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

Effective Date:

Approval Date: 69 Continuation of Enrollment Pending Disposition of Review and Reconsideration TexCare will grant continuation of enrollment pending review and reconsideration of a disenrollment determination, including disenrollment for failure to pay cost sharing.

Timelines for Reviews

(1) Families have 30 working days from date of notification letter to submit an appeal concerning TexCare’s decision to deny eligibility or disenroll. (2) TexCare has 10 working days after receiving appeal (in writing) to respond with a notice that the decision has been upheld or has been reversed. (3) Families have 15 working from date of response letter to submit written request for additional HHSC review. (4) Within 5 working days of date of receipt, TexCare notifies HHSC of request for additional HHSC review. (5) HHSC has 15 working days to respond to family and notify TexCare of HHSC decision

Health Services Matters

12.2 Please describe the review process for health services matters that complies with 42 CFR §457.1120.

HHSC requires health insurers to comply with State-specific grievance and appeal requirements currently in effect in the State. State regulations concerning adverse determination are found in the Texas Insurance Code, Section 843.261, Atr.21.58A. Health Services Matters are: 1) delay, denial, reduction, suspension, or termination of health services, in whole or in part, including a determination about the type or level of services; and 2) failure to approve, furnish or provide payment for health services in a timely manner. Complaints Concerning Health Services Matters Pursuant to Insurance Code A member, or a person acting on the member’s behalf, or the member’s physician or health care provider may file a complaint about an adverse determination made by a health plan provider pursuant to the provisions of Chapter 20A and article 21.58A, Insurance Code. Such a complaint may