Child Health Plus is a separate New York State program, not Medicaid

Child Health Plus is a health insurance program run by New York State for children and teens up to age 19 whose families earn too much to may have access to for Medicaid but cannot afford private insurance. It is not Medicaid itself, though the two programs often work together and share some rules. The program covers doctor visits, hospital care, prescriptions, dental work, and vision care.

The key difference: Medicaid is a federal program that each state runs with its own income limits and rules. Child Health Plus exists only in New York and is designed specifically for the income range between Medicaid and full-price insurance. If your child is under 19 and you live in New York, you may be in the income band where Child Health Plus is the right fit.

Key Takeaways

  • Child Health Plus covers children and teens up to age 19 in New York State and includes doctor visits, hospital care, prescriptions, dental, and vision coverage.
  • The program serves families whose income is above the Medicaid limit but below the amount needed to afford private insurance without help.
  • Child Health Plus and Medicaid are separate programs with different income rules, though a child can move between them if family circumstances change.
  • You enroll through the New York State Department of Health or through a health plan directly, and the process takes a few weeks.
  • Monthly premiums and copays depend on your household income, and some families pay nothing while others pay a small amount per visit.

Income ranges and how they determine which program you use

New York Medicaid covers children in households earning up to a certain income level, which changes each year. Once your household income goes above that line, you no longer may have access to for Medicaid. Child Health Plus then becomes available if your income is still below the upper limit for that program, which is also set annually and is higher than the Medicaid cutoff.

The exact income numbers vary by family size and change on January 1 each year. A family of three might may have access to for Medicaid at one income level and Child Health Plus at a higher one. If your income falls between those two thresholds, Child Health Plus is likely your option. You can call the New York State Department of Health at 1-800-698-4543 to learn the current limits for your household size, or you can check the limits on the state's website.

Income includes wages, self-employment earnings, Social Security, unemployment benefits, and other regular money coming into the household. The state counts gross income before taxes. Assets like savings accounts do not count toward the income limit for Child Health Plus, though they do for some other programs.

What Child Health Plus covers

Child Health Plus pays for preventive care (checkups and vaccines), treatment when your child is sick or injured, hospital stays, emergency room visits, prescription medications, dental care, vision care including glasses, and mental health services. The program also covers therapy and rehabilitation services if your child needs them.

You choose a health plan when you enroll, and each plan has its own network of doctors and hospitals. Some plans are offered by major insurers like Empire BlueCross or Aetna. Your child can see any doctor in the plan's network without needing permission first for most visits. If you need a specialist, some plans require your primary care doctor to refer you, while others do not.

Preventive services like annual checkups and vaccines are covered at no cost to you. For other services, you may have a copay — a small amount you pay at the time of the visit. The copay amount depends on your household income. Families with lower incomes may have zero copay, while families with higher incomes might pay $3 to $15 per visit.

How premiums and copays work based on income

Child Health Plus uses a sliding scale, meaning what you pay depends on your household income. Families earning below a certain threshold pay no monthly premium and have zero copays for most services. As income increases, the monthly premium goes up and copays may appear.

The state publishes the exact premium and copay amounts each year based on income brackets. A family of three earning $30,000 per year might pay $0 per month with no copays, while a family earning $50,000 might pay $15 to $20 per month with small copays for doctor visits. The state's website and the enrollment materials show the exact amounts for your income level before you enroll.

Premiums are due monthly, usually by automatic payment from your bank account. If you miss a payment, the program typically gives you a grace period before coverage ends. Copays are paid at the time of service — at the doctor's office or pharmacy.

How to enroll and what documents you need

You can enroll through the New York State Department of Health website, by phone at 1-800-698-4543, or through a health plan directly. The online process takes about 20 minutes. You will need your child's Social Security number, proof of New York residency (a utility bill or lease works), and information about your household income and size.

Proof of income can be a recent pay stub, tax return, or a letter from your employer stating your annual salary. If you are self-employed, bring tax returns from the past two years. If you receive benefits like unemployment or Social Security, bring the award letter or recent statement. The state accepts documents from the past 30 days.

After you submit your process, the state reviews it and sends you a notice by mail within two to three weeks. The notice tells you whether your child is approved, what your monthly premium is, and which health plans are available in your area. You then choose a plan, and coverage usually starts on the first day of the following month.

When your child moves from Medicaid to Child Health Plus or vice versa

If your income increases and your child loses Medicaid coverage, you can enroll in Child Health Plus right away. There is no waiting period. The state's system is designed so that children do not fall into a gap without insurance. When Medicaid ends, you receive a notice that tells you about Child Health Plus and how to enroll.

If your income later drops and your child becomes may be able to access for Medicaid again, you can switch back. Medicaid covers more services with lower or no copays, so it is worth checking your income status each year. You can report a change in income to the state at any time, and the change takes effect the month after you report it.

Your child's coverage continues without interruption during the switch as long as you enroll in the new program before the old one ends. If there is a gap, your child loses coverage and you will need to re-enroll, which can take several weeks.

How Child Health Plus differs from regular Medicaid

Medicaid is a joint federal and state program that covers low-income children, pregnant women, parents, seniors, and people with disabilities. In New York, Medicaid covers children in households below a certain income level. Child Health Plus is a state-only program that covers children in the income range above Medicaid but below where private insurance becomes affordable.

Medicaid typically has lower or no copays and covers more services without limits. Child Health Plus has small copays and some limits on certain services, though these limits are not strict. Both programs cover the same basic services — doctor visits, hospital care, prescriptions, dental, and vision.

The enrollment process is similar for both programs, and you can explore for either one through the same state system. If you are unsure which program your child qualifies for, the state's process will tell you based on your income. Some families are told they may have access to for Medicaid first, and only if they earn too much for Medicaid are they offered Child Health Plus.

Frequently Asked Questions

Can my child stay on Child Health Plus after turning 19?

No, Child Health Plus covers children and teens only up to age 19. When your child turns 19, coverage ends on the last day of that month. You will receive a notice before the end date explaining your options, which may include Medicaid for adults (if your child's income is low enough) or purchasing insurance through the health marketplace.

What happens if I do not pay the monthly premium?

If you miss a premium payment, the state sends you a notice and usually gives you a 30-day grace period to pay. If you do not pay within that time, coverage ends. You can restart coverage by paying the missed amount and any current month's premium. If you are having trouble paying, call the state to discuss payment plans or to report a change in income that might lower your premium.

Can my child see any doctor, or only doctors in the plan's network?

Your child can see any doctor in the health plan's network without extra cost. If you see a doctor outside the network, you will pay more or the visit may not be covered at all. When you enroll, you receive a list of doctors and hospitals in your plan's network. You can also search the plan's website to find doctors near you before you choose a plan.

Do I have to choose a primary care doctor?

Most Child Health Plus plans require you to choose a primary care doctor, who coordinates your child's care and provides referrals to specialists. Some plans do not require this. When you enroll, the plan materials will tell you whether a primary care doctor is required. You can change your primary care doctor once a year or if you move.

What if my child needs a service that is not covered?

Child Health Plus covers the major health services children need, but some services like cosmetic procedures or experimental treatments may not be covered. If your child's doctor recommends a service and you are unsure whether it is covered, call your health plan before the visit. The plan can tell you whether the service is covered and what you will pay.