(a) To complete CHIP enrollment, an applicant must:
(1) select and indicate on the enrollment form a health
care MCO and a dental MCO for all eligible children;
(2) select a PCP and a dental home, and place the names
on the enrollment form;
(3) if applicable, indicate if an eligible child has
special health care needs based on criteria in the member guide;
(4) sign and return the enrollment form; and
(5) pay any applicable enrollment fee on or before
the due date.
(b) If an applicant does not pay an applicable enrollment
fee as described in subsection (a) of this section, the child is not
enrolled in CHIP.
(c) Notwithstanding subsections (a) and (b) of this
section, if an application is for a child enrolled in Medicaid transitioning
to CHIP after being determined ineligible for Medicaid before the
end of the child's Medicaid certification period, the child may be
enrolled in CHIP prior to payment of the enrollment fee. However,
if the enrollment fee is not paid on or before the due date, the child
is disenrolled.
(d) An applicant may select a PCP, dental home, health
care MCO, and dental MCO by mail, telephone, or facsimile. Unless
the application is for a perinate receiving expedited enrollment in
accordance with §370.401 of this chapter (relating to Perinates),
the applicant will have 30 calendar days from the date the enrollment
packet is mailed to choose a health care MCO, dental MCO, PCP, and
dental home. If the applicant does not choose a health care MCO, dental
MCO, PCP, or dental home within the time period established by HHSC,
HHSC or its designee will assign one using the default assignment
methodologies described in this section.
(e) PCP assignment. If an applicant has not selected
a PCP, the health care MCO will assign one using an algorithm that
considers:
(1) the child's established history with a PCP, as
demonstrated by encounter history with the provider in the preceding
year, if available;
(2) the geographic proximity of the child's home address
to the PCP;
(3) whether the provider serves as a PCP to other members
of the child's household;
(4) limitations on default assignment, such as PCP
restrictions on age, gender, and capacity; and
(5) other criteria approved by HHSC.
(f) Dental home assignment. If an applicant has not
selected a dental home, the dental MCO will assign one using an algorithm
that considers:
(1) the child's established history with a dental home,
as demonstrated by encounter history with the provider in the preceding
year, if available;
(2) the geographic proximity of the child's home address
to the dental home;
(3) whether the provider serves as the dental home
to other members of the child's household;
(4) limitations on default assignment, such as dental
home restrictions on age and capacity; and
(5) other criteria approved by HHSC.
(g) MCO assignment. If an applicant has not selected
a health care MCO or dental MCO, HHSC or its administrative services
contractor will assign one using an algorithm that considers the child's
history, including PCP or dental home when possible. If this is not
possible, HHSC or its administrative services contractor will equitably
distribute members among qualified MCOs, using an algorithm that considers
one or more of the following factors:
(1) whether the child was previously enrolled in the
MCO in Medicaid or CHIP;
(2) whether other members of the child's household
are enrolled in the MCO in Medicaid or CHIP;
(3) MCO performance;
(4) the greatest variance between the percentage of
elective and default enrollments (with the percentage of default enrollments
subtracted from the percentage of elective enrollments);
(5) capitation rates;
(6) market share; and
(7) other criteria determined by HHSC.
(h) Modified default enrollment process. HHSC has the
option to implement a modified default enrollment process for MCOs
when contracting with a new MCO or implementing managed care in a
new service area, or when it has placed an MCO on full or partial
enrollment suspension.
(i) Request to change dental home or PCP. There is
no limit on the number of times a member can request to change his
or her dental home or PCP. A member can request a change in writing
or by calling the MCO's toll-free member hotline.
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Source Note: The provisions of this §370.303 adopted to be effective September 1, 2003, 28 TexReg 7337; amended to be effective January 1, 2006, 30 TexReg 8666; amended to be effective September 1, 2007, 32 TexReg 5359; amended to be effective March 1, 2012, 37 TexReg 1301; amended to be effective July 8, 2012, 37 TexReg 4854; amended to be effective January 1, 2014, 38 TexReg 9477; amended to be effective June 1, 2014, 39 TexReg 3983; amended to be effective October 9, 2016, 41 TexReg 7711 |