan purchased through the Marketplace.

This “no wrong door” approach simplifies the process for many individuals and families, particularly those whose eligibility might fall under the MAGI rules.

Directly with Your State’s Medicaid/CHIP Agency

You can always apply directly to your state’s Medicaid and/or CHIP agency. This is often the necessary route for individuals applying based on non-MAGI criteria (age 65+, blindness, disability) or those seeking specific state-run programs or assistance. Applying directly ensures you are interacting with the agency that ultimately manages the program and makes the final eligibility determination.

States typically offer multiple ways to apply directly, recognizing that applicants have varying levels of access and comfort with technology:

Online: Most states have dedicated websites or portals where you can complete and submit an application electronically.

By Phone: You can usually call your state agency to apply over the phone or get assistance with the application process. Many states have toll-free numbers specifically for enrollment help.

By Mail: Paper applications are generally available for download from state agency websites or can be requested by mail. You can then fill it out and mail it back.

In Person: Many states allow you to apply in person at local county social services or human services offices, or potentially at other community partner locations.

The availability of multiple application methods aims to reduce barriers and ensure that all potentially eligible individuals, including those without reliable internet access, can apply for coverage.

Finding Your State Agency Contact Information

Since application methods and contact details vary by state, you’ll need to find the information specific to where you live. Here are resources:

• HealthCare.gov State Selector: Use the dropdown menu to find your state agency’s contact information.
• InsureKidsNow.gov: Visit for state-specific program information and links, or call their free, confidential helpline at 1-877-KIDS-NOW (1-877-543-7669) to be connected to your state’s program.
• Medicaid.gov State Contacts: Find a list of state Medicaid agency phone numbers and websites.

Getting Ready to Apply: Information You’ll Likely Need

Applying for Medicaid or CHIP involves providing detailed information about yourself and your household members. Gathering necessary documents and information beforehand can help make the application process smoother and faster. While specific requirements differ by state, you will likely need:

Proof of Income: Documents showing your household’s earnings, such as recent pay stubs, W-2 forms, tax returns, letters from employers detailing wages, unemployment benefit award letters, or statements showing income from Social Security or pensions. This is essential for determining financial eligibility.

Proof of Citizenship or Lawful Immigration Status: Documents like a U.S. birth certificate, U.S. passport, Certificate of Citizenship or Naturalization, Permanent Resident Card (“Green Card”), or other specific immigration documents.

Social Security Numbers (SSNs): For all household members applying for coverage who have been issued an SSN.

Proof of State Residency: Documents showing you live in the state, such as a driver’s license or state ID with your current address, a recent utility bill, a lease agreement, or official mail addressed to you.

Household Information: Full names, dates of birth, and relationship to you for everyone living in your household, especially those you claim as tax dependents.

Information on Other Health Insurance: Details about any current health insurance coverage any household member has.

Information Related to Disability (if applicable): If applying based on a disability, you may need medical records or documentation related to your condition.

After you submit your application, the state agency will review it. They may need to verify some of the information you provided. You might receive a notice (by mail or electronically) asking you to submit copies of specific documents. It is crucial to respond to these requests by the deadline provided to avoid delays or having your application denied. Having common documents organized ahead of time can help you respond quickly if verification is needed.

State Differences Matter: What Varies Where You Live

It is essential to understand that Medicaid and CHIP programs are not the same in every state. The federal-state partnership model allows states significant flexibility in designing and running their programs within federal guidelines. This results in important variations across state lines in areas such as:

Eligibility Rules: States set specific income limits (though they must meet federal minimums), decide which optional groups to cover (like adults without children in non-expansion states), and establish rules for non-MAGI populations.

Covered Benefits: While federal law requires certain mandatory benefits (like hospital and physician services), states choose whether to cover many optional services, such as prescription drugs, comprehensive dental care (especially for adults), vision care, and physical therapy. Even for mandatory services, states can set limits on the amount or duration. CHIP benefits must meet federal standards but can also vary.

Costs: While Medicaid generally involves little to no cost for beneficiaries, some states charge modest monthly premiums or copayments for CHIP coverage. Federal rules cap total family out-of-pocket costs for CHIP, typically at 5% of annual family income.

Program Names: States often use unique names for their programs, such as “Medi-Cal” in California, “MassHealth” in Massachusetts, “HUSKY Health” in Connecticut, or “Health First Colorado”.

Application and Renewal Processes: The specific online portals, paper forms, required documentation, and procedures for applying and renewing coverage differ by state.

Because of these substantial state-by-state differences, national-level information can only provide a general overview. To get accurate details about eligibility requirements, covered services, potential costs, and how to apply in your specific location, you must consult resources from your state’s Medicaid and CHIP agency. Relying solely on general information could lead to misunderstandings about your eligibility or benefits.

Finding Your State’s Specific Rules

Use these resources to find information tailored to your state:

• HealthCare.gov State Finder
• InsureKidsNow.gov (includes state info and helpline 1-877-KIDS-NOW)
• Medicaid.gov State Contacts

What Health Services Are Typically Covered?

Medicaid and CHIP are designed to provide access to a wide range of necessary medical services, aiming for comprehensive coverage, particularly for children. However, the exact list of covered services depends on the state and the specific program.

Overview of Common Benefits

Medicaid: Federal law requires all state Medicaid programs to cover certain mandatory benefits. These include essential services like inpatient and outpatient hospital care, physician services, laboratory and X-ray services, and home health services for those who qualify. Beyond these requirements, states can choose to cover a wide array of optional benefits. Many states include coverage for prescription drugs, physical and occupational therapy, dental services, vision care, mental health services, and long-term services and supports (like nursing home care or home and community-based services). The availability and scope of these optional benefits vary significantly by state.

CHIP: CHIP programs are required by federal law to cover certain key services for children, including well-baby and well-child check-ups, immunizations (vaccines), dental coverage that meets federal standards, and behavioral health services (covering both mental health and substance use disorder treatment). Generally, CHIP also covers services such as doctor visits, prescription medications, inpatient and outpatient hospital care, laboratory tests and X-rays, and emergency services. While aiming for comprehensive coverage, the specific benefit package can differ based on how the state designed its CHIP program.

Note on State-Specific Benefit Packages

Because states have flexibility in designing their benefit packages (especially regarding optional Medicaid services and the specifics of CHIP coverage), it is always best to check directly with your state’s Medicaid or CHIP program for a definitive list of covered services. They can provide details on what is included, any limitations (like number of visits per year), and whether any copayments or other costs apply. For dental care, states are required to post lists of participating Medicaid and CHIP dental providers on InsureKidsNow.gov.

Medicaid and CHIP: Key Facts

These programs represent a significant part of the U.S. healthcare landscape.

Enrollment Highlights

Medicaid and CHIP together provide coverage for a substantial portion of the U.S. population. As of late 2024, combined enrollment was approximately 79 million individuals. This included roughly 72 million people enrolled in Medicaid and over 7 million in CHIP. Children consistently represent a large share of enrollees; in October 2024, nearly 38 million children were covered by either Medicaid or CHIP, making up almost half of the total enrollment. These high numbers underscore the vital role these programs play as a safety net.

Enrollment levels can fluctuate based on economic conditions and policy changes. For instance, enrollment grew significantly during the COVID-19 public health emergency due to federal requirements that kept people continuously enrolled. As states resumed standard eligibility reviews and renewals following the end of those emergency provisions (a process sometimes called “unwinding”), enrollment numbers have been adjusting. This responsiveness highlights how the programs expand to meet needs during crises.

(Note: Different official reports may show slightly different enrollment figures due to variations in reporting dates and methodologies.)

Important Websites Recap:

• Apply & Check Eligibility Estimates: HealthCare.gov
• Official Federal Program Information: Medicaid.gov and its CHIP section
• Find State-Specific Information & Help: InsureKidsNow.gov or call 1-877-KIDS-NOW (1-877-543-7669). Also, use the state finders on HealthCare.gov or Medicaid.gov’s contact page.

Remember, if you think you or your children might qualify for Medicaid or CHIP, you can apply at any time. Don’t wait for a special enrollment period. Use the resources listed here to find your state’s program information and start an application.

Our articles make government information more accessible. Please consult a qualified professional for financial, legal, or health advice specific to your circumstances.