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.