Revision 18-1; Effective January 1, 2018

 

 

D—1910 CHIP Complaint Process

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

 

D—1920 Request for Review

Revision 18-1; Effective January 1, 2018

 

CHIP, CHIP Perinatal

A request for review is any expression of dissatisfaction with an adverse action. HHSC defines “adverse action” as denial of eligibility, an untimely eligibility determination or termination of enrollment. Following an adverse action taken on a CHIP Eligibility Determination Group (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 request for review concerning the decision that resulted in an adverse action. Households can either submit the request for review in writing or fax the written request. To submit in writing send to:

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

Fax the written request for review to 866-559-9628.

The request must come from a person with case authority, 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 child’s 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 buisness days from the date of Form TF0001 to submit a request for review.

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

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

 

D—1921 Request for Review Processing

Revision 18-1; Effective January 1, 2018

 

CHIP, CHIP Perinatal

If any member of a household or the household's representative expresses dissatisfaction with a decision regarding benefits or services, the advisor takes 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;
  • consult with the supervisor if the individual requests information the advisor considers 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, HHSC reviews the adverse action and sends the household 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. HHSC staff document the final decision.

When the request for review is received, HHSC validates that the individual requesting the review has case authority.

  • If someone with case authority requests the review in writing, HHSC request for review staff review all case information and supporting evidence that the household provides. HHSC staff make a determination and send Form H1063 informing the household of the decision.
  • If the person requesting the review does not have case authority, the request is denied and Form H1063 is sent to the household informing it of the request for review denial.

HHSC staff review all case information and supporting evidence the household provides. If HHSC determines the case was processed accurately, the request for review is denied. Form H1063 is sent informing the household of the request for review outcome.

If the EDG was not processed accurately, or the applicant submitted additional information with the request for review that changes the eligibility outcome, the request for review is approved and staff takes the necessary action to re-establish eligibility and/or enrollment. The household is sent Form H1063 and Form TF0001 informing the household of its eligibility.

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

  • currently enrolled, HHSC tells 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 generates Form H1063. In addition, the household receives an Enrollment Confirmation Notice from the Enrollment Broker.
  • not enrolled due to renewal period ending adversely, request for review staff process the CHIP eligibility and send Form H1063 and Form TF0001 informing the household of CHIP eligibility. The Enrollment Broker re-enrolls the child for another 12-month period and once enrollment is re-established, the household receives 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, HHSC denies the request and generates Form H1063 that informs the household of the denial reason.