Revision 15-4; Effective October 1, 2015

 

 

D—1210 Health Insurance

Revision 15-4; Effective October 1, 2015

 

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, as explained in D-1723.6, Good Cause Exemptions for Children 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, as explained in D-1723.6.

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 individuals, the affected individual 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 individual's statement by phone or in writing.

At any time during the child's enrollment segment, 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.

Related Policy
Third Party Resources Changes, D-1437
Health Insurance, D-1632.2
Exceptions to the Continuous Enrollment Period, D-1731

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
Third Party Resources Changes, D-1437
Exceptions to the Continuous Enrollment Period, D-1731