Who Qualifies for CHIP in PA: Income Tiers, Costs, and Coverage

To qualify for CHIP in PA, a child must be under 19, live in Pennsylvania, be a U.S. citizen or qualified noncitizen, and be uninsured. There is no upper income limit: income only decides whether coverage is free, low-cost, or full-cost. For a family of four in 2026, CHIP is free up to $68,640 in annual household income, low-cost up to $103,620, and full-cost above that.¹

Age and Where You Live

The child must be under 19 and a Pennsylvania resident.² Grade level, school enrollment, and whether the child works don’t matter. Coverage continues through the end of the month the child turns 19, and the local county assistance office then reviews Medicaid eligibility so there isn’t a gap.³ A child who doesn’t qualify for Medicaid after aging out can enroll through HealthCare.gov during a special enrollment period triggered by the loss of CHIP.

Citizenship and Immigration Status

The child has to be a U.S. citizen, U.S. national, or a qualified noncitizen.² Qualified noncitizens include lawful permanent residents, refugees, and people granted asylum.⁴

A parent’s immigration status does not affect the child’s eligibility. If the child independently meets the citizenship or immigration requirement, the child can enroll regardless of the parent’s status.⁵ Noncitizen children who aren’t eligible for a Social Security number don’t need one to enroll.⁶

Insurance Status

CHIP is for uninsured children. A child can’t already be covered by a group health plan or qualify for Medical Assistance (Medicaid) at the time of enrollment.⁵

Pennsylvania does not impose a waiting period after other coverage ends.⁷ Some states require families to be uninsured for 90 days first. Pennsylvania does not. If you know existing coverage is about to end because of a job change or similar event, you can apply before it ends and note the expected termination date so CHIP starts without a gap.⁵

One narrower rule: under federal law, a child eligible for a state-organized employee health plan generally can’t enroll in CHIP if the employer contributes to the premium. Pennsylvania allows a hardship exception when the employee can’t get family coverage or when premiums and cost-sharing would exceed 5% of family income.⁵

Income: There’s No Upper Limit, Just Tiers

Every child who meets the age, residency, citizenship, and insurance requirements can enroll in some tier of CHIP. Income only changes what the family pays. Pennsylvania uses the Federal Poverty Level as the yardstick; the 2026 FPL for a family of four is $33,000 per year.⁸

The three tiers:

Free CHIP: household income up to 208% of the FPL. No premiums, no copays.
Low-Cost CHIP: income between 208% and 314% of the FPL. Monthly premium plus small copays.
Full-Cost CHIP: income above 314% of the FPL. Full premium and somewhat higher copays.

Those percentages come from the state’s 2026 Federal Income Guidelines for CHIP.⁹

The 2026 annual income cutoffs in dollars, by family size:¹

Family of 2: free up to $45,012; low-cost $45,012 to $67,950; full-cost above $67,950
Family of 3: free up to $56,826; low-cost $56,826 to $85,785; full-cost above $85,785
Family of 4: free up to $68,640; low-cost $68,640 to $103,620; full-cost above $103,620
Family of 5: free up to $80,455; low-cost $80,455 to $121,456; full-cost above $121,456

Pennsylvania calculates eligibility using Modified Adjusted Gross Income, based on the gross earnings of every adult legally responsible for the child. That means wages, tips, and other taxable income before deductions. Self-employed parents should pull their most recent tax return and business records together, because the state verifies net self-employment income from those documents.

What You’d Pay at Each Tier

Free CHIP has no premium and no copays. In the low-cost tier, monthly premiums in 2026 run roughly $45 to $140 depending on the insurer, region, and specific income bracket.¹⁰ Some CHIP insurers voluntarily reduce premiums further for certain enrollees.

Low-cost copays:¹

Doctor visit: $5
Specialist visit: $10
Generic prescription: $6
Brand-name prescription: $9
Emergency room visit (not admitted): $25

Full-cost copays are higher: $15 for a doctor visit, $25 for a specialist, $10 for generics, $18 for brand-name drugs, and $50 for an emergency room visit where the child isn’t admitted.¹ Even at full-cost, these are often lower than copays on comparable private plans.

What CHIP Covers

CHIP is comprehensive, not a bare-bones plan. The benefit package includes:²

Well-child checkups, immunizations, and sick visits
Prescription drugs, brand-name and generic
Dental care, including cleanings, fillings, X-rays, and medically necessary orthodontia
Vision and hearing services
Mental health care, including therapy, counseling, and partial hospitalization
Substance abuse treatment
Emergency and hospital care
Rehabilitation therapies and durable medical equipment
Home health, maternity, and hospice care
Autism spectrum disorder services

The dental and vision benefits are notably broader than what many private children’s plans offer, and mental health and substance use coverage runs from outpatient therapy through crisis intervention and medication-assisted treatment for older teens.

How to Apply

The fastest route is the COMPASS online portal at compass.state.pa.us. You can also request a paper application from the Department of Human Services by calling 1-800-986-KIDS (5437) or download one from the PA CHIP website.³

Have these ready before you start:

Social Security numbers for each household member applying (noncitizens not eligible for an SSN are exempt)⁶
Proof of income: recent pay stubs, W-2 forms, or tax returns. Self-employed families should include their Schedule C and business records.
Proof of Pennsylvania residency: a current utility bill, lease agreement, or similar document

Incomplete applications are the most common cause of delays. Check every field and confirm your income documentation is attached before submitting. Expect a decision within four to six weeks; online submissions through COMPASS tend to process faster than mailed paper forms.³ If more than 30 days pass without a response, call the Customer Service Center at 1-877-395-8930, or 1-215-560-7226 in Philadelphia.¹¹

1
Commonwealth of Pennsylvania. CHIP Income Guidelines Chart
2
Commonwealth of Pennsylvania. CHIP Eligibility and Benefits
3
Commonwealth of Pennsylvania. Apply for Children’s Health Insurance Program (CHIP)
4
Medicaid.gov. CHIP Eligibility and Enrollment
5
Commonwealth of Pennsylvania. CHILDREN’S HEALTH INSURANCE PROGRAM CHIP Eligibility and Benefits FAQ
6
Department of Public Welfare. 950.2 Providing or Applying for an SSN
7
Medicaid.gov. Waiting Periods in CHIP
8
U.S. Department of Health and Human Services. 2026 Poverty Guidelines – 48 Contiguous States
9
Commonwealth of Pennsylvania. Appendix 8-A 2026 Federal Income Guidelines for Determining CHIP Eligibility for All Children
10
Commonwealth of Pennsylvania. CHIP Contractor Rate Information
11
Commonwealth of Pennsylvania. CHIP Application Status FAQ