Tip for State-specific / Healthcare.gov

CHIP covers children in families earning too much for Medicaid but not enough for private insurance

Tip for State-specific / Healthcare.gov

Income limits vary by state — in many states, families earning up to 300% of the federal poverty level qualify

Tip for State-specific / Healthcare.gov

CHIP can be applied for year-round — there is no limited enrollment period

Maternal & Pediatricmoderate

CHIP Application

State-specific / Healthcare.gov · State CHIP agencies

Application for Children's Health Insurance Program for families with income too high for Medicaid but too low for private coverage. Uses MAGI-based financial eligibility. Children must be uninsured.

Form Details

Total fields: 60
Auto-fillable: 40 (67%)
Time without BeneFill: 40 minutes
Time with BeneFill: 10 minutes
Time saved: 30 minutes
Filled by: patient
Frequency: annual
State-specific: Yes — form may vary by state

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Where to Submit This Form

🌐

Healthcare.gov or your state CHIP program

https://www.healthcare.gov/medicaid-chip/childrens-health-insurance-program/

Apply through Healthcare.gov — you may be automatically screened for CHIP when applying for Marketplace coverage.

🏢

At your local Medicaid/CHIP office

📬

Mail to your state CHIP program

Required Attachments

📎 Proof of child's age and identity (birth certificate)
📎 Proof of household income (pay stubs, tax return)
📎 Proof of residency
📎 Social Security numbers for applying children
📎 Proof of citizenship or immigration status

Processing Time

Usually 2-4 weeks. Many states offer presumptive eligibility for immediate temporary coverage.

What Happens Next

Your state will determine eligibility and notify you of the benefit package. CHIP typically covers doctor visits, prescriptions, dental, vision, hospital care, and more.

Tips for This Form

✓ CHIP covers children in families earning too much for Medicaid but not enough for private insurance
✓ Income limits vary by state — in many states, families earning up to 300% of the federal poverty level qualify
✓ CHIP can be applied for year-round — there is no limited enrollment period
✓ Premiums are low or zero, and copays are minimal

More Maternal & Pediatric Forms

WIC Application

State-specific · USDA Food and Nutrition Service (state-administered)

Application for WIC nutrition assistance providing education, breastfeeding support, and benefits for healthy foods. Requires proof of identity, address, income (or Medicaid/SNAP/TANF participation), and a health screening.

WIC Medical Documentation / Nutrition Risk Form

State-specific · State WIC agencies

Medical documentation of nutrition risk factors qualifying an individual for WIC, such as anemia, underweight, or high-risk pregnancy.

School Entrance Health Form

State-specific (e.g., VA MCH213G) · State Departments of Health/Education

Required for school entry. Includes immunization records, health history, physical examination, and developmental screening. Must be completed no earlier than one year before school entry.

Immunization Record / Certificate of Immunization

State-specific · State Departments of Health

Official record of required childhood vaccinations for school enrollment. Exemption forms (medical, religious, philosophical) vary by state.

Medication Administration Authorization (School)

District-specific · School districts

Authorization for school nurse or designee to administer prescribed medication during school hours.

Section 504 Plan (Medical)

District-specific · School districts

Accommodation plan for students with health conditions (diabetes, allergies, asthma, ADHD) that impact school participation. Includes a medical management plan and emergency action plan.

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Disclaimer: BeneFill™ provides form-filling assistance and informational guidance only. It is not affiliated with, endorsed by, or sponsored by the State CHIP agencies or any government agency. The information provided is for general informational purposes and does not constitute legal, medical, financial, or tax advice. Always verify form requirements and submission details directly with the issuing agency.