Revision 21-2; Effective April 1, 2021

 

 

D—110 General Policy

Revision 21-2; Effective April 1, 2021

 

CHIP

The Children's Health Insurance Program (CHIP) provides health care coverage for children under 19 whose family income exceeds the Children's Medicaid income limit but is less than or equal to 201 percent of the federal poverty level (FPL), which is the applicable income limit for TA 84 (CHIP). Children who do not qualify for Medicaid and remain ineligible for Medicaid, are eligible to enroll in CHIP and receive up to 12 months of continuous coverage. Families with net income above 151 percent of the FPL are required to pay an enrollment fee. Families with income above 185 percent of the FPL will have an income check during their sixth month of eligibility. Most families also have copayments for doctor visits, prescription drugs and emergency care.

When an applicant requests children's health coverage, the child is first tested for Medicaid eligibility. If ineligible for Medicaid, the child is then tested for CHIP eligibility. When processing a change for a person certified for CHIP, the Texas Integrated Eligibility Redesign System (TIERS)  will automatically test the person for Medicaid eligibility. A new application is not required.

CHIP eligibility is prospective. The effective date is based on whether the Eligibility Determination Group (EDG) is disposed before or after cutoff and when the enrollment process is completed. TIERS provides the potential eligibility begin date, and Enrollment Broker provides the actual eligibility begin date.

 

CHIP Perinatal

CHIP perinatal provides services to unborn children of pregnant women, regardless of age. These pregnant women are ineligible for:

  • Medicaid due to income exceeding 198 percent of the FPL, which is the applicable income limit for TP 40, but whose household income is at or below 202 percent of the FPL, which is the applicable income limit for TA 85 (CHIP Perinatal); or
  • Medicaid or CHIP due to immigration status, since the pregnant woman is not a citizen or qualified alien.

When processing a change for a person certified for CHIP perinatal, TIERS will automatically test the person for Medicaid eligibility. A new application is not required. 

The unborn children of pregnant women eligible for CHIP perinatal are granted 12 months of continuous enrollment from the month the eligibility determination is made. The 12-month period includes the months of CHIP perinatal coverage before and after birth. The mother receives CHIP coverage related to the birth only; she does not receive personal health care coverage.

Because CHIP perinatal only provides coverage for pregnancy related services, women certified for CHIP perinatal must apply for Emergency Medicaid or Medically Needy (MN) with Spend Down to receive coverage for medical conditions not related to their pregnancy.  Receiving CHIP perinatal does not affect the mother's eligibility for:

  • MA-MN with Spend Down (TP 56);
  • MA-Pregnant Women – Emergency (TP 36),
  • MA-Parents and Caretaker Relatives Medicaid – Emergency (TA 31);
  • MA-MN with Spend Down – Emergency (TP 32); or
  • MA-Children 6-18 – Emergency (TP 34).

Pregnant women may receive the program(s) above in the same month as CHIP perinatal. This is not considered dual coverage.

When a child is born to a CHIP perinatal mother whose household income is above the applicable income limit for Pregnant Women Medicaid, the child's coverage begins on the date of birth and the mother's coverage is terminated on the last day of the month the birth occurs. The mother is eligible to receive two postpartum visits that may occur after the mother's CHIP perinatal coverage ends. At birth, the child receives perinatal coverage for the remainder of the 12-month eligibility period. The child's CHIP perinatal enrollment is terminated at the end of the 12-month period.

When a child is born to a CHIP perinatal mother whose household income is at or below the applicable income limit for Pregnant Women Medicaid and the mother receives Emergency Medicaid to cover the labor with delivery charges, the advisor must enroll the child in TP 45 effective the child's date of birth. The mother's perinatal coverage ends the last day of the child's birth month or the pregnancy's termination month. The mother is eligible to receive two postpartum visits that may occur after her CHIP perinatal coverage ends.

Related Policy

Federal Poverty Level (FPL), C-131.1
Type Programs (TP) and Type Assistance (TA), C-1150
Adding a New Child, D-1433.1

 

D—120 Eligibility Qualifications

Revision 08-1; Effective January 1, 2008
 

 

 

D—121 Children's Health Insurance Program (CHIP)

Revision 15-4; Effective October 1, 2015

 

CHIP

A child must:

  • be ineligible for Children's Medicaid;
  • not be on Medicare;
  • reside in Texas;
  • be under age 19;
  • be a U.S. citizen or non-citizen with valid proof of immigration/alien status;
  • have total household net income at or below the applicable income limit; and
  • be uninsured for at least 90 days or claim one of the good cause exemptions to the waiting period explained in D-1723.6, Good Cause Exemptions for Children Subject to the 90-day Waiting Period.

 

D—122 CHIP Perinatal

Revision 15-4; Effective October 1, 2015

 

CHIP Perinatal

To be eligible for CHIP perinatal, a woman must:

  • be pregnant;
  • reside in Texas;
  • have total household net income at or below the applicable income limit, depending on family size; and
  • be ineligible for ongoing Medicaid and CHIP because of income or immigration status.

A pregnant woman is considered to be an adult the month of her 18th birthday.

A pregnant woman must be determined ineligible for Medicaid and CHIP before being tested for perinatal eligibility. CHIP perinatal coverage begins the first day of the month in which the eligibility determination is made.

The woman's age is calculated as of the month in which the proposed effective date of coverage will occur.

 

D—122.1 Post-Birth Eligibility Determination

Revision 15-4; Effective October 1, 2015

 

CHIP Perinatal

A woman is not eligible for perinatal coverage if she applies after the child is born. The advisor must deny the application upon becoming aware that the pregnant woman has delivered or had a miscarriage before the eligibility determination is made. The advisor must then determine whether the newborn is eligible for Medicaid or CHIP.

If the pregnant woman delivers or has a miscarriage before the eligibility determination and the advisor becomes aware of the delivery or miscarriage after the eligibility determination has been made, the woman's coverage is terminated. The woman will receive one month of CHIP perinatal coverage.

 

D—122.2 Notification of Birth

Revision 13-4; Effective October 1, 2013

 

CHIP Perinatal

Staff are notified of the perinatal child's birth via the:

  • case authority who reports the child's birth by telephone or in writing;
  • the newborn file; or
  • birth notification from the health plan.