Revision 18-4; Effective October 1, 2018

 

 

D—1810 General Information

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.

 

D—1820 Enrollment Fees

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 13-4; Effective October 1, 2013

 

CHIP

If the redetermination is denied due to income and the household requests a review and continued enrollment coverage in a timely manner, the enrollment fee is waived until the request for review staff reviews the eligibility. If the household is determined eligible for CHIP, the Enrollment Broker will send the household an enrollment packet to request the enrollment fees. See D-1920, Request for Review.

 

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:

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.

 

D—1830 Copayment Requirements

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

 

D—1840 Cost Sharing Cap Amounts

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 13-4; Effective October 1, 2013

 

CHIP

The household must complete and submit the MPF to report that they meet 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 family 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.