Revision 17-2; Effective April 1, 2017

 

D—1710 General Information

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

 

D—1720 Enrollment Process

Revision 15-4; Effective October 1, 2015

 

CHIP, CHIP Perinatal

The Enrollment Broker receives an enrollment request that consists of member information for the eligible members on a daily basis. 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 15-4; Effective October 1, 2015

 

CHIP, CHIP Perinatal

Households can make a health plan selection by telephone, online, or by submitting a completed Enrollment Transfer Form (ETF) by mail or fax. If the selection is made by telephone, 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

Individuals 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 yourtexasbenefits.hhsc.texas.gov/programs/health/child/childrens-medicaid.

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

Individuals 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 www.hhsc.state.tx.us/chip/perinatal/CHIPPerinatalHMOsbyServiceArea.pdf.

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.

 

D—1730 Continuous Enrollment Period

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 17-2; Effective April 1, 2017

 

CHIP

The following are exceptions to the period of continuous enrollment:

  • a child who is determined eligible for coverage on a date subsequent to the beginning of coverage for at least one sibling;
  • a child age 19;
  • a pregnant child who is eligible for Medicaid;
  • current Children's Medicaid coverage;
  • confirmation that the child remains on health insurance (the household did not drop the third-party resource [TPR] at application or redetermination);
  • the household submits a new application and the child is 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 case authority requests disenrollment in writing; or
  • a child becomes an inmate of a public institution.

Note: Households with income above 185 percent of the FPIL are subject to the six-month income check. See D-1510, General Information.

 

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 case authority 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
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.

 

D—1740 Health Plan Change

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

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

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

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.

 

D—1750 Dental Benefits

Revision 15-4; Effective October 1, 2015

 

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. Dental office visit copays are assessed at the office visit copay rate. The applicable copayment requirements are:

Coverage Description

Up to 151% FPIL

Greater than (>) 151% to (<=) 186% FPIL

Greater Than (>) 186% to (<=) 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

Related Policy
Enrollment Process, D-1720

 

D—1760 Disenrollment

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.