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

Effective Date:

Approval Date: 66 Section 12. Applicant and enrollee protections (Sections 2101(a))

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan.

Eligibility and Enrollment Matters

12.1 Please describe the review process for eligibility and enrollment matters that complies with 42 CFR §457.1120.

Both the TexCare review and the HHSC review processes described below are impartial reviews. The TexCare review is impartial because it is performed by a TexCare unit that is separate from the unit that originally made the determination. The HHSC review is impartial since HHSC does not do any direct determinations.

Eligibility and Enrollment Matters Review and Reconsideration Process 1) Matters Subject to Review. An applicant or member may request a review of an initial adverse determination made by the administrative contractor concerning the following: a) denial of eligibility; b) failure to make a timely determination of eligibility; c) enrollment or disenrollment (disenrollment for failing to meet cost sharing obligations is not applicable); 2) Matters Not Subject to Review. The state is not required to provide an opportunity for review and reconsideration if the sole purpose for the decision is a provision in the State plan or in Federal or State law requiring an automatic change in eligibility, enrollment, or a change in coverage under the health benefits package that affects all applicants or members or a group of applicants or members without regard to their individual circumstances. 3) Reconsideration by the Health and Human Services Commission. If TexCare’s decision following its review is adverse to the applicant or member, he or she may request reconsideration by the Health and Human Services Commission. Notice of Adverse Determinations TexCare must provide the applicant or member written notice of any adverse eligibility or enrollment determination. The notice must include: 1) the action or determination and the reasons supporting it;