Revision 15-4; Effective: October 1, 2015
CHIP, CHIP Perinatal
The Enrollment Broker must ensure that individual correspondence is clear, concise and has been approved by the Texas Health and Human Services Commission (HHSC).
|Charge Back Letter
|Sent to notify an individual that the individual’s credit card was charged more than once for the enrollment fees and that the individual will need to contact the credit card company or bank to get a refund.
|Cost Share Recalculation
|Sent when a household submits new income information and its cost share is re-evaluated.
|Cost Share Met
|Sent to notify an applicant that the cost share has been met.
|Cost Share Not Met
|Sent to notify a household that the cost share has not been met.
|Dental Enrollment Transfer Form
|Captures dental plan selections.
|Sent to remind the applicant that the enrollment form and/or enrollment fee has not been received.
|Enrollment Confirmation Notice
|Sent to confirm enrollment for new enrollees and at redetermination. It also informs the applicant of their cost share amount.
|Enrollment Fee Extension Letter
|Sent to households who have completed their Children’s Health Insurance Program (CHIP) redetermination process completely by cutoff of the 12th month of their current coverage, but who have not paid the enrollment fee. The letter tells the household they have until cutoff of their first month of new coverage to pay this fee.
|Enrollment Missing Information
|Sent to notify the applicant that the enrollment form was either missing, incomplete or was received without the entire enrollment fee amount due.
|Sent with the new enrollment packet. The child is pending eligibility for enrollment and enrollment fee, if not entered.
|Enrollment Transfer Form
|Captures health plan and primary care physician (PCP) selections along with special health care needs.
|Form Request – Enrollment Transfer Form (medical and dental)
|Sent when an individual requests a new ETF and/or DTF.
|Form Request – Medical Payment Form (blank)
|Sent when an individual requests a blank Medical Payments Form (MPF).
|Form Request – Medical Payment Coupon
|Sent when an individual requests a new Payment Coupon (MPC).
|Form Request – Medical Payment Form (prepopulated)
|Sent when an individual requests a new prepopulated MPF.
|Form Request – All Forms (ETF, DTF, MPC, Blank MPC)
|Sent when an individual requests a new copy of any combination of ETF, DTF, MPC, prepopulated MPF and/or blank MPF.
|Health Plan Transfer Letter
|Sent to notify the applicant of the completion of either a forced or requested plan transfer.
|Health/Dental Plan Transfer Approval Letter
|Sent to notify the applicant of the individual's authorization to make a plan transfer.
|Health Plan Change Denial Letter
|Sent to notify the applicant that the individual's transfer request was denied.
|Last Payment Due Reminder Letter
|Sent to inform the applicant their enrollment fee has not been received, and the final day it can be paid
|Coupon requesting that the household pay its enrollment fee.
|Medical Payments Form
|Used by the individual to track all copay cost sharing so that the individual can report it.
|Sent to notify an individual that a payment was returned for non-sufficient funds. The letter instructs the individual on how to make a new payment.
|Payment History Letter
|Letter that provides a listing of payments made during a specified time period. The letter is manually printed and mailed to the individual by the Enrollment Broker Funds team.
|Payment Not Needed
|Sent to inform an individual that a payment is being returned to the household because the household does not owe any payments at this time or the payment is unable to be processed.
|POD Cover Letter
|Print on Demand Cover Letter
|Cover letter sent when a client requests a copy of the letter that had previously been sent to the individual.
|Refund Address Confirmation
|Sent to a CHIP household that qualifies for a refund in order to confirm the household’s current mailing address. The letter is generated when the household is owed a refund and a current phone number does not exist in the case or when the customer care representative is unable to reach the household using the existing phone listed in the case.
|Retro Notification Letter
|Sent to inform an individual that the enrollment start date for their children has changed.
|Unclaimed Property Letter
|Sent to a participant of CHIP or the Medicaid Buy-In (MBI) program who is owed a refund of $250 or more for a closed Eligibility Determination Group (EDG) and who has had no account activity for at least three years. The letter is generated on a yearly basis.