Benefits Summary Children’s Health Insurance Program (CHIP)

CHIP

Children ages 0 through 18
Monthly cost $0 for Free CHIP

$34.84, $51.77, or $62.73 per month per child for Low-Cost CHIP

$288.42 per month per child for Full-Cost CHIP
Type of coverage Keystone Health Plan East HMO
Eligibility based on Family size and income
Wait period (if eligible) None
Pre-existing condition rule No
Copays $0 for Free CHIP

$5 PCP*/$10 specialist for Low-Cost CHIP

$15 PCP/$25 specialist for Full-Cost CHIP
Benefits
Doctor office visits $0 for Free CHIP

$5 PCP*/$10 specialist for Low-Cost CHIP

$15 PCP/$25 specialist for Full-Cost CHIP
Hospitalization limited to 90 days per year
Surgery and anesthesia covered
Emergency care $0 for Free CHIP, $25 for Low-Cost CHIP, and $50 for Full-Cost CHIP (waived if admitted)
Diagnostic services covered
Chemotherapy and radiation covered
Maternity care covered
Newborn care covered for up to 31 days following birth
Dental covered; no orthodontia
Vision and hearing covered; includes eyeglasses and hearing aids
Prescription drugs $0 for Free CHIP

$6 generic/$9 brand name for Low-Cost CHIP

$10 generic/$18 brand name for Full-Cost CHIP
Durable medical equipment (DME) covered
Mental health covered
Serious mental illness covered
Substance abuse covered

1 Except for well-child visits

2 Orthodontic Services: Covered only if your child is diagnosed with a significant handicapping malocclusion or other severe condition. (Prior authorization is mandatory and must be provided by a participating orthodontist.)