Revision 21-2; Effective April 1, 2021

CHIP

The Children's Health Insurance Program (CHIP) provides health care coverage for children under 19 whose family income exceeds the Children's Medicaid income limit but is less than or equal to 201 percent of the federal poverty level (FPL), which is the applicable income limit for TA 84 (CHIP). Children who do not qualify for Medicaid and remain ineligible for Medicaid, are eligible to enroll in CHIP and receive up to 12 months of continuous coverage. Families with net income above 151 percent of the FPL are required to pay an enrollment fee. Families with income above 185 percent of the FPL will have an income check during their sixth month of eligibility. Most families also have copayments for doctor visits, prescription drugs and emergency care.

When an applicant requests children's health coverage, the child is first tested for Medicaid eligibility. If ineligible for Medicaid, the child is then tested for CHIP eligibility. When processing a change for a person certified for CHIP, the Texas Integrated Eligibility Redesign System (TIERS)  will automatically test the person for Medicaid eligibility. A new application is not required.

CHIP eligibility is prospective. The effective date is based on whether the Eligibility Determination Group (EDG) is disposed before or after cutoff and when the enrollment process is completed. TIERS provides the potential eligibility begin date, and Enrollment Broker provides the actual eligibility begin date.

CHIP Perinatal

CHIP perinatal provides services to unborn children of pregnant women, regardless of age. These pregnant women are ineligible for:

• Medicaid due to income exceeding 198 percent of the FPL, which is the applicable income limit for TP 40, but whose household income is at or below 202 percent of the FPL, which is the applicable income limit for TA 85 (CHIP Perinatal); or
• Medicaid or CHIP due to immigration status, since the pregnant woman is not a citizen or qualified alien.

When processing a change for a person certified for CHIP perinatal, TIERS will automatically test the person for Medicaid eligibility. A new application is not required. 

The unborn children of pregnant women eligible for CHIP perinatal are granted 12 months of continuous enrollment from the month the eligibility determination is made. The 12-month period includes the months of CHIP perinatal coverage before and after birth. The mother receives CHIP coverage related to the birth only; she does not receive personal health care coverage.

Because CHIP perinatal only provides coverage for pregnancy related services, women certified for CHIP perinatal must apply for Emergency Medicaid or Medically Needy (MN) with Spend Down to receive coverage for medical conditions not related to their pregnancy.  Receiving CHIP perinatal does not affect the mother's eligibility for:

• MA-MN with Spend Down (TP 56);
• MA-Pregnant Women – Emergency (TP 36),
• MA-Parents and Caretaker Relatives Medicaid – Emergency (TA 31);
• MA-MN with Spend Down – Emergency (TP 32); or
• MA-Children 6-18 – Emergency (TP 34).

Pregnant women may receive the program(s) above in the same month as CHIP perinatal. This is not considered dual coverage.

When a child is born to a CHIP perinatal mother whose household income is above the applicable income limit for Pregnant Women Medicaid, the child's coverage begins on the date of birth and the mother's coverage is terminated on the last day of the month the birth occurs. The mother is eligible to receive two postpartum visits that may occur after the mother's CHIP perinatal coverage ends. At birth, the child receives perinatal coverage for the remainder of the 12-month eligibility period. The child's CHIP perinatal enrollment is terminated at the end of the 12-month period.

When a child is born to a CHIP perinatal mother whose household income is at or below the applicable income limit for Pregnant Women Medicaid and the mother receives Emergency Medicaid to cover the labor with delivery charges, the advisor must enroll the child in TP 45 effective the child's date of birth. The mother's perinatal coverage ends the last day of the child's birth month or the pregnancy's termination month. The mother is eligible to receive two postpartum visits that may occur after her CHIP perinatal coverage ends.

Related Policy

Federal Poverty Level (FPL), C-131.1
Type Programs (TP) and Type Assistance (TA), C-1150
Adding a New Child, D-1433.1

D—121 Children's Health Insurance Program (CHIP)

Revision 15-4; Effective October 1, 2015

CHIP

A child must:

• be ineligible for Children's Medicaid;
• not be on Medicare;
• reside in Texas;
• be under age 19;
• be a U.S. citizen or non-citizen with valid proof of immigration/alien status;
• have total household net income at or below the applicable income limit; and
• be uninsured for at least 90 days or claim one of the good cause exemptions to the waiting period explained in D-1723.6, Good Cause Exemptions for Children Subject to the 90-day Waiting Period.

D—122 CHIP Perinatal

Revision 15-4; Effective October 1, 2015

CHIP Perinatal

To be eligible for CHIP perinatal, a woman must:

• be pregnant;
• reside in Texas;
• have total household net income at or below the applicable income limit, depending on family size; and
• be ineligible for ongoing Medicaid and CHIP because of income or immigration status.

A pregnant woman is considered to be an adult the month of her 18th birthday.

A pregnant woman must be determined ineligible for Medicaid and CHIP before being tested for perinatal eligibility. CHIP perinatal coverage begins the first day of the month in which the eligibility determination is made.

The woman's age is calculated as of the month in which the proposed effective date of coverage will occur.

D—122.1 Post-Birth Eligibility Determination

Revision 15-4; Effective October 1, 2015

CHIP Perinatal

A woman is not eligible for perinatal coverage if she applies after the child is born. The advisor must deny the application upon becoming aware that the pregnant woman has delivered or had a miscarriage before the eligibility determination is made. The advisor must then determine whether the newborn is eligible for Medicaid or CHIP.

If the pregnant woman delivers or has a miscarriage before the eligibility determination and the advisor becomes aware of the delivery or miscarriage after the eligibility determination has been made, the woman's coverage is terminated. The woman will receive one month of CHIP perinatal coverage.

D—122.2 Notification of Birth

Revision 13-4; Effective October 1, 2013

CHIP Perinatal

Staff are notified of the perinatal child's birth via the:

• case authority who reports the child's birth by telephone or in writing;
• the newborn file; or
• birth notification from the health plan.

D—210 Application Procedures

Revision 15-4; Effective October 1, 2015

CHIP, CHIP Perinatal

Applications may be received in person, by telephone, fax, email, Internet or mail. Texas Health and Human Services Commission (HHSC) Benefits Offices are equipped with telephones, lobby computers and fax machines for applicants to submit applications.

Households can apply using any of the Medical Program application channels explained in A-113, Application Requests and Submissions.

If the applicant fails to provide a name, address or signature on a faxed or mailed application, consider it an invalid application.

No interview is required for the Children's Health Insurance Program (CHIP) or CHIP perinatal. Schedule an appointment only upon the household's request.

On the same day of the application receipt, advisors mail the applicant Form H0025, HHSC Application for Voter Registration. If the individual contacts HHSC to decline the opportunity to register to vote after receipt of Form H0025, the advisors mail Form H1350, Opportunity to Register to Vote, to the individual for a signature. Advisors send Form H1350 for imaging when the individual returns the form and retain the form for at least 22 months.

Related Policy

Application Processing, A-100
Registering to Vote, A-1521

 

D—211 Application Assistance

Revision 15-4; Effective October 1, 2015

CHIP, CHIP Perinatal

If an applicant needs help completing the application packet, a volunteer or staff member must help. The person helping the applicant complete an application must initial the part he/she completed, or sign the application showing that he/she helped complete it.

 

D—212 Applications Received by Fax, Email, Mail or Internet

Revision 20-4; Effective October 1, 2020

CHIP and CHIP Perinatal

The applicant's file date is the date the Texas Health and Human Services Commission (HHSC) or an HHSC agent receives an application that contains, at a minimum, the person's name, address and signature. A faxed or electronic signature (if using the online application available through YourTexasBenefits.com) is acceptable. A typed signature is not valid if the application is received via fax, mail or in person. If the application does not contain a signature, return the application with Form H1020, Request for Information or Action, requesting a signature.

The file date is the date an application is received at an HHSC Benefits Office or online through YourTexasBenefits.com during state business hours. For applications received outside of state business hours, the file date is established as the next business day.

Once the initial application disposition occurs, requests for coverage for additional types of assistance are handled separately and a new application is required.

 

D—213 Applications Received by Telephone

Revision 17-1; Effective January 1, 2017

CHIP, CHIP Perinatal

The file date is the date the applicant submits the application by telephone through 2-1-1, and the telephonic application contains the applicant's:

• name;
• address; and
• signature by telephone.

An applicant may complete and sign an application by telephone following the policy for Medical Programs explained at A-122.1, Application Signature.

Related Policy

Application Signature, A-122.1

 

D—214 Withdrawal of an Application

Revision 13-4; Effective October 1, 2013

CHIP, CHIP Perinatal

A person with case authority may submit a request to voluntarily disenroll a member. The case authority person must sign and submit the request in writing.

 

D—215 Authorized Representatives (AR)

Revision 15-4; Effective October 1, 2015

A household may designate an individual or organization as an AR, following the policy explained in A-170, Authorized Representatives (AR).

Revision 13-4; Effective October 1, 2013

CHIP, CHIP Perinatal

When a household is denied for failure to provide information, the household has until the 60th day after the file date to provide the information without submitting a new application. The date the household submits all of the missing information becomes the new file date. Review the information provided by the household with the information listed on the application to ensure all information remains accurate.

If the household submits the missing information after the time frame, the household must reapply by submitting a new application.

Revision 13-4; Effective October 1, 2013

CHIP, CHIP Perinatal

Provide Form TF0001, Notice of Case Action, by the:

• 45th day after the file date for an application requesting health care for children.
• 15th working day after the file date for an application requesting health care coverage for a pregnant woman.

 

D—231 CHIP Perinatal Application

Revision 18-1; Effective January 1, 2018

CHIP Perinatal

Pregnant women who apply for medical assistance are screened for Pregnant Women Medicaid (TP 40). If ineligible for Medicaid, pregnant women under age 19 are tested for CHIP. If ineligible for CHIP because of age, income, or immigration status, pregnant women are tested for CHIP perinatal.

Women certified on CHIP perinatal due to not meeting immigration status requirements and whose household income is at or below Medicaid for Pregnant Women income limits at the time of application must submit Form H3038, Emergency Medical Services Certification, or Form H3038-P, CHIP Perinatal – Emergency Medical Services Certification, to cover the costs of labor and delivery.

Accept the applicant’s (pregnant woman’s, case name’s or authorized representative’s) verbal or written statement of pregnancy, including the start month, number of children expected and the anticipated date of delivery, unless questionable. The woman’s statement would be considered questionable if the information provided regarding the due date is discrepant, such as the pregnancy start month and pregnancy end month are less than or more than nine months apart or if the woman reports a pregnancy with overlapping start and end months.

If questionable, verify the applicant's pregnancy by using:

• Form H3037, Report of Pregnancy; or
• other documentation containing the same information as Form H3037.

The verification must be from an acceptable source such as a physician, hospital, family planning agency, or social service agency.

A physician, nurse, advanced nurse practitioner or other medical professional must sign Form H3037 or another document for it to be considered verification from a medical source. If it is completed by another medical professional, ensure that the information about the supervising physician is provided.

The application contains a field for the number of children expected and the anticipated date of delivery, but does not contain a field for the applicant to enter the pregnancy start month. Staff must use the following procedures when certain information regarding pregnancy is left blank on any application for benefits:

• If the only item missing on the application form is the pregnancy start month, staff must count nine months back from the pregnancy end month to determine the pregnancy start month. The pregnancy end month is month zero.
• If the only item missing on the application form is the pregnancy end month, staff must count nine months from the pregnancy start date to determine the anticipated date of delivery. The pregnancy start month is month zero.
• If both the pregnancy start and end months are missing, attempt to obtain the information by phone. If unable to obtain the information by phone, send Form H1020, Request for Information or Action, to request the information.

If the pregnancy verification is not received by the 15th workday from the request, deny the application. See D-220, Reopening an Application, if the verification is provided after the application is denied.

Related Policy

Pregnancy, A-144.5

 

D—231.1 Minor Pregnant Women with Potential Medicaid Eligibility

Revision 13-4; Effective October 1, 2013

CHIP, CHIP Perinatal

If an application is received for a minor pregnant woman, request all missing information and test for potential Medicaid eligibility.

Revision 15-4; Effective October 1, 2015

CHIP, CHIP Perinatal

If additional information is required, send the household Form H1020, Request for Information or Action. Upon receipt of the missing information, determine if the household is eligible.

Allow the household until the final due date to provide all the missing information. If the missing information is not provided by the final due date, deny the application.

If the missing information is received after the application is denied, but by the 60th day, reopen the application following the policy explained in D-220, Reopening an Application.

Revision 17-2; Effective April 1, 2017

CHIP

A child may be eligible from birth through the month of the child’s 19th birthday. Age is self-declared.

The certified group contains only the Children’s Health Insurance Program (CHIP) eligible child. Only one child is certified per Eligibility Determination Group (EDG).

CHIP Perinatal

A pregnant woman of any age may qualify for perinatal coverage.

When the pregnant woman is age 18 and it is anticipated that she will turn age 19 before her CHIP enrollment start date, the CHIP coverage is denied. She is tested for Pregnant Women Medicaid (TP 40) and then for CHIP perinatal, if ineligible for Pregnant Women Medicaid (TP 40). If eligible for CHIP perinatal, her enrollment start date is the first day of the eligibility determination month.

Only one pregnant woman is certified per EDG.

If the mother’s income is:

• Above the applicable income limit for Pregnant Women Medicaid (TP 40), as defined in C-131.1, Federal Poverty Income Limits (FPIL), the mother will be the only individual on the EDG for the majority of the certification period. During the month the child is born, the mother and the child are certified on the same EDG. After the month the child is born, the child is the only individual certified on the EDG.
• At or below the applicable income limit for Pregnant Women Medicaid (TP 40), as defined in C-131.1, and the mother receives Emergency Medicaid (TP 36) to cover the birth, the child will be certified on their own Medicaid for Newborn Children (TP 45) EDG.

CHIP, CHIP Perinatal

The following individuals are not eligible to receive CHIP or CHIP perinatal:

• Medicare recipients;
• inmates of a public institution; and
• residents of state supported living centers or institutions.

Exception: A child who is institutionalized (except for inmates of a public institution) during the child's continuous enrollment period remains eligible until the CHIP redetermination.

Revision 15-4; Effective October 1, 2015

CHIP, CHIP Perinatal

Modified Adjusted Gross Income (MAGI) household composition is used to determine whose needs, income, and expenses are considered in determining an individual’s eligibility for CHIP and CHIP perinatal. Each MAGI household composition is determined on the individual level. Individuals living at the same physical address may have a different MAGI household composition. MAGI household composition is based on federal income tax rules.

An individual does not have to file a federal income tax return to apply for CHIP or CHIP perinatal.

 

D—321 Who Is Included

Revision 16-4; Effective October 1, 2016

CHIP, CHIP Perinatal

Advisors must follow the policy described in A-240, Medical Programs, to determine who should be included in each individual’s MAGI household composition.

CHIP

When determining eligibility for a pregnant child, the expected number of the pregnant child's unborn children are included in the pregnant child's MAGI household composition.

CHIP Perinatal

When determining eligibility for a pregnant woman, the expected number of unborn children are included in the pregnant woman's MAGI household composition.

If the CHIP perinatal MAGI household composition includes other pregnant women, the expected number of unborn children of the other pregnant women are also included in the CHIP perinatal MAGI household composition, regardless of whether the other pregnant women are certified on a medical program.

Related Policy

Inclusion of the Unborn, A-241.1.5

 

D—322 Who Is Not Included

Revision 16-4; Effective October 1, 2016

CHIP, CHIP Perinatal

Advisors must follow the policy described in A-240, Medical Programs, to determine who should be included in each individual’s MAGI household composition.

CHIP

The expected number of  unborn children are not included in a non-pregnant child's MAGI household composition for CHIP when a pregnant child is included in the household.

 

D—323 Minor Parent Situations

Revision 15-4; Effective October 1, 2015

CHIP, CHIP Perinatal

Advisors must follow the policy described in A-240, Medical Programs, to determine who should be included in each individual’s MAGI household composition.

Revision 15-4; Effective October 1, 2015

CHIP, CHIP Perinatal

Either parent may apply on behalf of the child(ren) if they meet the criteria explained in A-121, Receipt of Application for Medical Programs. A custodial parent is established based on the policy explained in A-240, Medical Programs, Living Arrangements.

Revision 15-4; Effective October 1, 2015

CHIP, CHIP Perinatal

Children in state hospitals may be eligible as independent children for a 12-month period. In order to be admitted to a state hospital, the child must:

• be under age 19;
• be a U.S. citizen or Lawful Permanent Resident who entered the U.S. prior to Aug. 22, 1996;
• be a ward of HHSC via court civil commitment; or
• have or obtain a Social Security number (SSN).

A representative from the state hospital completes the application and attaches a cover sheet to specify the application is from the state hospital. In addition, the representative attaches copies of unpaid medical bills and, if applicable, Form H1113, Application for Prior Medicaid Coverage.

The application lists the:

• independent child's name as the head of household;
• SSN;
• date of birth;
• parents or UNKNOWN in other parent section;
• income and resources (if any);

Note: Resources are not considered as a factor in determining eligibility for CHIP or CHIP perinatal.

• insurance information;
• dates of service may be in the month of the child's 19th birthday or sooner;
• representative from the state hospital in the authorized representative section;
• signature of the representative from the state hospital who completed the application; and
• address of the state hospital in the residence and mailing address section, except for Terrell State Hospital (Terrell State Hospital lists the independent child's original residence address and the facility address in the mailing address).

If the independent child has no income, no other information is required to complete the application processing.

CHIP

An institutionalized child is not eligible to apply for CHIP. Exception: When a child is currently enrolled in CHIP and enters a state mental health facility, the child remains enrolled in CHIP until the end of the child's current enrollment segment.

Revision 15-4; Effective October 1, 2015

CHIP

An individual must be a U.S. citizen or alien with acceptable status to qualify for the Children’s Health Insurance Program (CHIP). The date of entry does not apply.

Review the alien status document from the U.S. Citizenship and Immigration Services (USCIS) and status code to determine the immigration/alien status. Refer to A-342, TANF and Medical Programs Alien Status Eligibility Charts.

CHIP Perinatal

A pregnant woman does not have to meet the citizenship or alien status requirements in order to be eligible for CHIP perinatal.

Applicants who possess temporary visas are eligible for CHIP perinatal as long as they meet residency eligibility requirements. See D-700, Residency.

Pregnant women potentially eligible for Medicaid who fail to provide verification of citizenship or alien status are not eligible for CHIP perinatal.

Revision 11-4; Effective October 1, 2011

CHIP, CHIP Perinatal

U.S. citizens meet the citizenship criteria for CHIP and CHIP perinatal. U.S. citizens are persons born:

• in the 50 states, District of Columbia, Puerto Rico, Guam, the U.S. Virgin Islands, America Samoa, Swain's Island or Northern Marianna Islands; or
• abroad to at least one parent who is a U.S. citizen. The child may claim derivative citizenship.

Revision 23-2; Effective April 1, 2023

CHIP

Qualifying immigrants and non-immigrants, as defined in A-311.1, Definition of Qualified Immigrant, are eligible for CHIP regardless of the date of entry. Review the alien status document and code to determine if the child meets the immigration or alien status requirements. Refer to A-342, TANF and Medical Programs Alien Status Eligibility Charts.

CHIP Perinatal

Immigration or alien status is not applicable to CHIP perinatal.

D—441 Citizenship

Revision 11-4; Effective October 1, 2011

CHIP

CHIP applicants or recipients who declare that they are U.S. citizens must provide verification of citizenship.

Use Medicaid Programs proof/verification sources found in A-358.1, Citizenship, for citizenship and A-621, Verification Sources, for identity.

CHIP Perinatal

Citizenship is self-declared.

D—441.1 Reasonable Opportunity to Provide Citizenship and Alien Status Verification

Revision 15-4; Effective October 1, 2015

CHIP

CHIP applicants or recipients who declare themselves to be a U.S. citizen or declare an alien status, but for whom verification is unavailable, must be allowed a period of reasonable opportunity explained in A-351.1, Reasonable Opportunity.

D—441.2 Using State Online Query (SOLQ) or Wire Third-Party Query (WTPY) to Verify Citizenship

Revision 15-4; Effective October 1, 2015

CHIP

If an applicant has a Social Security number, use SOLQ or WTPY to verify citizenship. See A-351.2, Using State Online Query (SOLQ) or Wire Third-Party Query (WTPY) to Verify Citizenship.

D—442 Using Systematic Alien Verification for Entitlements (SAVE) Program to Verify Alien Status

Revision 15-4; Effective October 1, 2015

CHIP

Access the Verification Information System (VIS) through the USCIS using the Department of Homeland Security's SAVE program for verification validity.

Do not reverify an alien’s documents if the non-citizen status was previously verified and documented, and the documents have not expired. If the USCIS document is expired, and the alien wants to continue receiving or reapplies for benefits, then request updated documents. If the family fails to provide the updated documents, the child cannot receive benefits.

CHIP Perinatal

Immigration status is self-declared. The pregnant woman may be:

• a U.S. citizen,
• a lawful permanent resident, or
• an undocumented alien.

Do not trigger missing information for immigration status or date of entry.

CHIP, CHIP Perinatal

If the applicant provides documents other than those listed in A-358.2, Alien Status, take the following action to request additional verification:

• complete Form G-845, Document Verification Request;
• attach fully readable photocopies (front and back) of original immigration documents containing the alien's registration number; and
• mail one set of copies to the USCIS office serving the county of application (see the instructions to Form G-845).

If the applicant's name changed since the alien registration card was issued, the applicant must provide verification of the change.

If the alien is otherwise eligible, do not delay or deny the child's eligibility while waiting for a response from USCIS. When USCIS returns Form G-845, follow these procedures:

If the response indicates that the alien's document is...	then ...
valid,	document the detailed information and send the documents for imaging.
not valid and the child is enrolled,	take adverse action to disqualify the child or deny the case, as appropriate; and process a fraud referral.

Revision 20-2; Effective April 1, 2020

CHIP

All applicants must provide a Social Security number (SSN) or apply for one through the Social Security Administration (SSA) before certification.  

CHIP follows the SSN policy in A-400, Social Security Number, under the All Programs or Medical Programs headings. 

CHIP Perinatal

A pregnant woman is not required to provide or apply for an SSN.

The applicant is not required to provide SSNs for other members included in the budget group. If SSNs are provided, staff record and may attempt to verify the SSN using the procedures explained in A-440, Verification Requirements. If verification is not available through electronic data sources, verification of the SSN must not be requested from the applicant.

Revision 20-2; Effective April 1, 2020

D—611 Application

Revision 15-4; Effective October 1, 2015

CHIP

Advisors must verify the identity of all individuals applying for Medical coverage. Once identity has been verified for an individual, advisors do not re-verify.

CHIP Perinatal

Identity is self-declared.

 

D—612 Renewals

Revision 15-4; Effective October 1, 2015

CHIP

Advisors must verify the identity of the certified individual if identity has not been previously verified.

Revision 15-4; Effective October 1, 2015

CHIP

Birth records and other official records are preferred sources of verification.

Advisors use proof/verification sources from the list under Medical Programs in A-621, Verification Sources. Once identity has been verified for an individual, advisors do not re-verify.

Note: If an applicant/recipient receives reasonable opportunity, verification of identity will be required when the reasonable opportunity period expires.

Revision 10-2; Effective April 1, 2010

CHIP

Document the source of identity proof/verification.

Revision 11-4; Effective October 1, 2011

CHIP, CHIP Perinatal

An eligible applicant must be a Texas resident. Residency in Texas is self-declared. An applying person does not lose resident status when out of state for less than a 12-month period.

Applicants meet the residency requirement if they live in Texas and intend to make Texas their home. The household is not required to have a permanent dwelling or fixed residence. A Texas residence address listed on the application meets the "intent to make Texas their home" rule.

People who live in Texas for a temporary purpose do not meet the residency requirement.

Migrant and itinerant workers meet the residency requirement when applying if they:

• live in Texas,
• entered Texas with a job commitment or an intention to seek employment (regardless of current employment status), and
• do not receive assistance from another state.

Revision 11-4; Effective October 1, 2011

CHIP, CHIP Perinatal

Child support requirements do not apply to CHIP. Applicants may obtain child and medical support assistance by contacting the Office of Attorney General.

Revision 15-4; Effective October 1, 2015

CHIP, CHIP Perinatal

Resources are not considered as a factor in determining eligibility for the Children’s Health Insurance Program (CHIP) or CHIP perinatal.

Revision 15-4; Effective October 1, 2015

CHIP, CHIP Perinatal

Income is any type of payment that is of gain or benefit to a household. Income is either counted or exempted from the budgeting process. Earned income is related to employment and entitles a household to deductions not allowed for unearned income. Unearned income is income received without performing work-related activities. It includes benefits from other programs. To determine the date income can reasonably be anticipated, the advisor should use factors specific to the source of income, distance it has to travel through the mail, weekends and holidays.

Advisors must use Modified Adjusted Gross Income (MAGI) rules to determine financial eligibility for the Children’s Health Insurance Program (CHIP) and CHIP perinatal following the Medical Programs policy, explained in A-1300, Income.

Revision 15-4; Effective October 1, 2015

CHIP, CHIP Perinatal

Income limits for CHIP and CHIP perinatal are defined in C-131.1, Federal Poverty Income Limits (FPIL).

Revision 15-4; Effective October 1, 2015

CHIP, CHIP Perinatal

Use the Medical Programs policy, explained in A-1320, Types of Income, to determine the countable and exempt income types for CHIP and CHIP perinatal.

Revision 15-4; Effective October 1, 2015

CHIP, CHIP Perinatal

For CHIP and CHIP perinatal, each individual’s MAGI household income is calculated following the Medical Programs policy explained in A-1341, Income Limits and Eligibility Tests.

 

D—1051 Income Frequency

Revision 15-4; Effective October 1, 2015

CHIP, CHIP Perinatal

Income received must be converted to a monthly amount, unless received monthly. Advisors must use the following conversion factors. (Monthly pay means that the employee is paid once a month.)

Income Frequency	Conversion Factor
Weekly (paid once every week)	Multiply by 4.33
Bi-weekly (paid every other week)	Multiply by 2.17
Semi-monthly (paid twice a month)	Multiply by 2.0
Annually (paid once a year)	Divide by 12

If the income frequency cannot be determined based on the information listed on the application or from the verification, the advisor must generate Form H1020, Request for Information or Action, to request the income frequency.

 

D—1052 Terminated Income

Revision 15-4; Effective October 1, 2015

CHIP, CHIP Perinatal

Count terminated income in the month received. Use actual income and do not use conversion factors if terminated income is less than a full month's income. If the income terminated in the application month, the advisor must request missing information to verify the termination. Self-declaration is not acceptable verification.

 

D—1053 Budget Months

Revision 15-4; Effective October 1, 2015

CHIP

The system will determine CHIP eligibility for the following months:

At Application

• Application month
• Process month

At Redetermination

The month following the last month of CHIP coverage.

D—1060 Verification Requirements

Revision 15-4; Effective October 1, 2015

CHIP, CHIP Perinatal

Income verification requirements for CHIP and CHIP perinatal align with the Medical Programs policy explained in A-1370, Verification Requirements.

 

D—1061 Verification Sources

Revision 15-4; Effective October 1, 2015

CHIP, CHIP Perinatal

Determining whether client-reported income is reasonably compatible with electronic data sources is the preferred method of wage verification for CHIP and CHIP perinatal. Reasonable compatibility is explained in A-1370, Verification Requirements, Medical Programs.

Other income verification sources for CHIP and CHIP perinatal align with the Children’s Medicaid (TP 33, TP 34, TP 35, TP 43, TP 44 and TP 48) policy explained in A-1371, Verification Sources.

Revision 15-4; Effective October 1, 2015

CHIP, CHIP Perinatal

Exempt Income

Document:

• why it is exempt, and
• the name and address or telephone number of the income source.

Terminated Income

Document:

• the name and address or telephone number of the income source, and
• vacation pay received before or after termination, including the dates received.

Income

Document the:

• date of each income statement or stub used;
• date income is actually received;
• date income is anticipated using factors such as time it has to travel via mail, weekends and holidays;
• name and address or telephone number of the income source;
• gross amount of income;
• frequency of receipt (such as weekly, every two weeks, semi-monthly, monthly); and
• calculations used.

Income Computations

Document verification and computation of household income at the initial application, when a change is reported and at each subsequent application/redetermination. Record all sources, amounts, dates and computations.

Other Income

Document the method used to verify income other than earned income. This documentation includes the type of income, the check or document seen, the date on the check or document, the amount recorded on the check or document, the date the income was verified and any computations performed to determine the total income.

Self-Employment

Document:

• the method for averaging income;
• deductions for the cost of doing business;
• the number of hours engaged in the enterprise;
• other factors used to determine the amount of income;
• that the individual was informed to keep self-employment records and receipts for verification purposes for future recertifications; and
• when using Form H1049, Client's Statement of Self-Employment Income, as the only source of verification, the reason Form H1049 is the only source of income.

Revision 15-4; Effective October 1, 2015

CHIP, CHIP Perinatal

Households may be allowed the Modified Adjusted Gross Income (MAGI) deductions explained in A-1410, General Policy, for Medical Programs.

Revision 20-2; Effective April 1, 2020

Revision 15-4; Effective October 1, 2015

CHIP, CHIP Perinatal

The deduction verification requirements for the Children’s Health Insurance Program (CHIP) and CHIP perinatal align with the Medical Programs policy explained in A-1440, Verification Requirements.

 

D—1131 Verification Sources

Revision 15-4; Effective October 1, 2015

CHIP, CHIP Perinatal

The deduction verification sources for CHIP and CHIP perinatal align with those for Medical Programs explained in A-1441, Verification Sources.

Revision 11-4; Effective October 1, 2011

CHIP, CHIP Perinatal

Document:

• amount of expense,
• who pays the expense,
• how often the expense is paid,
• to whom the expense is paid,
• calculations used to determine monthly amounts, and
• justification for not allowing the deduction.

Revision 23-2; Effective April 1, 2023

CHIP, CHIP Perinatal

Third-party resources (TPR) are sources of payment for medical expenses other than the recipient or Medicaid. TPR includes payments from private and public health insurance and from other liable third parties that can be applied toward the recipient’s medical expenses. Note: Separate dental or vision plans, auto, workers’ compensation, county medical discount cards, student accident, travel insurance or sports-related insurance are not considered TPRs.

Consider Medicare a TPR. Do not certify a Medicare recipient for the Children’s Health Insurance Program (CHIP) or CHIP perinatal.

CHIP

Households that have health insurance in which the monthly premium amount for the child(ren) costs:

• less than 5 percent of the household's net income in the application month are not eligible for CHIP coverage.
• 5 percent or more of the household's net income in the application month are eligible for CHIP coverage. However, the household must drop the insurance before CHIP coverage begins. Children cannot be covered by CHIP and health insurance at the same time. These children are not subject to the 90-day waiting period.

Households that have health insurance in which the monthly premium amount for the family’s coverage that includes the child(ren) costs:

• less than 9.5 percent of the household’s net income in the application month are not eligible for CHIP coverage.
• 9.5 percent or more of the household’s net income in the application month are eligible for CHIP coverage. However, the household must drop the insurance before CHIP coverage begins. Children cannot be covered by CHIP and health insurance at the same time. These children are not subject to the 90-day waiting period.

When the family reports TPR at application or redetermination, send Form H1020, Request for Information or Action, to request:

• a coverage end date,
• the monthly premium amount for the child(ren) or for family coverage that includes the child(ren), and
• information that will verify the insurance policy.

Deny the CHIP Eligibility Determination Group (EDG) if the household does not provide the verification by the due date and the verification is required for all certified group members. If the verification is not required for all members, the affected person will be disqualified.

Acceptable verification of the private health insurance end date includes:

• health insurance ID card indicating the end date,
• letter from the employer indicating the end date, or
• the person's statement by phone or in writing.

At any time during the child's enrollment period, if the Texas Health and Human Services Commission (HHSC) is notified that the child remains on health insurance or that the child has Medicare (the household did not drop the TPR at application or redetermination), the child is denied and disenrolled.

If a household reports that it has obtained health insurance during the continuous enrollment period, document the change and process the change at the next redetermination.

The Texas Integrated Eligibility Redesign System (TIERS) will pend the TPR logical unit of work at redetermination when HHSC receives TPR information via the TPR interface for a child currently eligible or enrolled in CHIP.

When a household reports a new child in the household and the child is potentially eligible for CHIP, TPR requirements must be addressed following application procedures. Deny the CHIP EDG if the child has an active TPR but does not meet any of the good cause exemptions. 

CHIP Perinatal

Pregnant women with any type of private health insurance are not eligible for perinatal coverage, even if the current health insurance does not provide maternity coverage. Pregnant women cannot be covered by perinatal and private health insurance at the same time.

The 5 percent and 9.5 percent rules regarding monthly premium costs compared to the household’s monthly net income that apply to CHIP do not apply to CHIP perinatal.

Related Policy

Adding a New Child, D-1433.1
Third Party Resources Changes, D-1437
Health Insurance, D-1632.2
Good Cause Exemptions for Children Subject to the 90-Day Waiting Period, D-1723.6
Exceptions to the Continuous Enrollment Period, D-1731
 

Revision 15-4; Effective October 1, 2015

CHIP, CHIP Perinatal

Case disposition is the result of the eligibility determination once all required information is obtained and an individual’s notice of eligibility status is generated.

The notice explains if the case/application is pended, certified, sustained or denied.
The household must submit all missing information by the 45th calendar day from the file date. If the family fails to submit the required information timely, the application is denied.

When an eligibility determination is made, the household is notified of the child's eligibility status in writing. In addition, households must be informed in the denial and disenrollment letter of:

• their rights and responsibilities;
• right to request a review of the case decision; and
• commercial insurance options through a referral to the Texas Department of Insurance toll-free telephone number at 1-800-252-3439 and the website at www.texashealthoptions.com.

The system automatically sends individuals determined ineligible for Medicaid and the Children's Health Insurance Program (CHIP) at application, redetermination or when processing a change to the Marketplace for an eligibility determination for federal health care coverage programs.

To qualify for the federal health care coverage programs, all individuals must first be determined ineligible for Medicaid and CHIP. Advisors must test whether an individual is eligible for all Medical Programs. The Texas Works Medical Programs Hierarchy, explained in A-132.1, Medical Programs Hierarchy, does this automatically for most clients.

Note: Advisors must follow a manual process when retesting eligibility for a minor parent aging out of CHIP, as explained in A-2342.1, Retesting Eligibility.

Revision 13-4; Effective October 1, 2013

CHIP, CHIP Perinatal

Form TF0001, Notice of Case Action, advises the household of the:

• potential household eligibility and who is potentially eligible;
• need for the household to return a health plan selection and enrollment fee, if required;
• reason the application was denied, terminated or reinstated;
• effective date of the denial, termination or reinstatement; and
• right to request a review.

Revision 15-4; Effective October 1, 2015

CHIP, CHIP Perinatal

CHIP correspondence refers to written documents or a request for review from a household or applicant for enrollment into CHIP. Correspondence may be submitted online at YourTexasBenefits.com, by fax, or through the mail. Uploaded, faxed, or hard copy correspondence documents are linked with the appropriate case. Types of correspondence may include:

• provider claims;
• plan transfer form or letter;
• letter requesting address or name change;
• missing information requested by CHIP through application processing;
• requests for disenrollment;
• enrollment requests;
• request for review of an eligibility or enrollment decision; and
• cost share updates.

Revision 20-4; Effective October 1, 2020

CHIP and CHIP Perinatal

Changes are situations in a household that may affect eligibility. Action must be taken on reported changes to ensure program integrity.

Cost share adjustments are handled by the Enrollment Broker at application, redetermination and the six-month income check.

When a change is processed that is missing required information, send Form H1020, Request for Information or Action, within one business day from the report date. Allow 10 full days to provide the requested information or verification. Action must be taken on the change within one business day of receipt of the missing information.

Revision 15-4; Effective October 1, 2015

CHIP, CHIP Perinatal

Households must report the following changes to:

• address;
• intent to reside in Texas;
• the individuals living in the home;
• income, including sources of income, regular hours worked, and pay rate;  
• Modified Adjusted Gross Income (MAGI) expenses;
• pregnancy termination;
• a child being institutionalized or dying; and
• medical insurance coverage.

Exceptions: A child is disenrolled if the child reapplies and becomes eligible for Medicaid or at the end of the month of the child’s 19th birthday.

Process all other changes, including agency-generated changes, at the time of report.

D—1421 How to Report

Revision 15-4; Effective October 1, 2015

CHIP, CHIP Perinatal

Persons with case authority may report changes by one of the following means:

• online through YourTexasBenefits.com;
• in person at a Texas Health and Human Services Commission Benefits Office;
• telephone;
• mail;
• fax;
• Form H1019, Report of Change, and;
• signed Form H1028, Employment Verification.

A person with case authority is an individual who has the authority to apply on the child’s behalf, as explained in A-121, Receipt of Application, for Medical Programs. 

D—1422 Receipts for Reported Changes

Revision 13-4; Effective October 1, 2013

CHIP, CHIP Perinatal

Households may request a receipt to acknowledge the change report. The receipt includes the type of change(s) and the date reported. If an individual requests a receipt, issue Form H1800, Receipt for Application/Medicaid Report/Verification/Report of Change.

D—1431 Address Change Processing

Revision 13-4; Effective October 1, 2013

CHIP, CHIP Perinatal

The case address is updated when the household reports an address change.

If the household reports a change of address, the individual is mailed Form H0025, HHSC Application for Voter Registration, to register to vote based on the new address. If the individual declines the opportunity to register to vote after receipt of Form H0025, mail Form H1350, Opportunity to Register to Vote, to the individual for their signature. Send Form H1350 for imaging when the individual returns Form and retain Form for at least 22 months.

Related Policy

Registering to Vote, A-1521

D—1432 Moves

Revision 13-4; Effective October 1, 2013

CHIP, CHIP Perinatal

For moves within Texas, the case is updated to reflect the newly reported address.

For moves outside of Texas, the case is updated to reflect the:

• temporary address, if the move is temporary.
• address and disenrolls the child as soon as possible, if the move is permanent.

D—1433 Household Composition Changes

Revision 15-4; Effective October 1, 2015

CHIP Perinatal

No action is taken on a request to add or remove a non-certified person from an existing perinatal Eligibility Determination Group (EDG).

D—1433.1 Adding a New Child

Revision 23-2; Effective April 1, 2023

CHIP, CHIP Perinatal

A separate application is required;

• to start benefits for a new child being added if there is not an existing Medicaid or Children's Health Insurance Program (CHIP) EDG on the case; and
• if a household requests benefits for a sibling of a child released from a juvenile facility whose TP 44 eligibility is reinstated to a denied or newly created case.

CHIP

When a household reports a new child in the household, determine if the new child and other children in the household that are certified for CHIP meet Medicaid eligibility criteria. Certify the children for Medicaid if they are eligible. A new application is not required.

When a household reports a new child in the household and the child is potentially eligible for CHIP, third-party resources (TPR) requirements must be addressed following application procedures. Deny the CHIP EDG if the child has an active TPR but does not meet any of the good cause exemptions.

Note: If the Texas Juvenile Justice Department (TJJD) or Juvenile Probation Department (JPD) reports by the TJJD or JPD Released Logical Unit of Work (LUW) that a child was released from a juvenile facility and is now living in the household, TIERS automatically tests the child's eligibility for Medicaid. 

If the new child is ineligible for Medicaid but eligible for CHIP and has siblings or a parent currently enrolled in the program, they are considered to meet good cause. TIERS calculates the new child's effective date of coverage for the next possible month following cutoff. The new child will receive the remaining months of coverage with the siblings or parent. The coverage end date is the same date as the child's currently enrolled siblings or parent. The new child may not receive the full 12 months of coverage and is required to renew coverage along with the child’s siblings or parent on the scheduled renewal date.

Once the new child is determined eligible for CHIP, TIERS notifies the Enrollment Broker via an interface. The Enrollment Broker generates and mails a welcome letter to the household.

CHIP Perinatal

Income Above the Limit for Medicaid for Pregnant Women (TP 40)

A child born to a CHIP perinatal mother whose household income is above 198 percent of the federal poverty level (FPL), which is the applicable income limit for Pregnant Women Medicaid (TP 40), will have an effective date beginning with the date of birth and continuing through the remainder of the 12-month CHIP perinatal enrollment segment. The mother's perinatal coverage ends the last day of the child's birth month or the pregnancy's termination month. The mother will receive two postpartum visits even if they are beyond the birth month.

Example: A pregnant mother is approved for CHIP perinatal effective June 1. The child is born on Oct. 4. The newborn's effective date of coverage is Oct. 4, and the end date is May 30. The mother's perinatal coverage ends Oct. 31.

A perinatal child whose coverage ends, and who has siblings currently enrolled in CHIP, meets good cause upon determination of CHIP eligibility. The child's enrollment start date is the first day of the month following the perinatal end date. The child's CHIP end date is the end date of the existing CHIP enrollment segment. The child may not receive the 12 months of CHIP coverage and must renew eligibility in accordance with the existing CHIP redetermination date.

Income at or Below the Limit for Medicaid for Pregnant Women (TP 40)

A child born to a CHIP perinatal mother whose household income is at or below 198 percent of the FPL, which is the applicable income limit for Pregnant Women Medicaid (TP 40), and who receives Emergency Medicaid to cover the labor with delivery charges, will be enrolled in TP 45 coverage effective the date of birth. The mother's perinatal coverage ends the last day of the child's birth month or the pregnancy's termination month. The mother will receive two postpartum visits even if they are beyond the birth month.  

Related Policy

Receipt of Application, A-121
CHIP Perinatal Application Process, A-128.3
Neonatal Intensive Care Unit (NICU) Newborn Process, A-126.3.1
Federal Poverty Level (FPL), C-131.1

D—1433.2 Child Leaves the Home

Revision 20-4; Effective October 1, 2020

CHIP

Under MAGI household composition rules, explained in A-240, Medical Programs, a certified child leaving the home may or may not affect their continued eligibility for CHIP based on their tax status, tax relationships, and family relationships.

When a child dies, terminate the child’s eligibility effective the last day of the month the child died.

Follow policy in B-510, Termination of Medical Coverage for People Confined in a Public Institution, if the child is confined in any public institution, including a juvenile facility.

Related Policy

Termination of Medical Coverage for People Confined in a Public Institution, B-510
Persons Confined in a Texas County Jail, B-542
Child Placed in a Juvenile Facility, B-543

D—1433.3 Child Institutionalized

Revision 13-4; Effective October 1, 2013

CHIP, CHIP Perinatal

When a certified child enters a state hospital or institution for a temporary absence, the child remains enrolled for the remainder of the 12-month period. See A-920, Temporary Absence From the Home, to determine if stay is considered a temporary absence.

D—1433.4 Head of Household

Revision 20-1; Effective January 1, 2020

CHIP, CHIP Perinatal

Under MAGI household composition rules, explained in A-240, Medical Programs, a head of household leaving the home may or may not affect eligibility depending on that person’s tax status, tax relationships, and family relationships.

When the current head of household dies or leaves the home, change the head of household to another responsible adult household member without requiring the remaining household members to reapply for benefits. An adult household member is someone 19 years or older.

If there is no responsible adult member identified in the household, and a child in the household is receiving benefits, send Form H1020 to notify the household that a responsible adult who is caring for the child must apply for benefits if the child continues to need assistance. If an application is not submitted by the Form H1020 due date, deny benefits since the whereabouts of the child is unknown.

Related Policy

Who Is Included, D-321
New Head of Household, D-1632.1

D—1434 Demographic Changes

Revision 15-4; Effective October 1, 2015

CHIP, CHIP Perinatal

A demographic change is a change to a person's identifying information, such as date of birth, Social Security number (SSN), gender or name.

Process these changes and do not interrupt the child’s continuous coverage.

D—1435 Pregnancy Reports

Revision 15-4; Effective October 1, 2015

CHIP

When a household reports a CHIP child's pregnancy before her CHIP end date, the child is tested for Pregnant Women Medicaid (TP 40) and verification of the pregnancy is requested. A verbal or written statement of pregnancy from the pregnant child, case name or authorized representative that includes the pregnancy start month, number of children expected and the anticipated date of delivery is an acceptable verification source. If potentially eligible and the household provides the pregnancy verification, the child is terminated from CHIP and certified for Medicaid.

If the pregnant child is determined ineligible for Pregnant Women Medicaid (TP 40), she remains in CHIP up to two months beyond the original CHIP end date if the pregnancy due date is in the 11th or 12th month of her CHIP coverage, unless the:

• pregnant child reports pregnancy termination,
• household reports she has other insurance,
• pregnant child no longer lives in Texas, or
• pregnant child turns age 19.

Before the pregnancy ends, extend coverage for:

• one month if the pregnancy due date is in the 11th month of the CHIP certification; or
• two months if the pregnancy due date is in the 12th month of the CHIP certification.

If the household does not report a CHIP child’s pregnancy until she gives birth or later, the child remains in CHIP, and the CHIP child’s newborn is tested for Medicaid eligibility. If eligible, the newborn is certified for Children Under Age One Medicaid (TP 43). If not eligible, the newborn is enrolled in the mother’s CHIP health plan. The effective date of CHIP coverage is the next possible month following cutoff. The newborn’s CHIP coverage ends with the household’s current enrollment segment.

Related Policy

Adding a New Child, D-1433.1

D—1436 Income and Deduction Changes

Revision 21-2; Effective April 1, 2021

CHIP

When a household reports a change in income, test the child or children for Medicaid eligibility. A new application is not required. If the child is still eligible for CHIP and the household requests that its cost share responsibilities be recalculated, refer the household to the Enrollment Broker.

D—1437 Third Party Resources Changes

Revision 15-4; Effective October 1, 2015

CHIP

If a household reports that they have obtained health insurance during the continuous enrollment period, document the change and process the change at the next redetermination.

Related Policy

Health Insurance, D-1632.2

CHIP Perinatal

Do not take any action if a woman reports private health insurance coverage during her certification period.

Revision 19-4; Effective October 1, 2019

CHIP

Children certified on the Children’s Health Insurance Program (CHIP) with income above 185 percent of the Federal Poverty Level (FPL) will have a six-month income check to determine whether the child remains financially eligible.

An automated income check, explained in B-637, Periodic Income Checks, is run in the fifth month of the certification period when the following conditions have been met:

• the household’s income at application was above 185 percent of FPL;
• the child will not age out before or during the fifth month;
• any of the following is true for at least one person in the Modified Adjusted Gross Income (MAGI) household for at least one countable income or expense source:
  • an income or expense is not verified;
  • one of the following income types uses “Verified by Reasonable Compatibility” as the verification source:
    • employment income;
    • unemployment compensation income; or
    • retirement, Survivors, and Disability Insurance (RSDI) income; or
  • the verification source is anything other than “Verified by Reasonable Compatibility” and the verification received date is more than 60 days old;
• the case is in Approved Ongoing Mode; and
• there are no pending Task List Manager (TLM) tasks for the case.

The result of the income check may impact eligibility in the seventh month.

The household is given at least 30 days advance notice before disenrollment. The household is entitled to a request for review and continued enrollment based on actions related to the six-month income check.

Note: The household is not eligible for continued enrollment if the denial is because the household failed to provide the information requested during the six-month income check.

If the household's income is at or below the applicable income limit for CHIP, the household remains on CHIP.

At the six-month income check, updated eligibility status or cost share details are automatically sent to the CHIP enrollment broker.

CHIP Perinatal

CHIP perinatal households are not subject to the income check.

Related Policy

Periodic Income Checks, B-637
Exceptions to the Continuous Enrollment Period, D-1731
Request for Review, D-1920

Revision 15-4; Effective October 1, 2015

CHIP

Individuals enrolled in the Children's Health Insurance Program (CHIP) must complete the administrative renewal process explained in B-122.4, Medical Program Administrative Renewals. 

Depending on the renewal status outcome and client action, final eligibility determinations for CHIP may be made manually by advisors processing renewal documents or automatically by the system.

For individuals required to return a renewal packet, advisors must process the manual renewal as explained in B-122.4.2, Processing a Manual Renewal, while following the timelines explained in D-1630, Timely Redeterminations, and D-1631, Redetermination Processing Time Frames. 

CHIP Perinatal

There is no redetermination of CHIP perinatal coverage. The household is mailed a packet during the ninth month of eligibility, allowing the household to apply for medical coverage for the child.

Revision 21-4; Effective October 1, 2021

CHIP

Renewal correspondence for people enrolled in CHIP is generated following the same process used for Children’s Medicaid.

CHIP Perinatal

A packet is mailed to the household after cutoff in the ninth month of coverage. This mailing occurs over a five-day period. The household is instructed to complete the application, attach verification and return within seven days from the date on the letter.

In the 10th month of the perinatal enrollment segment, TIERS determines if the case has both a CHIP and a CHIP perinatal Eligibility Determination Group (EDG). If the CHIP perinatal enrollment segment ends before the end of the CHIP enrollment segment, the perinatal child is added to the CHIP EDG if the child is not eligible for Medicaid.

Related Policy

Notice of Redetermination/Certification Expiration, B-121 

D—1621 Redetermination Reminder Notifications

Revision 15-4; Effective October 1, 2015

CHIP

Form H1014-A, Children’s Health Care Benefits – Final Reminder, is mailed to individuals who are required to return a signed renewal form as part of the administrative renewal process, as explained in B-122.4, Medical Program Administrative Renewals, and have not returned the packet. Form H1014-A is sent to individuals who have not responded by the first calendar day of the 11th month of coverage.

The letter reminds households that coverage will end if the completed redetermination form is not received.

Revision 15-4; Effective October 1, 2015

CHIP

A CHIP redetermination is considered received timely when received by cutoff of the 11th month of the certification period. This allows time for the enrollment process to be completed by the cutoff of the 12th month to avoid the client having a break in coverage.

 

D—1631 Redetermination Processing Time Frames

Revision 21-4; Effective October 1, 2021

CHIP

For households that are required to return a CHIP renewal form, process renewals received timely or untimely, by the 30th day from the date the renewal form is received, or by cutoff of the 11th month of the certification period, whichever is later.

When an acceptable Medical Program renewal form is not returned, the system automatically makes an eligibility determination through a mass update based on the eligibility outcome from the automated renewal process.

The automated renewal process does not require staff to run eligibility or dispose the EDG. Households receive a Form TF0001, Notice of Case Action, after cutoff in the 11th month. Children will continue to receive coverage until the end of their 12-month certification period.

Process renewal forms received after the date of denial following the policy for processing untimely redeterminations for TP 08, TP 43, TP 44, and TP 48.

Related Policy

Processing Untimely Redeterminations, B-124

 

D—1632 Changes Reported at Redetermination

Revision 13-4; Effective October 1, 2013

 

D—1632.1 New Head of Household

Revision 15-4; Effective October 1, 2015

CHIP

Accept a renewal form as valid when it is received reflecting a new head of household who is not someone with existing case authority.

Take the following action:

• accept the application and link it to the existing case,
• create a new case number for the household, and
• certify the new case to begin the month after the old case coverage ends.

 

D—1632.2 Health Insurance

Revision 15-4; Effective October 1, 2015

CHIP

When a household reports that it has acquired health insurance, determine if:

• The monthly premium amount for the child(ren) is less than 5 percent of the household’s net income; or
• The monthly premium amount for the family’s health insurance that includes the child(ren) is less than 9.5 percent of the household’s net income. 

If the health insurance coverage meets one of the scenarios above, deny the CHIP EDG.

If the health insurance coverage does not meet either of the scenarios above, the child(ren) is(are) still eligible for CHIP, but the household must drop the insurance in order to continue to receive CHIP. Send Form H1020, Request for Information or Action, to the household requesting proof of the insurance end date. If the household does not provide proof, the child(ren) is(are) no longer eligible for CHIP. Deny the CHIP EDG.

Acceptable verification of the private health insurance end date includes:

• health insurance identification card indicating the end date,
• letter from the employer indicating the end date, or
• individual's statement by phone or in writing.

Related Policy

Health Insurance, D-1210
Third Party Resources Changes, D-1437
Exceptions to Continuous Enrollment Period, D-1731

 

D—1633 Missing Information

Revision 15-4; Effective October 1, 2015

CHIP

During the automated renewal process, electronic data is used to automatically verify the following required verifications for CHIP:

• Income and expenses, and
• Immigration status.

Depending on the outcome of the automated renewal process, the system generates and sends renewal correspondence, including Form H1020, Request for Information or Action, if more information is needed, to individuals enrolled in CHIP following the process explained in B-121, Notice of Redetermination/Certification Expiration, for TP 08 and Children’s Medicaid (TP 43, TP 44 and TP 48).

All missing information must be received before cutoff of the 11th month of the coverage period to receive continuous coverage. If the missing information is received before cutoff of the child's 11th month of coverage, update the EDG with the new information. If the information is received after cutoff of the 11th month of coverage, there may be a break in CHIP coverage.

When a renewal is denied due to failure to provide information or verification, advisors follow the policy for TP 08, TP 43, TP 44 and TP 48 explained in B-122.3.2, Denied for Failure to Provide Information/Verification.

Households that complete the redetermination process (eligibility and enrollment) by cutoff in the 11th month of the eligibility period and remain eligible will be enrolled for a new 12-month period. If the individual fails to pay the enrollment fee by cutoff of the first month of the new 12-month period, the EDG is placed in a Pending Enrollment Fee and/or Plan Selection and/or TPR Delay status for up to three months. If the household pays the enrollment fee within the three months, the EDG is reinstated and the child(ren) receive the remainder of the 12-month enrollment segment beginning with the month of reinstatement.

 

D—1634 Redetermination Application Complete

Revision 13-4; Effective October 1, 2013

CHIP

Once the household completes the redetermination and is eligible for CHIP, health care coverage begins the first of the next possible month after the household pays the applicable enrollment fee.

Households that complete the redetermination process receive a Form TF0001, Notice of Case Action, indicating the potential outcome for each child. If an enrollment fee is due, the Enrollment Broker sends the household a payment coupon and return envelope. The enrollment fee due date is set to 10 calendar days.

 

D—1634.1 Missing Enrollment Fee

Revision 15-4; Effective October 1, 2015

CHIP

If a household completes the redetermination process, but does not pay the applicable enrollment fee by the cutoff date of the 12th month, the child receives a one-month extension of CHIP coverage. The Enrollment Broker mails the family a letter to inform the family of the one-month extension and the requirement to pay the enrollment fee by cutoff in the first month of the new 12-month period, in order to continue coverage. The extended month of coverage is counted as month one in the new 12-month enrollment segment.

The Enrollment Fee Extension (EFX) letter is mailed the first week of the first month of the new 12-month enrollment segment. The letter advises households that the household must pay the enrollment fee to continue the child(ren)'s coverage.

If the household:

• pays the enrollment fee by cutoff of the first month of its new 12-month period, then the child remains enrolled for the remainder of the 12-month period.
• does not pay the enrollment fee by cutoff of the first month of the new 12-month period, then the child is disenrolled. The EDG is placed in Pending Enrollment Fee and/or Plan Selection and/or TPR Delay status starting the second month, for a period of up to three months.

If the household pays the enrollment fee after the:

• cutoff of the first month in the new 12-month period, but before the cutoff of what would have been the second month, then the child is suspended for one month and reinstated the following month for the remainder of the 12-month enrollment segment.
• second month's cutoff and before the third month's cutoff, then the child is suspended for two months and reinstated the following month for the remainder of the 12-month enrollment segment.
• third month's cutoff and before the fourth month's cutoff, then the child is suspended for three months and reinstated the following month for the remainder of the 12-month enrollment segment.
• cutoff of the fourth month, the application is denied and the household must reapply.

Note: If the payment is returned with non-sufficient funds (NSF), an NSF letter is mailed to the household as if the household had not paid the enrollment fee, and the EDG is placed on Pending Enrollment Fee and/or Plan Selection and/or TPR Delay status the following month.

 

D—1635 Redetermination Applications Eligible for Medicaid

Revision 14-3; Effective July 1, 2014

CHIP

When processing a redetermination application, test the application for Medicaid eligibility. If a child in the CHIP household is eligible for Medicaid and the action is processed:

• before cutoff, CHIP coverage ends the last day of the current month. Medicaid coverage begins the first day of the next month.
• after cutoff, CHIP coverage ends the last day of the following month. Medicaid coverage begins the first day of the month following the next month.

Any children in the household who are ineligible for Medicaid remain on CHIP through the end of the current CHIP certification period. They are then certified with a new CHIP certification period if they continue to be eligible for CHIP.

A child who is eligible for Medicaid based on income, and who has reported that she is pregnant, is denied at the end of the next possible month and certified for Medicaid. If the pregnancy due date is later than the end date of her CHIP coverage month and she is not eligible for Medicaid, she continues on CHIP through the end of the current certification period. Certify her with a new certification period if she continues to be eligible for CHIP.

If the household no longer qualifies for CHIP, deny the CHIP EDG at the end of the CHIP certification period. Send the household Form TF0001, Notice of Case Action, notifying the household that the child is no longer eligible for CHIP.

Related Policy

Advisor Action for Determining Eligibility for Children, A-126.3

Revision 15-4; Effective October 1, 2015

CHIP, CHIP Perinatal

Once determined eligible for the Children’s Health Insurance Program (CHIP) or CHIP perinatal, households must complete the enrollment process in order to receive benefits. The enrollment process includes choosing a health and dental plan and paying an enrollment fee, if applicable.

CHIP

CHIP eligibility is prospective. TIERS provides the potential eligibility begin date and the Enrollment Broker provides the actual eligibility begin date.

The earliest a child can be eligible for CHIP is based on cutoff rules. When the Eligibility Determination Group (EDG) is disposed on or before the cutoff date, the potential eligibility begin date is the first of the month following the disposition month. When the EDG is disposed after cutoff, the potential eligibility begin date is the first of the second month following the disposition month.

Example 1 – Disposed on or before cutoff:

Disposed May 1, 2015; eligible June 1, 2015

Example 2 – Disposed after cutoff:

Disposed May 23, 2015; eligible July 1, 2015

 

D—1711 Expedited CHIP Enrollment

Revision 17-2; Effective April 1, 2017

Individuals who transfer during their non-continuous eligibility period to CHIP before their Medicaid certification period ends and who owe a CHIP enrollment fee may be eligible for expedited CHIP enrollment, with no gap in coverage if they are certified for one of the following Medicaid types of assistance:

• MA-Pregnant Women (TP 40);
• MA-Children Under 1 (TP 43);
• MA-Children 6-18 (TP 44); and
• MA-Children 1-5 (TP 48).

Individuals who meet the criteria may be enrolled in CHIP beginning the first of the month following their last month on Medicaid even when an enrollment fee is due but not yet paid.

The following case actions are eligible for expedited CHIP enrollment:

• Periodic Income Check (PIC) (except TP 40);
• change;
• appeal and reactivation due to change or PIC; and
• renewal processed by an advisor resulting in a shortened Medicaid certification period (except TP 40).

The following case actions are not eligible for expedited CHIP enrollment:

• application;
• appeal and reactivation due to reason other than change or PIC;
• retesting eligibility; and
• third party resources. 

If determined eligible for CHIP, the Enrollment Broker will send an enrollment packet to households with eligible members. The enrollment packet will indicate the enrollment fee and options for selecting a health and dental plan.

Expedited CHIP enrollment is only applicable when transferring from Medicaid to CHIP when an enrollment fee is owed to ensure health coverage is maintained with no gap in coverage. Once the enrollment fee is paid in full, the household follows normal CHIP policy and procedure. If the enrollment fee is not paid by the deadline, the household is disenrolled.

Households who do not owe an enrollment fee do not qualify for Expedited CHIP Enrollment and are enrolled in CHIP and defaulted into a plan following current policies and procedures and cutoff rules if a health and/or dental plan is not selected.

Related Policy

Medicaid Termination, A-825
Enrollment Fees at Application, D-1821
Expedited CHIP Enrollment Process, D-1720.1
Involuntary Disenrollment, D-1761
Denial at Redetermination, A-2342
Eligibility Transition from Medicaid to CHIP, B-123.4
Actions on Changes, B-631
Periodic Income Checks, B-637

Revision 20-4; Effective October 1, 2020

CHIP and CHIP Perinatal

The Enrollment Broker receives a daily enrollment request that consists of member information for the eligible members. The Enrollment Broker sends an enrollment packet or confirmation notice to households with eligible members within three business days of receipt of the eligibility information. The household completes the enrollment process by choosing a health plan and dental plan and by paying a fee, if applicable.

Once the enrollment process is complete, the household is mailed an enrollment confirmation letter confirming the child's enrollment start date.

Related Policy

Dental Providers, D-1751

D—1720.1 Enrollment Packets

Revision 17-2; Effective April 1, 2017

CHIP

Households eligible for expedited CHIP enrollment are enrolled in CHIP beginning the first of the month following their last month on Medicaid. This occurs even when a fee is due but not yet paid, with no gap in coverage. The household is given at least 90 days to pay the enrollment fee and remains enrolled pending payment of the enrollment fee.

For households determined eligible for expedited CHIP enrollment, the length of the expedited CHIP enrollment period depends upon when HHSC completes the action:

When action is processed during the  classification period ...	Length of Expedited CHIP Enrollment  period is ...
Before or on cutoff of the 5th month	Up to three months.
After cutoff of the 5th month Note: This includes changes completed in  the 6th, 7th, 8th, 9th, 10th, and 11th month.	Up to four months.

If the fee is not paid by the due date, all individuals in the household enrolled in CHIP are disenrolled. The household must reapply for benefits and would follow normal CHIP processing. In reapplying for benefits, the household would not be eligible for expedited CHIP enrollment.

If the fee is paid by the due date, all individuals in the household remain enrolled in CHIP and receive the remainder of the 12-month CHIP certification period. The months a household received CHIP coverage through expedited CHIP enrollment count towards the 12-month CHIP certification period.

Notes:

• The six-month continuous eligibility period of Medicaid is not impacted regardless of when HHSC completes the change.
• Households that transfer to CHIP and do not owe an enrollment fee follow current policies and procedures and are enrolled in CHIP and defaulted into a plan following cutoff rules. These households are not eligible for expedited enrollment.

Related Policy

Expedited CHIP Enrollment, D-1711 
Enrollment and Non-Sufficient Funds, D-1723.4 
Involuntary Disenrollment, D-1761

D—1721 Enrollment Packets

Revision 15-4; Effective October 1, 2015

CHIP, CHIP Perinatal

The enrollment packet includes a variety of information including a Welcome Letter, cost share requirement information, and health and dental plan choice information.

CHIP

Enrollment packets are mailed to all households. The enrollment packet includes the:

• enrollment/transfer form;
• enrollment return envelope;
• comparison chart of the value-added services provided by the health plans;
• explanation of CHIP benefits;
• Welcome Letter that includes –
  • cost sharing information, if applicable, specific to the income level of the household receiving the enrollment packet; and
  • cost share limit amount for households required to pay cost sharing. This amount is a percentage of the household's net income and reflects the maximum amount of health care expenses and cost sharing payments that a household is obligated to pay during a term of coverage.
• flier summarizing the importance of the health plan selection;
• CHIP member guide; and
• enrollment fee invoice and envelope, if applicable.

Households that are not required to pay an enrollment fee, or that paid the enrollment fee but did not select a health plan, are defaulted into the available health plan and sent an enrollment confirmation notice.

CHIP Perinatal

CHIP perinatal members are not subject to cost sharing. All members receive an enrollment packet. The enrollment packet includes the:

• enrollment/transfer form;
• enrollment return envelope;
• comparison chart of the value-added services provided by the health plans;
• explanation of benefits;
• flier summarizing the importance of the health plan selection; and
• CHIP perinatal member guide.

D—1722 Children with Special Health Care Needs

Revision 15-4; Effective October 1, 2015

CHIP

The enrollment packet includes a list of questions as determined by the Texas Health and Human Services Commission (HHSC) to identify Children with Special Health Care Needs (CSHCN).

Health plans evaluate and confirm whether a child meets the CSHCN criteria by contacting the self-identified families. If the plan determines the child does not meet the CSHCN criteria, the plan sends the CSHCN status determination to the Enrollment Broker.

The Enrollment Broker reports the number of CSHCN monthly.

D—1723 Selecting a Health Plan

Revision 19-1; Effective January 1, 2019

CHIP, CHIP Perinatal

Households can make a health plan selection by phone, online, or by submitting a completed Enrollment Transfer Form (ETF) by mail or fax. If making the selection by phone, the requirement for a signed enrollment form is waived.

Households that do not choose a health plan are automatically defaulted into a health plan. Families are notified that they have been defaulted and are given 90 days to choose a new health plan.

CHIP

People with case authority select the health plan for CHIP-eligible children. Households that fail to choose a health plan are defaulted into a health plan.

Information concerning CHIP health plans and the areas covered is available at Medicaid Medical and Dental Policies.

Upon completion of the enrollment process, the system triggers an Enrollment Confirmation Notice (ECN) that informs the household of each CHIP-eligible child's:

• unique identification number;
• enrollment start date;
• selected or assigned health plan;
• applicable copays; and
• cost share limit, if applicable.

The ECN includes a Medical Payments Form (MPF). The MPF helps the household track expenditures by date, event and amount. See D-1800, Cost Sharing.

If a child is subsequently added to a CHIP-enrolled case, the Enrollment Broker mails the household an ECN.

CHIP Perinatal

People with case authority select a health plan for CHIP perinatal eligible children. Households that do not select a health plan are defaulted into a health plan.

Information concerning CHIP perinatal health plans and the areas covered is available at 
CHIP Perinatal FAQs.

Upon completion of the enrollment process, the system triggers an ECN that includes the pregnant woman's:

• unique identification number;
• enrollment start date; and
• selected or assigned health plan.

Related Policy

Health Plan Change, D-1740

D—1723.1 Enrollment Reminder Notification

Revision 13-4; Effective October 1, 2013

CHIP

Fifteen calendar days after the enrollment packets are mailed, an enrollment reminder notification is mailed to households that fail to select a health plan and/or pay the enrollment fee.

If the household does not respond within 90 calendar days of mailing the enrollment packet and the household fails to pay any required enrollment fee, the EDG is denied and the household must submit a new application.

D—1723.2 Missing Information Processing for Enrollment Forms

Revision 15-4; Effective October 1, 2015

CHIP

Missing information for an enrollment form must be received within 90 calendar days of the date the Welcome Packet is mailed.

When all missing information is received before cutoff of the month before the member's enrollment start date (and within 90 calendar days of the date the Welcome Packet is mailed), the Enrollment Broker updates the enrollment information and the child's/children's enrollment start date is recalculated to the first day of the next possible month.

After 90 calendar days from the day the Welcome Packet is mailed, if the enrollment fee is not received, the Enrollment Broker sends an eligibility request to deny for non-payment. The denial letter informs the household that the enrollment missing information was not received or was received beyond the required period, and the household must submit a new application and reapply.

D—1723.3 Address Change While Pending Enrollment

Revision 15-4; Effective October 1, 2015

CHIP

At initial application, health plan changes are allowed when the household moves to a new coverage service area and enrollment is complete, but pending a future enrollment start date due to the 90-day waiting period or cutoff.

D—1723.4 Enrollment and Non-Sufficient Funds

Revision 17-2; Effective April 1, 2017

CHIP

Households with children in a pended status, determined to have paid the enrollment fee with non-sufficient funds (NSF), do not receive health care coverage until the enrollment fee is received and processed. The household must submit the enrollment fee in full so that the child(ren) can be moved to a CHIP-eligible status. Households have 90 calendar days to submit the enrollment fee. If the household's payment is received before the due date, the child(ren) is (are) enrolled, based on the scheduled coverage date or the first month thereafter, and receives a new enrollment segment of 12 months.

If a child has an active enrollment segment and the Enrollment Broker determines the enrollment fee as NSF, the child is disenrolled at the next possible month, and the household must submit payment via money order, cashier's check, or debit or credit card via YourTexasBenefits.com. Once the household submits an acceptable payment, the Enrollment Broker re-establishes the child's enrollment the next possible month and provides the remaining months of coverage.

The following chart shows NSF situations and the action taken by the Enrollment Broker in each situation.

If the enrollment fee is...	then the Enrollment Broker...
returned with NSF before cutoff of the first month of a new 12-month enrollment period,	disenrolls the child and places the case in suspension starting in the second month for a period of up to three months.
submitted by a replacement payment after the extension month cutoff but before renewal month four cutoff,	reopens the case in the following month for the remainder of the 12-month period.
returned with NSF before the extension month cutoff and no replacement payment is made by renewal month four cutoff (the end of the suspension period),	does not reopen the case. The household must submit a new application.
returned with NSF after the extension month cutoff and a replacement payment is made before renewal month two cutoff,	continues enrollment for the remainder of the 12-month period.
returned with NSF after the extension month cutoff and a replacement payment is received after renewal month two cutoff but before renewal month three cutoff,	disenrolls the child and suspends the case for one month. The case is reinstated for the remainder of the 12-month period (nine more months).
returned with NSF after the extension month cutoff and a replacement payment is received after renewal month three cutoff but before renewal month four cutoff,	disenrolls the child and suspends the case for two months. The case is reinstated for the remainder of the 12-month period (eight more months).
returned with NSF after the extension month cutoff and a replacement payment is not made before renewal month four cutoff,	does not reopen the case. The household must submit a new application.

Related Policy

Missing Enrollment Fee, D-1634.1

Expedited CHIP Enrollment

Households whose enrollment fee returns with NSF will be disenrolled and must reapply for benefits.

Related Policy

Expedited CHIP Enrollment, D-1711 
Expedited CHIP Enrollment Process, D-1720.1

D—1723.5 Coverage Start Dates

Revision 15-4; Effective October 1, 2015

CHIP

If the enrollment process is completed prior to cutoff, the coverage start date begins the first of the following month, unless the household is subject to the 90-day waiting period or has a future Medicaid end date.

If the enrollment process is completed after cutoff, the coverage start date begins the first of the second month following the disposition month, unless the household is subject to the 90-day waiting period or has a future Medicaid end date.

Example 1 – Enrollment completed on or before cutoff:

Enrollment completed May 1, 2015; coverage starts June 1, 2015

Example 2 – Enrollment completed after cutoff:

Enrollment completed May 23, 2015; coverage starts July 1, 2015

For children subject to the 90-day waiting period, the coverage start date is 90 days (three calendar months) after the last month in which the child was covered by a third-party health benefits plan, as long as the enrollment fee is paid.

The waiting period only applies to children who were covered by a third-party health benefits plan (private health insurance) at any time during the 90 days (three calendar months) before the date of application for CHIP. The good cause exemptions apply to children subject to the waiting period. See D-1723.6, Good Cause Exemptions for Children Subject to the 90-day Waiting Period.

CHIP Perinatal

The coverage start date begins the first day of the month in which eligibility is determined. When the child is born, the child begins coverage on the date of birth. The mother may receive two postpartum visits.

D—1723.5.1 Coverage Start Date for Adding a Child

Revision 15-4; Effective October 1, 2015

CHIP

The CHIP coverage start date is coordinated with the Medicaid end date, if applicable.

D—1723.6 Good Cause Exemptions for Children Subject to the 90-day Waiting Period

Revision 15-4; Effective October 1, 2015

CHIP

The waiting period for CHIP enrollment may be waived if the household claims one of the following good cause exemptions:

• A parent's insurance benefit under the Consolidated Omnibus Budget Reconciliation Act of 1984 (COBRA) is terminated;
• A change in a parent's marital status;
• The child is no longer covered by the Texas Employee Retirement System;
• Loss of CHIP eligibility from another state;
• Involuntary loss of insurance coverage;
• The employer stops offering health insurance coverage for dependents (or any coverage);
• A change in employment, including involuntary separation, resulting in the child’s loss of coverage (other than through full payment of the premium by the parent under COBRA);
• Loss of Medicaid coverage for any reason;
• Loss of coverage in any insurance affordability program, including Advanced Premium Tax Credits (APTCs), Cost Sharing Reductions (CSRs), Medicaid, and CHIP;
• The premium paid by the family for coverage of the child under the group health plan is more than 5 percent of the Modified Adjusted Gross Income (MAGI) household income;
• The premium that a family pays for the family’s coverage that includes the child is more than 9.5 percent of the MAGI household income;
• Death of a parent;
• The child has special health care needs;
• HHSC determines that good cause exists based on information provided by the applicant or information otherwise obtained by the agency; or
• HHSC Directive — other reasons for an exemption that have not yet been defined by HHSC.

An applicant may declare good cause at any point during the application processing or after eligibility is determined. An applicant may claim a good cause exemption as follows:

• On Form H1010, Texas Works Application for Assistance — Your Texas Benefits:
  • Addendum, Section 5 – Insurance Offered Through Your Job; and
  • Appendix A, Health Coverage From Jobs;
• On Form H1010-M, Applying for or Renewing Medicaid or CHIP?:
  • Addendum, Section 5 – Insurance Offered Through Your Job; and
  • Appendix A, Health Coverage From Jobs;
• On Form H1205, Texas Streamlined Application:
  • Step 5 – Your Family's Health Coverage; and
  • Appendix A, Health Coverage From Jobs;
• Online at YourTexasBenefits.com;
• By telephone; or
• In writing.

Staff must accept the client’s self-declaration of a good cause exemption to the CHIP 90-day waiting period, except as follows.

Staff must not grant the applicant or client a good cause exemption to the CHIP 90-day waiting period if:

• the applicant selects "other" as the reason the insurance from a job ended;
• the end date of the health insurance coverage from a job is left blank; or
• the cost of the insurance coverage from a job is left blank.

Children exempt from the 90-day waiting period whose households subsequently report a change that nullifies the exemption become subject to the 90-day waiting period. The child(ren)'s scheduled coverage date is determined from the date the eligibility determination is made.

CHIP Perinatal

There is no 90-day waiting period for CHIP perinatal. Good cause exemptions do not apply.

Note: A perinatal child whose coverage ends, and who has siblings currently enrolled in CHIP, meets good cause upon determination of CHIP eligibility. The system calculates the child's enrollment start date as the first day of the month following the perinatal end date. The child's CHIP end date is the end date of the existing CHIP enrollment segment.

D—1723.6.1 CHIP Good Cause and Account Transfers

Revision 15-4; Effective October 1, 2015

CHIP

If a client is determined eligible for CHIP but is subject to the 90-day waiting period, HHSC will transfer that individual’s account information to the Marketplace to be assessed for eligibility for other health care coverage programs. This allows the individual access to coverage during the 90-day waiting period and to avoid sanctions for failing to acquire health coverage.

 

Revision 15-4; Effective October 1, 2015

CHIP

Children are granted 12 months of continuous coverage. Note: Households with income above 185 percent of the Federal Poverty Income Limit (FPIL) are subject to the six-month income check. See D-1510, General Information.

CHIP Perinatal

CHIP perinatal recipients are granted 12 months of continuous enrollment from the first day of the eligibility determination month. The 12-month period includes the months of CHIP perinatal coverage before and subsequent to birth. When the child is born, if the household's income was above the income limit for TP 40, defined in C-131.1, Federal Poverty Income Limits (FPIL), the child's coverage begins on the date of birth. The pregnant woman's coverage ends on the last day of the month that the child is born. The child's enrollment ends at the end of the original 12-month segment.

The child receives full CHIP benefits from the date of birth through the end of the continuous perinatal enrollment segment. Subsequent to delivery, the mother of the perinatal child qualifies for two postpartum care visits.

If a household reports a change in household size or income that would otherwise impact the household's eligibility, there is no disruption to the child's active enrollment segment.

 

 

D—1731 Exceptions to the Continuous Enrollment Period

Revision 23-2; Effective April 1, 2023

CHIP

The following are exceptions to the period of continuous enrollment:

• a child who is determined eligible for coverage on a date after the beginning of coverage for at least one sibling;
• a 19-year-old child;
• a pregnant child eligible for Medicaid;
• child currently covered on Children's Medicaid;
• confirmation that the child remains on health insurance and the household did not drop the third-party resource (TPR) at application or redetermination;
• the household reports a change that makes the child eligible for Medicaid;
• the household submitted a request for review because the household failed to provide information requested during the six-month income check;
• the household did not submit a redetermination packet;
• confirmation that the child no longer lives in the state;
• the child or authorized representative (AR) requests voluntary disenrollment in writing; 
• a child becomes an inmate of a public institution.
• confirmation that eligibility was granted in error at the most recent determination or renewal of eligibility due to agency error or fraud, abuse, or perjury attributed to the child or AR;
• the child dies; or
• failure to pay required premiums or enrollment fees on behalf of a child.

Note: Households with income above 185 percent of the Federal Poverty Level (FPL) are subject to the six-month income check.

CHIP Perinatal

The following are exceptions to the period of continuous enrollment:

• current Medicaid coverage;
• confirmation of current health insurance coverage;
• confirmation that the woman or newborn no longer lives in the state;
• the AR requests disenrollment in writing;
• termination of pregnancy with no live birth;
• the birth is not reported by two months after the expected due date; or
• the mother was determined eligible after the birth month of the child.

Related Policy

Health Insurance, D-1210
Third Party Resources Changes, D-1437
General Information, D-1510 
Health Insurance, D-1632.2

 

 

D—1732 Pregnant Members Aging Out of CHIP

Revision 15-4; Effective October 1, 2015

CHIP

A pregnant CHIP member who ages out of CHIP before her expected due date and who is determined eligible for CHIP perinatal is enrolled in perinatal beginning the first day of the month following her CHIP end date.

Revision 15-4; Effective October 1, 2015

CHIP

Households are eligible to change health plans for any reason up to 90 calendar days after the enrollment start date. There is no limit to the number of times a household may change plans within that time frame. In addition, households may change health plans once per year at redetermination for any reason or during the child’s enrollment segment for specific reasons.

The household may request and complete a health plan transfer:

• by phone,
• in writing using the Enrollment/Transfer form submitted by fax or mailed to:

HHSC
PO Box 149023
Austin, TX 78714-9023

• by Interactive Voice Response (IVR), or
• online using YourTexasBenefits.com.

CHIP Perinatal

Households are eligible to change health plans for any reason up to 120 calendar days after the enrollment start date. There is no limit to the number of times a household may change plans within that time frame. Households may change health plans during the enrollment segment for specific reasons.

The household may request and complete a health plan transfer:

• by phone,
• in writing using the Enrollment/Transfer form submitted by fax or mailed to:

HHSC
PO Box 149023
Austin, TX 78714-9023

• by IVR, or
• online using YourTexasBenefits.com.

Related Policy

Plan Change During Current Enrollment Segment, D-1741

 

D—1741 Plan Change During Current Enrollment Segment

Revision 15-4; Effective October 1, 2015

CHIP, CHIP Perinatal

Following the first 90 days of CHIP enrollment or 120 days for CHIP perinatal, a household is allowed to change health plans during the child's enrollment segment if the household:

• permanently relocates to a different health maintenance organization service delivery area.
• permanently relocates to a different location within a service area and this relocation would necessitate a change in primary care provider.
• has good cause to request a plan change. A household's request to change health plans on the basis of good cause can be approved in limited situations, and HHSC determines the situations that constitute good cause.
• is unable to receive the service the member is seeking because the plan does not cover the service because of moral or religious objections.
• needs related services (for example, a cesarean section and a tubal ligation) to be performed at the same time; not all related services are available within the network; and the member's primary care provider or another provider determines that receiving the services separately would subject the member to unnecessary risk.
• has other reasons, including but not limited to, poor quality of care, lack of access to services covered under the contract, or lack of access to providers experienced in dealing with the member's health care needs.

A household may submit a request for a health plan change or disenrollment to the Enrollment Broker, who reviews and considers each request on an individual basis. If the household disagrees with the decision, the household may request a review. The household, health plan and Enrollment Broker receive notification from HHSC regarding disposition of the review.

 

D—1742 Plan Change at Redetermination

Revision 15-4; Effective October 1, 2015

Households can change health plans once per year during redetermination.

If the household’s request for a health plan change is received by the cutoff date of the last month of the child's certification period, the ECN letter is sent to inform the household of the new health plan selection.

For a household with health plan change information processed after the cutoff date of its last month of certification, a grace period extends to the cutoff date of the first month of the child's new certification period. The household's CHIP coverage continues under the original health plan through the end of the first month of the child's new certification period. Coverage under the new health plan begins the first day of the following month. The household is sent the Health Plan Transfer (HCC) letter informing the household of the new health plan selection.

Health plan change requests received by the Enrollment Broker as part of the redetermination process are applied to the new certification period and do not affect the current certification period, unless the requests are submitted due to a change of address or other good cause reason.

Once the health plan change form is received and processed, additional enrollment health plan changes are granted for address changes and other good cause reasons only.

 

D—1743 Redetermination Indicates a Change of Address

Revision 15-4; Effective October 1, 2015

CHIP

If the redetermination form indicates a household moved and now has different health plan options, a Health Plan Change (HPC) letter is mailed to the household and includes:

• a health plan change form;
• a comparison chart that includes a value-added service matrix;
• the health plan change/redetermination instruction letter; and
• a self-addressed stamped envelope.

The health plan change/redetermination instruction letter informs the household they may change health plans:

• by phone,
• in writing using the Enrollment/Transfer form submitted by fax or mailed to:

HHSC
PO Box 149023
Austin, TX 78714-9023

• by IVR, or
• online using YourTexasBenefits.com.

The Enrollment Broker must receive the completed health plan change form before enrolling a household in a new health plan. A household that moves to an area of choice remains with its current health plan until the Enrollment Broker receives the completed health plan change form or the health plan transfer is completed by phone. If the household reports the change of address online, the household is also able to make a health plan change online. If the household does not return its completed health plan change form by the cutoff of its last month of certification, the household is enrolled in the next available health plan using a default process. The household is sent the ECN informing the household of the new health plan selection.

The child is enrolled in the designated health plan during the next certification period.

Revision 18-4; Effective October 1, 2018

CHIP, CHIP Perinatal

All children enrolled in CHIP are eligible to receive dental benefits. Dental benefits include both therapeutic and preventive services. CHIP perinatal pregnant women do not receive dental benefits. However, upon birth, the newborn is eligible for dental benefits. The dental benefit is for a 12-month period that is the same as the child's 12-month enrollment period. Note: Children with private dental insurance still qualify for CHIP.

Households are required to pay copayments for dental services. Assess dental office visit copays at the office visit copay rate. The applicable copayment requirements are:

Coverage Description	At or below 151% FPIL	Above 151% up to and including 186% FPIL	Above 186% up to and including 201% FPIL
Office visit	$5	$20	$25
Non-emergency ER visit	$5	$75	$75
Generic prescription	$0	$10	$10
Name-brand prescription	$5	$35	$35
Inpatient hospital care (per admission)	$35	$75	$125

 

D—1751 Dental Providers

Revision 15-4; Effective October 1, 2015

CHIP, CHIP Perinatal

DentaQuest and Managed Care of North America (MCNA) Dental are the dental managed care organizations (DMOs) for dental benefits. Eligible CHIP households receive an enrollment packet that provides information on the DMOs available in their area and how to choose a dental plan. The packet contains plan comparison charts, an enrollment form and a business reply envelope. A 30-day reminder letter is sent to households that have not made a dental plan selection. CHIP households make a dental plan selection through the following options:

• by phone,
• in writing using the Enrollment/Transfer form submitted by fax or mailed to:

HHSC
PO Box 149023
Austin, TX 78714-9023

• by IVR, or
• online using YourTexasBenefits.com.

Related Policy

Enrollment Process, D-1720

Revision 15-4; Effective October 1, 2015

CHIP, CHIP Perinatal

The applicant or someone with case authority may request disenrollment at any time. Disenrollment requests received and processed before the current month’s cutoff are effective at the end of the current month unless the applicant requests a specific date. Disenrollment requests received after cutoff of the current month are effective the next possible month. When the request is due to death, the member is disenrolled effective the last day of the month the member died.

Upon completion of processing the disenrollment request, Form TF0001, Notice of Case Action, is sent to the household. Form TF0001 informs the household of the reason the member’s coverage is ending.

Once eligibility has been terminated, members will be disenrolled.

Regardless of the disenrollment reason or month, if a member has received at least one month of CHIP coverage, the household is not eligible for a refund of the enrollment fee.

 

D—1761 Involuntary Disenrollment

Revision 17-2; Effective April 1, 2017

CHIP

Verbal notification is sufficient to generate an involuntary disenrollment for a CHIP-enrolled child. Reasons for involuntary disenrollment include:

• aging out when the child turns age 19;
• the household moves out of state;
• the death of a child;
• a child is certified for Medicaid;
• notification of pregnancy;
• if a household is eligible for expedited CHIP enrollment while owing an enrollment fee and does not pay the fee by the due date;
• self-disclosure of the child's non-lawful permanent resident, non-qualified alien or non-U.S. citizen status; and
• direction by HHSC based on evidence that the child's original eligibility determination was incorrect.

CHIP Perinatal

Verbal notification is sufficient to generate an involuntary disenrollment for women enrolled in CHIP perinatal. Reasons for involuntary disenrollment include:

• the pregnant woman is enrolled in Medicaid;
• a household submits a new application and specifically requests Medicaid in writing once the perinatal child is born;
• the confirmation is received that the pregnant woman has private health insurance;
• the woman is disenrolled on the last day of the month in which the pregnancy terminates without a live birth, and the EDG is denied;
• no birth is reported by two months after the expected due date;
• a child with special needs (who requires neonatal intensive care) is retroactively disenrolled back to the child's date of birth; and
• a household moves out of state.

 

D—1762 Health Plan Request to Disenroll a Member

Revision 15-4; Effective October 1, 2015

CHIP, CHIP Perinatal

Based on Texas Department of Insurance guidelines, a limited number of situations exist when a health plan may request the disenrollment of a member from its plan.

The situations in which a health plan may request the disenrollment of a member are limited to one or more of the following:

• fraud or intentional material misrepresentation (coverage may be cancelled after not less than 15 days written notice from the Enrollment Broker to the member).
• fraud in the use of services or facilities (coverage may be cancelled after not less than 15 days written notice from the Enrollment Broker to the member).
• misconduct detrimental to safe plan operations and the delivery of services (coverage may be cancelled by the Enrollment Broker immediately).
• failure of the enrollee and a plan physician to establish a satisfactory patient/physician relationship if it is shown that the plan has, in good faith, provided the enrollee with the opportunity to select an alternative plan physician. The enrollee is notified in writing that the plan considers the patient/physician relationship to be unsatisfactory and specifies the changes that are necessary in order to avoid disenrollment, and the enrollee has failed to make such changes (coverage may be cancelled 30 days following written notice from the Enrollment Broker to the member).

The Enrollment Broker has the option of enrolling the member in another health plan and notifies the second plan of the reason for disenrollment from the first.

Revision 18-4; Effective October 1, 2018

CHIP

There are two types of cost share obligations – enrollment fees and copayments. Most CHIP eligible households are subject to cost share obligations. Exceptions:

• households with gross income at or below 151% of the Federal Poverty Income Limit (FPIL) are not subject to an enrollment fee;
• American Indians and Alaska Natives are exempt from all cost sharing. American Indian or Alaska Native status is self-declared on the application. If one child within the household is an American Indian or Alaska Native, the entire household application has American Indian or Alaska Native status; and
• unaccompanied refugee minors are exempt from all cost sharing.

Cost sharing is processed by the Enrollment Broker.

CHIP Perinatal

CHIP perinatal recipients are not subject to cost share obligations. Perinatal recipients do not pay enrollment fees or copayments.

Revision 18-4; Effective October 1, 2018

CHIP

The enrollment broker assesses an enrollment fee before initial enrollment and at redetermination. The enrollment fee is money submitted by a family for CHIP coverage to the enrollment broker. The enrollment broker bases the amount of the enrollment fee on the household’s FPIL. It covers the continuous enrollment period. The enrollment broker assesses all enrollment fee requirements on a per-household basis, not on a per-child basis.

Enrollment fees are:

• $0 for households with net income at or below 151% FPIL;
• $35 for households with net income above 151% up to and including 186% FPIL; and
• $50 for households with net income above 186% up to and including 201% FPIL.

Related Policy

General Information, D-1810

 

D—1821 Enrollment Fees at Application

Revision 17-2; Effective April 1, 2017

CHIP

Eligible children cannot enroll and receive covered benefits before receipt of the enrollment fee.

Exception: Children determined eligible for expedited CHIP enrollment can enroll and receive covered benefits before receipt of the enrollment fee. See D-1711, Expedited CHIP Enrollment.

 

D—1821.1 Change During the Enrollment Process

Revision 13-4; Effective October 1, 2013

CHIP

If during the enrollment process, a reported change alters the cost share obligation, the child or children begin health care coverage based on the payment requirement of the current eligibility determination. The household is charged or credited the difference and a letter is sent to the household explaining the change.

 

D—1822 Enrollment Fees at Redetermination

Revision 13-4; Effective October 1, 2013

CHIP

Households must pay the enrollment fee at redetermination before continuing coverage.

 

D—1822.1 Request for Review and Continued Benefits

Revision 19-4; Effective October 1, 2019

CHIP

If the household is denied at redetermination due to income and requests a review and continued enrollment coverage before the stated deadline, the child continues to receive CHIP and the enrollment fee is waived until the request for review staff complete the eligibility review. If the request for review staff determine the household is eligible for CHIP, the Enrollment Broker will send the household an enrollment packet to request the applicable enrollment fees.

Related Policy

Enrollment Fees, D-1820
Request for Review. D-1920

 

D—1823 Enrollment Fee Payment Processing

Revision 13-4; Effective October 1, 2013

CHIP

Enrollment fee payments can be submitted in one of the following ways.

Method of Payment at Initial Enrollment:

• money order,
• personal check (not valid if original payment is non-sufficient funds),
• cashier's check, or
• credit card via www.yourtexasbenefits.com.

Method of Payment at Redetermination:

• money order,
• personal check,
• cashier's check, or
• credit card via www.yourtexasbenefits.com.

Payment for enrollment must be received and processed before cutoff prior to the last month of current CHIP certification.

The vendor receives all payments made to the program via money order, personal check or cashier's check. The vendor scans images and processes the payments. If the household mistakenly sends the payment to the Document Processing Center (DPC), the DPC logs the receipt of the payment and forwards the payment to the vendor for normal processing.

Enrollment fees submitted via www.yourtexasbenefits.com are charged a $2 non-refundable convenience fee. The household is mailed an electronic receipt.

 

D—1824 Refunds

Revision 13-4; Effective October 1, 2013

CHIP

Households that overpay the enrollment fee can request a refund. In addition, refunds are sent to households that submit the enrollment fee, but are never enrolled or have credit balances due at the time of disenrollment from the program. Note: Households enrolled in CHIP are not eligible for a refund if the household received at least one month of CHIP coverage and was required to pay an enrollment fee.

The Enrollment Broker issues a refund in Form of an individual check to the household, regardless of how the household made the payment. If the household pays by credit card, the $2 convenience fee is not refunded. Undeliverable refund checks are returned and voided. The vendor annotates the CHIP case and makes the necessary adjustment to the case to reflect the returned and voided refund. Once a refund is voided and processed, households may request reissuance of a voided refund. The vendor confirms the correct address with the individual before reissuing the previously voided refund.

Revision 18-4; Effective October 1, 2018

CHIP

Households are required to pay copayments for medical services or prescription drugs at the time of the service. The applicable copayment requirements are:

Coverage Description	At or below 151% FPIL	Above 151% up to and including 186% FPIL	Above 186% up to and including 201% FPIL
Preventative health care and shots	$0	$0	$0
Non-emergency ER visit	$5	$75	$75
Generic prescription	$0	$10	$10
Name-brand prescription	$5	$35	$35
Inpatient hospital care (per admission)	$35	$75	$125
Outpatient hospital care	$0	$0	$0
Other doctor visits	$5	$20	$25

Revision 18-4; Effective October 1, 2018

CHIP

The cost-sharing cap is the maximum amount of out-of-pocket expenses a household is required to pay during the certification period. When a household reaches its cost-sharing cap during the certification period, the household is not required to make copayments for the remainder of the certification period. Households are assigned a cost-sharing cap and a reporting threshold at application and at each redetermination. The reporting threshold is the amount in expenditures the household must report to the enrollment broker. The threshold is a cushion to ensure additional cost-sharing expenditures are not made during the period the enrollment broker and the health plan process the documentation.

The cost-sharing cap amount and reporting threshold are based on the household’s net income as it relates to the FPIL amount.

The cost-sharing cap is 5.0% of the total net income for the term of coverage. The reporting threshold is 4.75%.

The household is informed of the reporting threshold and sent a medical payments form (MPF) with the welcome letter and enrollment packet. The MPF helps the family track medical expenditures by type, date and amount.

 

D—1841 Cost Sharing Processing

Revision 20-4; Effective October 1, 2020

CHIP

The household must complete and submit the MPF to report that it meets the cost sharing cap.

When the MPF is submitted, the Enrollment Broker reviews the types of expenses listed on Form. The household is not required to provide receipts. Valid medical expenses include:

• enrollment fees, if applicable;
• office visit copayments;
• prescription medicines;
• emergency room visits;
• inpatient or outpatient hospital care; and
• out-of-pocket expenses, such as dental or vision.

The Enrollment Broker reviews the amounts and dates of the expenses to ensure that the household incurred the expenses during the current certification period.

If the household meets the cost sharing cap, a Cost Share Met (CSM) letter is sent to inform the household that it is exempt from copayments for the remainder of the current certification period. The Enrollment Broker notifies the affected health plan within two business days. The health plan is responsible for issuing a new identification card reflecting the absence of copayments.

If the household does not meet the cost sharing cap, the Enrollment Broker triggers a Cost Share Not Met (CSN) letter to inform the household that the cost sharing limit was not met. The following situations may cause the household not to meet the cost sharing cap:

• invalid expenses;
• expenses incurred outside the current certification period;
• valid expenses, but the dates and amounts are blank; or
• the total amount listed on the form is less that the cost sharing cap/threshold.

The CSN includes the cost sharing limit and the total amount of valid expenses submitted. An MPF is included with the CSN.

 

D—1842 Cost Sharing Re-Evaluation

Revision 13-4; Effective October 1, 2013

CHIP

The household’s cost sharing is re-evaluated at redetermination and the six-month income check.

For children who are currently enrolled, the Enrollment Broker does not use new income for eligibility determination.

The Enrollment Broker determines if all information is present to complete the evaluation at the six-month income check. If the income verification is not received and the reported income:

• increases, the Enrollment Broker recalculates the cost sharing for the household. A Cost Sharing Recalculation (CSC) letter is sent to inform the household that the change was complete and provides the household with the new cost sharing amount.
• decreases, a cost sharing re-evaluation is not processed. The Enrollment Broker sends a CSC No Change letter to inform the household that there is no change to the family’s cost sharing obligation.

When no information is missing, the Enrollment Broker uses the new income reported during the six-month income check to determine if there has been a change in the household’s cost sharing amount.

Revision 16-2; Effective April 1, 2016

CHIP, CHIP Perinatal

Households may call 2-1-1 to report complaints regarding:

• a delay in processing a CHIP application,
• rude treatment by customer service staff,
• a gap in coverage after Medicaid denial, or
• the income used to determine the household's enrollment fee.

To report a delay in the CHIP enrollment process or complaints regarding plan selection, cost sharing and/or amount of the enrollment fee, households may contact the Enrollment Broker at 1-800-964-2777.

If a household is not satisfied with the response it received, the household must submit the issues in writing to:

Health and Human Services Commission
Attention: Complaint Department
P.O. Box 149027
Austin, TX 78714-9027

Revision 20-4; Effective October 1, 2020

CHIP and CHIP Perinatal

A request for review (RFR) is any expression of dissatisfaction with an adverse action taken by HHSC.

Following an adverse action taken on a CHIP EDG, HHSC sends a disenrollment or denial letter to the family. The letter informs the CHIP household of its right to request a review.

Households have 30 business days from the date of Form TF0001, Notice of Case Action, to submit a written request for review concerning the decision that resulted in an adverse action. Households can submit the written request for review by:

• faxing the request to 866-559-9628; or
• mailing the request to:
  • Texas Health and Human Services Commission
    P.O. Box 149027
    Austin, TX 78714-9027

The request must come from the head of household or authorized representative or the child’s provider or health plan (for expedited situations). If the child's physician or health plan determines that a suspension or termination of enrollment could seriously jeopardize the child's life, health or the ability to attain, maintain or regain maximum function, the household is entitled to an expedited review process. When disenrolled at the six-month income check, the household has 30 business days from the date of Form TF0001 to submit a request for review.

Allow continued enrollment for all people when HHSC receives the request for review anytime from the first day of the last benefit month through cutoff of the last benefit month.

Exception: A household is not eligible for continued enrollment if the household was denied for failure to provide information requested during a six-month income check.

Related Policy

Six-Month Income Check, D-1500
Exceptions to the Continuous Enrollment Period, D-1731

 

D—1921 Request for Review Processing

Revision 20-4; Effective October 1, 2020

CHIP and CHIP Perinatal

If any member of a household or the household's representative expresses dissatisfaction with a decision regarding benefits or services, take the following action:

• explain the basis for the decision and the applicable policies;
• provide the household an opportunity to have a conference with the supervisor;
• provide the household an opportunity to request a review; and
• consult with the supervisor if the person requests information considered confidential.

Note: The member is entitled to any information used to determine suspension, reduction or termination of benefits. See B-1210, Disclosure of Information, for information considered confidential.

Upon receipt of the request for review, review the adverse action and send Form H1063, Request for Review Outcome Letter, within 10 business days from the date of receipt of the request. The response letter contains information addressing the answer to the request for review. Document the final decision.

When the request for review is received, validate that the person requesting the review has case authority.

• If a person with case authority requests the review in writing, request-for-review staff review all case information and supporting evidence that the household provides. Make a determination and send Form H1063 informing the household of the decision.
• If the person requesting the review does not have case authority, deny the request and send Form H1063 to inform the household of the request for review denial.

Review all case information and supporting evidence the household provides. If the case was processed accurately, deny the request for review. Send Form H1063 to inform the household of the request for review outcome.

If the EDG was not processed accurately or the person submitted additional information with the request for review that changes the eligibility outcome, approve the request for review and take the necessary action to re-establish eligibility or enrollment. Send Form H1063 and Form TF0001, Notice of Case Action, to inform the household of its eligibility.

When the request for review is approved and the reason for the request is related to a disenrollment decision, review the child's current status to determine if the child is currently enrolled. If the child is:

• currently enrolled, advise the Enrollment Broker to cancel the disenrollment for the future month to ensure the child's enrollment continues through the end of the current enrollment period and generate Form H1063. In addition, the Enrollment Broker will send an Enrollment Confirmation Notice.
• not enrolled due to renewal period ending adversely, request-for-review staff process the CHIP eligibility and send Form H1063 and Form TF0001 to inform the household of CHIP eligibility. The Enrollment Broker re-enrolls the child for another 12-month period and once enrollment is re-established, the Enrollment Broker will send an Enrollment Confirmation Notice.

When HHSC receives a request for review after 30 business days from the date of Form TF0001 or determines that the request for review is not for an adverse action, deny the request and generate Form H1063 to inform the household of the denial reason.

Revision 13-4; Effective October 1, 2013

CHIP, CHIP Perinatal

Eligibility Determination Group (EDG) information may be released to individuals who have case authority.

A CHIP or CHIP perinatal household member may give verbal permission to discuss their case with a third party. Staff must authenticate the CHIP or CHIP perinatal household member before discussing the case with a third party.

Limited information may be released to contracted organizations, providers and their contractors, public officials and other state agencies. Reasonable efforts must be made to limit the use, request or disclosure of individually identifiable health information to the minimum necessary to determine eligibility and operate the program. The disclosure of individual medical information from agency records must be limited to the minimum necessary to accomplish the requested disclosure.

It is acceptable to release the following general denial or disenrollment reasons.

• Failure to provide missing Information
• Voluntary withdrawal

It is unacceptable to provide specific EDG details, such as the specific reason for denial (excess assets, excess income).

 

D—2011 Community Based Organizations

Revision 13-4; Effective October 1, 2013

CHIP, CHIP Perinatal

Limited information may be released to contracted or sub-contracted community-based organization (CBO) representatives. The CBO representative must provide the CBO identification number in order to receive EDG information. In addition, the CBO representative must provide the:

• name of the head of household,
• address, and
• child's Social Security number (SSN).

Staff may then release the following CHIP EDG information to the CBO:

• status of the application or EDG (denied, disenrolled, enrolled, missing information),
• missing information on an EDG (types of information needed to complete eligibility determination),
• enrollment coverage dates (start and end dates), and
• enrollment fee amount.

Do not release specific EDG details, such as:

• the reason for denial,
• sources or amounts of income,
• types of assets,
• household size, and
• citizenship/alien status.

 

D—2012 Providers and Health Plans

Revision 13-4; Effective October 1, 2013

CHIP, CHIP Perinatal

Limited information may be released to providers and health plans. Health care providers must give their provider identification number. If a provider participates with more than one CHIP health plan, the provider may have multiple identification numbers. Accept and document any identification number the provider gives.

The provider or health plan must confirm the:

• name of the head of household,
• address, and
• child's Social Security number (SSN).

Staff may then release the following EDG information to the provider or health plan:

• status of the application or EDG (denied, disenrolled, enrolled, missing information);
• missing information on an EDG (types of information needed to complete eligibility determination);
• enrollment coverage dates (start and end dates); and
• other EDG information as requested (enrollment fee, cost share limit, copayments).

 

D—2013 Federal and State Executive and Legislative Officials

Revision 13-4; Effective October 1, 2013

CHIP, CHIP Perinatal

Limited information may be released to federal and state executive and legislative branch members and their staff. Managers and supervisors may release to State of Texas legislators and legislative staff members the following information:

• Case or EDG eligibility status
• Missing information on an application or EDG
• Enrollment coverage dates
• Enrollment status
• Enrollment fee amount

 

D—2014 Teacher Retirement System (TRS)

Revision 13-4; Effective October 1, 2013

CHIP, CHIP Perinatal

Limited information may be released to TRS representatives. In order to obtain any EDG information, the representative must provide the assigned TRS personal identification number and any of the following CHIP EDG information:

• Case or EDG number
• Name of the person with case authority
• Home telephone number
• Child's name
• Child's Social Security number

Staff may then release the following EDG information to the TRS representative:

• status of the application or EDG (denied, disenrolled, enrolled, missing information);
• missing information on a EDG (types of information needed to complete eligibility determination);
• enrollment coverage dates (start and end dates); and
• other EDG information as requested (enrollment fee, cost share limit, copayments).

Revision 13-4; Effective October 1, 2013

CHIP, CHIP Perinatal

Policies and procedures have been established for the secure communication of Protected Health Information (PHI) or confidential information to ensure employees do not use or share any PHI in violation of HIPAA laws and standards. Unauthorized disclosure of PHI is grounds for disciplinary action.

When sharing information is appropriate, HIPAA allows staff to speak to the individual or others with case authority about PHI.

Calls received by the Customer Care Center staff are recorded, which safeguards PHI. These records keep track of who has accessed a recipient's information. Requests from recipients for copies of their records, corrections to mistakes in records and information pertaining to who has accessed the records are forwarded to HHSC.

Revision 13-4; Effective October 1, 2013

CHIP, CHIP Perinatal

Advance Notice — A notice of adverse action that expires 13 days after it is sent, with the exception of a six-month income check. Households denied at a six-month income check are given a 30-day advance notice of adverse action.

Adverse Action — An action resulting in denial or termination of assistance.

Applicant — An individual who submits an application to apply for assistance.

Case Authority — An individual who has the authority to act on behalf of the child. Examples include parents who live with the child, grandparents who live with the child, spouse, independent child, payee or authorized representative.

Children's Insurance — Includes Children’s Medicaid and Children's Health Insurance Program (CHIP).

Community Based Organization (CBO) — Organization providing assistance to an applicant applying for and enrolling in state-funded programs by aiding in the application process and seeking answers to case inquiries.

Disenrollment — The process by which a child's CHIP coverage is removed.

Enrollment — The process by which a child's CHIP coverage begins.

Enrollment Broker – Entity that enrolls an eligible child into CHIP or an eligible pregnant woman into CHIP perinatal once health and dental plan selections have been made and any required enrollment fees have been paid.

Enrollment Missing Information — Required information needed to complete the enrollment process that includes choosing a health plan and paying an enrollment fee.

Net Income — Gross income less the allowable child care deduction.

Perinate — An individual from the period of conception to birth. The unborn child.

Plan Partners — Organizations contracted through HHSC to provide health, dental or vision care services to CHIP enrolled children.

Request for Review — A written expression of dissatisfaction of an adverse action taken on a CHIP case. CHIP recipients are not allowed fair hearings.