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Model Application Template for the State Children’s Health Insurance Program

Effective Date:

Approval Date: 53 a family does not exceed 5 percent of such family’s income for the length of the child’s eligibility period in the State. Include a description of the procedures that do not primarily rely on a refund given by the state for overpayment by an enrollee: (Section 2103(e)(3)(B)) (42CFR 457.560(b) and 457.505(e))

Families receive information during the enrollment process on how to track and report their cost sharing expenditures. Texas uses a 1.25% aggregate cap per 6-month term of coverage for families at or below 150% of the FPL. For families at 151% to 200% of the FPL, a 2.5% aggregate cap applies per 6-month term of coverage (see section 8.2.3).

When a family is near their cap on out of pocket cost sharing, they submit a form to the SCHIP administrative services contractor, which in turn, notifies the member’s HMO. The HMO sends the member a new membership card that indicates no cost sharing is required through the end of that member’s enrollment period.

In addition to seeing the member’s card (which would indicate no cost sharing required if cap has been reached), providers can also access a toll-free line operated by the SCHIP administrative services contractor that provides eligibility information.

8.6 Describe the procedures the state will use to ensure American Indian (as defined by the Indian Health Care Improvement Act of 1976) and Alaska Native children will be excluded from cost sharing. (Section 2103(b)(3)(D)) (42CFR 457.535)

American Indian and Alaska Native applicants identify themselves on the application. The administrative services contractor uses special identifying codes for American Indians and Alaska Natives. This code ensures that American Indians and Alaska Natives are not charged an enrollment fee. The American Indian and Alaska Native identifiers are transmitted electronically to the health plans. Under the state’s contract, the health plans are prohibited from assessing co-payments for American Indians and Alaska Natives. Heath plan Member ID cards for American Indians and Alaska Natives must show that they owe no co-payments for services. The health plan also is contractually required to educate providers about the cost- sharing waiver for American Indians and Alaska Natives.

8.7 Please provide a description of the consequences for an enrollee or applicant who does not pay a charge. (42CFR 457.570 and 457.505(c))

New enrollees must pay the enrollment fee prior to enrollment in the program. Families renewing coverage have until cut-off of the first month of the new six-month coverage period to pay the enrollment fee. Cut-off is usually 10-15 days prior to the end of the month. As long as payment is received by the cut-off date, no lapse in coverage is experienced. If the family fails to pay the enrollment fee by cut-off of the first month of the new