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CHIP Scope of Benefits

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CHIP children are covered for these services provided they are “medically necessary” or needed to restore or maintain health. Medically Necessary means: (1) Health Care Services that are:

Reasonable and necessary to prevent illnesses or medical conditions, or provide early screening, interventions, and/or treatments for conditions that cause suffering or pain, cause physical deformity or limitations in function, threaten to cause or worsen a handicap, cause illness or infirmity of a Member, or endanger life;

Provided at appropriate facilities and at the appropriate levels of care for the treatment of a Member’s health conditions;

Consistent with health care practice guidelines and standards that are endorsed by professionally recognized health care organizations or governmental agencies;

Consistent with the diagnoses of the conditions;

No more intrusive or restrictive than necessary to provide a proper balance of safety, effectiveness, and efficiency; and

Are not experimental or investigative; and are not primarily for the convenience of the Member or Provider; and

(2) Behavioral Health Services that are:

Are reasonable and necessary for the diagnosis or treatment of a mental health or chemical dependency disorder, or to improve, maintain, or prevent deterioration of functioning resulting from such a disorder;
Are in accordance with professionally accepted clinical guidelines and standards of practice in behavioral health care;
Are furnished in the most appropriate and least restrictive setting in which services can be safely provided;
Are the most appropriate level or supply of service that can safely be provided;
Could not be omitted without adversely affecting the Member’s mental and/or physical health or the quality of care rendered;
Are not experimental or investigative; and
Are not primarily for the convenience of the Member or Provider.

Emergency care is a covered CHIP service. “Emergency” and “emergency condition” means a medical condition of recent onset and severity, including, but not limited to, severe pain that would lead a prudent layperson, possessing an average knowledge of medicine and health, to believe that the child’s condition, sickness, or injury is of such a nature that failure to get immediate care could result in:

Placing the child’s health in serious jeopardy;
Serious impairment to bodily functions;
Serious dysfunction of any bodily organ or part;
Serious disfigurement; or
In the case of a pregnant woman, serious jeopardy to the health of the fetus.

“Emergency services” and “emergency care” means health care services provided in an in-network or out-of-network hospital emergency department or other comparable facility by in-network or out-of network physicians, providers, or facility staff to evaluate and stabilize medical conditions. Emergency services also include, but are not limited to, any medical screening examination or other evaluation required by state or federal law that is necessary to determine whether an emergency condition exists.

There is a limit on the co-payments that a family pays for CHIP benefits during each six-month enrollment period. CHIP notifies families of co-payment maximums upon enrollment. Families are responsible to keep up with how much they have paid and to provide proof to CHIP. CHIP provides families with a simple form that they can use to keep up with the amount that they have paid.

Families notify CHIP when the maximum co-payment has been paid. When CHIP is notified about reaching the co-payment maximum, we will issue a new Member ID Card for each child in a family. The new Member ID Card will notify participating Physicians and providers to waive co-payments for the remainder of the enrollment period.

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