When your children qualify and you do not

It is entirely normal for one household to end up across two programmes: the children on CHIP or Medicaid, the parents on a Marketplace plan with a premium tax credit.

That is not a mistake or a failure of the application. It is how the programmes are designed to fit together, and it is the case most likely to be got wrong on a first attempt.

Why it happens

Children’s eligibility for Medicaid and CHIP is assessed against different — and generally more generous — income rules than adults’ eligibility for anything.

So a household can sit above the line for adult Medicaid, qualify for a premium tax credit on the Marketplace for the adults, and be comfortably below the line for the children’s programmes at the same time. One household, one income, three answers.

What CHIP is

The Children’s Health Insurance Program covers children in households that earn too much for Medicaid but would struggle to buy coverage otherwise.

Practical points:

• Costs are low. Premiums where they exist are modest, and cost-sharing is limited.
• Coverage is comprehensive, including dental and vision, which Marketplace children’s coverage handles differently.
• There is no enrollment window. You can apply at any time of year — this is the single most useful fact here, because it means a household that missed Open Enrollment can still get the children covered today.
• Each state runs its own, with its own name, its own rules and its own thresholds. Kansas, Missouri, Nebraska and Iowa each differ.

How the application handles it

You apply once, for the whole household, through HealthCare.gov. The application assesses each person against every programme and tells you who is eligible for what.

Two things to get right:

Include everyone in the tax household, even the people who will not be taking a Marketplace plan. Household size and household income both depend on the full list, and leaving someone off changes both numbers.

Answer the questions about existing coverage accurately. If a child is found eligible for CHIP or Medicaid, they generally cannot receive a premium tax credit for a Marketplace plan instead. The programmes do not stack.

The two mistakes we see

Not applying at all because the parents assume they earn too much. The children’s thresholds are considerably higher than most people expect, and the adult answer tells you nothing about the child answer. It costs nothing to be told no.

Refusing CHIP to keep everyone on one plan. Understandable — one card is simpler. But if a child is eligible for CHIP, that child generally cannot receive a tax credit on a Marketplace plan, so refusing means paying full price for their coverage. The convenience is expensive.

What changes during the year

Report changes as they happen. Income going up or down, a child’s birthday, someone joining or leaving the household. Eligibility for the children’s programmes can change even when nothing about the Marketplace plan does.

If a child loses CHIP or Medicaid eligibility, that opens a special enrollment window to add them to a Marketplace plan. The window is short, so act when the letter arrives rather than when you next think of it.

If a child becomes eligible, the reverse applies, and continuing to pay for Marketplace coverage for them is money spent for nothing.

Renewals

Medicaid and CHIP are renewed periodically, and renewals ask for current information. The most common reason a child loses coverage is not ineligibility — it is a renewal letter that went unanswered.

Keep the address on the account current and open the post from the state agency. It is the same advice as for everything else here, and it matters most in this one.

Where to get help

HealthCare.gov assesses the whole household in one application, free. The Marketplace Call Center is on 1-800-318-2596, TTY 1-855-889-4325, open at any hour. Your state’s Medicaid and CHIP agency handles the children’s side directly.

Navigators and certified application counselors are particularly worth using for mixed households — they do these every day, in person, free, and are not paid by insurance companies. Find one at localhelp.healthcare.gov.

We handle mixed households routinely across all four states, at no cost to you. If yours looks like this, ask before filling anything in.