PMA-22028-1107, Revised 2025 Federal Poverty Income Guidelines (FPIGs) (Revised February 21, 2025, Published January 31, 2025)
PCH-21941-1107, Revised AmeriCorps Stipends as Excluded Income (Published October 10, 2024 Revised July 9, 2025)
PMA-21620-1107, Revised 2024 Federal Poverty Income Guidelines (FPIGs) (Published January 26, 2024 Revised February 28, 2024)
PMA-21505-1107, Income Verification for Full-Cost Children’s Health Insurance Program (CHIP) (Published October 4, 2023)
CHIP regulation 42 CFR 457.315, Application of modified adjusted gross income and household definition, refers back to paragraphs (b) through (i) of § 435.603 in determining the financial eligibility of all individuals for CHIP. The exception to application of such methods for individuals for whom the State relies on a finding of income made by an Express Lane agency at § 435.603(j)(1) of this subpart also applies.
Effective January 1, 2014, the Affordable Care Act ACA) changed Medical Assistance (MA) and Childrens Health Insurance (CHIP) rules in Pennsylvania. Modified Adjusted Gross Income (MAGI) is the new income methodology used for determining MA and CHIP eligibility for children through age 18, parents (biological, adoptive or step), caretakers, pregnant women and adults ages 19-64.
CHIP benefits are available to all children under the age of 19 who are not enrolled in or eligible for Medical Assistance, regardless of income, who meet all other eligibility requirements
The CHIP category CHP is used to identify CHIP-related budget groups, (See Chapter 305, Appendix E: Medical Assistance Cascade Table). Individuals receiving category CHIP will be assigned a program status code based on the coverage group.
CHIP categories and program status codes:
CHP 00 – Free: A child is eligible for Free CHIP if the annual tax household income is between 157% to 208% for children 1-5 and 133%-208% for children 6-19.
CHP 01 - Sub 1: A child is eligible for Low-Cost subsidized coverage 1 if the annual tax household is between 209% to 262% of the FPL (See Appendix A) Federal Income Guidelines for Determining CHIP Eligibility for All Children)
CHP 02 – Sub 2: A child is eligible for Low-Cost subsidized coverage 2 if the annual tax household income is between 263% and 288% of the FPL (See Appendix A) Federal Income Guidelines for Determining CHIP Eligibility for All Children)
CHP 03 – A child is eligible for Low-Cost subsidized coverage 3 if the annual tax household income is between 289% and 314 % of the FPL. (See Appendix A) Federal Income Guidelines for Determining CHIP Eligibility for All Children)
CHP 04 – Full Cost: A child is eligible for Full-Cost CHIP if the annual tax household income is greater than 314% of the FPL. Families may purchase the CHIP benefits package at 100% of the rate negotiated by the state. (See Appendix A) Federal Income Guidelines for Determining CHIP Eligibility for All Children)
Note: The bottom income limit for CHIP forms the upper income limit for Medicaid. The Affordable Care Act permits an income disregard of 5% of the upper Medicaid limit for applicants with incomes near the limit. This provision could result in some CHIP applicants being becoming eligible for MA if the household income is near the upper Medicaid limit.
1107.11 Eligibility Requirements
The CAO must review applications and renewals using the rules in this chapter and the following chapters:
CHIP Eligibility Handbooks
1107.12 Pregnancy in the Applicant Family
When an application is received, a determination of eligibility must be made for CHIP. A fetus is not counted in the family size for CHIP. However, MA does count the fetus in its determination of eligibility. The federal regulations require that a child be enrolled in the program for which the child is eligible. Therefore, a determination must be made to see if an applicant is eligible for MA, which is 215 percent of FPL for children under 1 and 208 percent of FPL for children ages 1 through 18.
EXAMPLE 1:
A family of four submits a renewal for CHIP and the children are enrolled – ACR (household income is $53,613) with an effective date of May 1. On April 23, the family reports that one of the children is pregnant. As is stated above, the CAO is responsible for screening for MA eligibility. The fact that one of the children is pregnant would have no impact on the rest of the household unless the current head of household states that the newborn will become a tax dependent and mother of newborn is not required to file a tax return. If that is the case, when the child is born, the household size would increase to five and would be reassessed against 215 percent of FPL for the newborn, 157 percent for any child under age six and 133 percent for ages six to 18. The children would be enrolled in the proper program for their income and age group. If the head of household is not claiming the child as a dependent, upon birth, the child would be referred to DHS for an eligibility determination as a family of two.
EXAMPLE 2:
A family of four applies for CHIP and the children are in ACR status (household income is $51,316) with an effective date of May 1. On April 23, the family reports that one of the children is pregnant. As is stated above, contractors are responsible for screening for MA eligibility. In this case, the contractor would check to see if the pregnant child had income exceeding the limit for a two person household at 215% FPL. If not, the contractor would manage the pregnant child to a Terminated – CAO Referral status because the change is effective prior to the enrollment effective date. The child is not enrolled in CHIP and according to federal and state law must be enrolled in the program for which the child is eligible. The 12 months of continuous eligibility rule does not come into play because the enrollment period has not begun. The child should be found eligible for MA.
EXAMPLE 3:
A family of four applies for CHIP – mom, dad, Jane (3), and John (6). Mom indicates on the application that she is pregnant with twins. The household income is reported as $43,692. For a family size of four, the children would have been found eligible for Free CHIP; however, because mom is pregnant, the contractor must add the two fetuses to the family size for the MA screening creating a family size of six. Jane will be referred to the CAO for an MA eligibility determination. John will be enrolled in Free CHIP.
The CAO must allow specific disregards and deductions from the gross income of the MAGI household. Tax deductions are shared between joint filers.
The only income disregard applied in MAGI eligibility determinations is a disregard of 5 percent of the 100 percent FPIG for the budget family size (See Section 312.52, Income Disregard). The 5 percent disregard is applied only if the disregard would make a difference in the eligibility determination.
Certain tax deductions reported to the CAO or SBE may be used as deductions from gross income if they are verified by the CAO (See Appendix B).
See Chapter 1109, Healthcare Services/Benefits for Children for information about CHIP benefits.
Resources are not considered for CHIP eligibility.
Issued March 31, 2023