D-1720, Enrollment Process

Revision 20-4; Effective October 1, 2020

CHIP and CHIP Perinatal

The Enrollment Broker receives a daily enrollment request that consists of member information for the eligible members. 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 19-1; Effective January 1, 2019

CHIP, CHIP Perinatal

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

People 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 https://www.hhs.texas.gov/services/health/medicaid-chip/about-medicaid-chip/medicaid-medical-dental-policies.

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

People 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 hhs.texas.gov/services/health/medicaid-chip/programs/medical-dental-plans.

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.