Does CHIP Cover Mental Health Services?

The Children’s Health Insurance Program (CHIP) provides health coverage for millions of children and pregnant women across the United States. It ensures young people have access to necessary medical care, including mental health services. CHIP aims to make these services accessible to families who may not qualify for Medicaid but struggle to afford private insurance, bridging a coverage gap for comprehensive physical and behavioral health care.

Understanding CHIP Coverage for Mental Health

CHIP offers comprehensive mental health and substance use disorder services. These encompass individual, group, and family therapy sessions, counseling, psychiatric evaluations, and medication management. Crisis intervention services and both inpatient and outpatient treatment for mental health conditions are also covered. States are required to provide coverage for these services to prevent, diagnose, and treat mental health and substance use disorder conditions.

Mental health parity, mandated by federal law under the Mental Health Parity and Addiction Equity Act (MHPAEA), governs CHIP. This means financial requirements (such as copayments, coinsurance, and deductibles) and treatment limitations (like visit limits or prior authorization requirements) for mental health and substance use disorder benefits must be no more restrictive than those applied to medical and surgical benefits. The intent is to ensure mental health services are treated similarly to physical health services regarding coverage and utilization management.

While federal guidelines establish minimum standards, each state administers its own CHIP program, leading to variations in specific benefits or service delivery models. All state CHIP programs must meet comprehensive federal standards for mental health coverage.

CHIP is designed to be affordable, with many families receiving coverage for free. For those with higher incomes, cost-sharing, such as low monthly premiums and small co-pays for some services, may apply. Federal rules cap these out-of-pocket costs, ensuring families do not pay more than 5% of their annual household income for CHIP coverage.

CHIP Eligibility and Enrollment

Eligibility for CHIP depends on household income relative to the Federal Poverty Level (FPL), the child’s age, and citizenship or immigration status. CHIP is for children under 19 years of age who are uninsured and whose family income is too high for Medicaid but too low to afford private health insurance. The 2025 FPL for a family of three is $26,650, and income thresholds for CHIP can range from 170% to 400% of the FPL, varying significantly by state.

Applicants must be U.S. citizens or qualified non-citizens, such as lawful permanent residents, and residents of the state where they are applying. Some states may offer coverage to lawfully present children during a reasonable opportunity period of up to 90 days while their immigration status is verified. Children who qualify for Medicaid are enrolled in Medicaid, highlighting CHIP’s role for families just above Medicaid’s income limits.

Families can apply online through their state’s Medicaid/CHIP agency website, via Healthcare.gov, by phone, or by mail. Many states utilize a single application for both Medicaid and CHIP, streamlining the process.

To complete an application, families need to provide documents and information. This often includes Social Security numbers for all applicants, proof of income (such as recent pay stubs, W-2 forms, or tax returns), and proof of citizenship or immigration status (like birth certificates or permanent resident cards). Information about household size and any other health insurance coverage is also requested.

Accessing Mental Health Care Through CHIP

Once a child is enrolled in CHIP, families can access mental health services. A primary step involves finding mental health professionals who accept CHIP plans. This can be done by checking the state’s CHIP website, utilizing online provider directories, or contacting the CHIP plan directly for a list of in-network providers. Some plans may also offer “Find a Doctor” tools on their websites.

Many CHIP plans do not require a referral from a primary care physician to access mental health services, allowing families direct access to behavioral health specialists. However, for other specialized medical services, a primary care provider may coordinate referrals. Families should review their specific plan’s details to understand any referral requirements.

Some mental health services, particularly certain types of therapy or a higher number of sessions, may require prior authorization from the CHIP plan. Federal parity rules dictate that these prior authorization requirements for mental health services should not be more restrictive than those for medical or surgical care. Providers handle the prior authorization process, submitting necessary documentation to the plan.

If difficulty arises in finding a specific type of mental health care or if there are questions about coverage for a particular service, families are encouraged to contact their CHIP plan’s member services directly. They can provide precise information tailored to the enrollee’s specific plan and guide them through the process.