| (a) Eligibility for health care benefits. In order
to be determined eligible for program health care benefits, applicants
must meet the medical, financial, and other criteria in this section.
(1) Medical or dental criteria. At least annually,
a physician or dentist must certify that the person meets the definition
of "child with special health care needs" as defined by §38.2(5)
of this title (relating to Definitions). The medical or dental criteria
certification must be based upon a physical examination conducted
within the 12 months immediately preceding the date of certification.
The physician or dentist must document the medical or dental diagnosis
code and descriptor from the International Classification of Diseases,
Ninth Revision, Clinical Modification (ICD-9-CM), or its successor,
for the person's primary diagnosis that meets the medical or dental
criteria certification definition and for each of the person's other
medical or dental conditions for statistical and referral purposes.
To facilitate application to the program for certain applicants, the
program Medical Director or Assistant Medical Director may accept
written documentation of medical or dental criteria certification
submitted by a physician or dentist who is licensed to practice in
a state or jurisdiction of the United States of America other than
Texas. The program does not reimburse for written documentation of
medical or dental criteria certification. If a physician or dentist
requests coverage of diagnosis and evaluation services to determine
if the person meets the definition of a "child with special health
care needs" and the person meets all other eligibility criteria for
health care benefits, then the person may be given up to 60 days of
program coverage for diagnosis and evaluation services only. Only
program providers as specified in §38.6 of this title (relating
to Providers), may be reimbursed for services as defined in §38.2
of this title.
(2) Financial criteria. Financial criteria are determined
at least annually or as directed by statute. Financial criteria are
based upon the determinations of income, family size, and disregards.
All families must verify their income and disregards.
(A) The income level for eligibility is 200% of the
FPL. If the family income exceeds this level, and the applicant's
family can document its responsibility for family medical bills incurred
within 12 months prior to the application date or within 6 months
after the financial eligibility denial date that are equal to or greater
than the amount in excess of the 200% level, the applicant may be
determined financially eligible for a period of 6 months, or as directed
by statutory requirements, beginning on the eligibility date.
(B) Applications to Medicaid and the SSI programs.
(i) If actual or projected program expenditures for
an ongoing client currently not eligible for Medicaid exceed $2,000
per year and the client's age and citizenship status meet Medicaid
eligibility criteria, the client shall be required to apply for any
applicable Medicaid programs and, if eligible, to participate in those
programs in order to remain eligible for further program benefits.
Within 60 days of the date of the notification letter, the client
must submit to the program documentation of an eligibility determination
from Medicaid. During this 60-day period, program coverage will continue.
If the client does not provide documentation of an eligibility determination
from Medicaid within the 60-day time limit, program coverage shall
be terminated and may not be reinstated unless an eligibility determination
is received. The program may grant the client a 30-day extension to
obtain the determination.
(ii) The program also may require an ongoing client
for whom actual or projected expenditures exceed $2,000 per year
to apply for the SSI program and, if eligible, to participate in that
program in order to remain eligible for further program benefits.
Within 60 days of the date of the notification letter, the client
must submit to the program verification of a timely and complete application
to SSI. During this 60-day period, program coverage will continue.
If the client does not provide this verification within the 60-day
time limit, program coverage may be terminated. With verification
of an application to SSI, the program may continue coverage pending
receipt of an SSI eligibility determination.
(3) Health insurance.
(A) All health insurance coverage insuring the applicant
and family must be listed on the application. If insurance coverage
was effective prior to program eligibility, such coverage must be
kept in force. Noncompliance with this requirement may result in the
termination of program benefits. If insurance cannot be maintained,
the applicant or parent, guardian, or managing conservator must, upon
request, provide to the program proof of:
(i) cancellation from the insurer or plan sponsor;
(ii) discontinuation of the insurance plan by the insurer
or plan sponsor;
(iii) exhaustion of the right to continue group insurance
coverage as provided under federal or state law; or
(iv) financial inability to continue paying the cost
of any health insurance except CHIP.
(B) Applicants or clients who may be eligible for coverage
under Medicare, Medicaid, or CHIP by reason of citizenship, residency
status, age, or medical condition must apply for coverage. Proof of
eligibility determination must be received within 60 days of the date
of notification by the program. With verification of an application
to Medicare, Medicaid, CHIP, or an available health insurance plan,
the program may extend this deadline pending receipt of an insurance
eligibility determination. If the applicant or client is eligible
for any health insurance or buy-in program, the applicant or client
must be enrolled. Such insurance must be kept in force as though it
were effective prior to program eligibility.
(C) The program will assist in determining possible
eligibility for insurance and may provide program benefits for ongoing
clients during insurance application, enrollment, or limited or excluded
coverage periods.
(D) Before canceling, terminating, or discontinuing
existing health insurance or electing not to enroll a client in available
health insurance, including canceling, terminating, discontinuing,
or not enrolling in CHIP, the parent, guardian, or managing conservator
must notify the program 30 days prior to cancellation, termination,
discontinuance, or end of the enrollment period. When the program
provides assistance in keeping or acquiring health insurance, the
parent, guardian, or managing conservator must maintain or enroll
in the health insurance.
(4) Age. The applicant, other than one with cystic
fibrosis, must be under the age of 21.
(5) Residency. The applicant must be a Texas resident.
(6) Application.
(A) Applications are available to anyone seeking assistance
from the program. To be considered by the program, the application
must be made on forms currently in use.
(B) A person is considered to be an applicant from
the time that the program receives an application. The program will
respond in writing regarding eligibility status within 30 working
days after the completed application is received. Applications will
be considered:
(i) denied if eligibility requirements are not met;
(ii) incomplete if required information that includes
a CHIP, Medicaid, or SSI determination or any other data and document(s)
needed to process the application is not provided or if an outdated
form is submitted; or
(iii) approved if all criteria are met.
(C) The denial of any application submitted to the
program shall be in writing and shall include the reason(s) for such
denial. The applicant has the right of administrative review and a
fair hearing as set out in §38.13 of this title (relating to
Right of Appeal).
(D) Any person has the right to reapply for program
coverage at any time or whenever the person's situation or condition
changes.
(7) Verification of information.
(A) The program shall make the final determination
on a person's eligibility using the information provided with the
application. The program may request verification of any information
provided by the applicant to establish eligibility.
(B) The program shall verify selected information on
the application. Documentation of date of birth, residency, income,
and income disregards shall be required. The program shall notify
the applicant and family in writing when specific documentation is
required. It is the responsibility of the applicant and family to
provide the required information.
Cont'd... |
