Texas Administrative Code
Title 1 - ADMINISTRATION
Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION
Chapter 370 - STATE CHILDREN'S HEALTH INSURANCE PROGRAM
Subchapter C - ENROLLMENT, RENEWAL, DISENROLLMENT, AND COST SHARING
Division 2 - COST-SHARING REQUIREMENTS
Section 370.325 - Cost-Sharing Cap

Universal Citation: 1 TX Admin Code ยง 370.325

Current through Reg. 49, No. 38; September 20, 2024

(a) The aggregate annual Children's Health Insurance Program (CHIP) cost-sharing cap is based on household income (as defined in § RSA 370.803 of this chapter (relating to Definitions)), established at the time of eligibility determination, as a percentage of the Federal Poverty Level (FPL). The aggregate annual CHIP cost-sharing cap is established in the Texas CHIP State Plan and approved by the Centers for Medicare and Medicaid Services (CMS). The aggregate annual CHIP cost-sharing cap will not exceed 5 percent of the annual household income as required under federal law and federal regulations (see Social Security Act §2103(e)(3)(B) and § RSA 457.560(a)). The applicant is responsible for tracking CHIP cost-sharing expenditures for the household on the form provided by HHSC or its designee and advising HHSC's designee when the CHIP cost-sharing cap is reached. HHSC or its designee is responsible for:

(1) computing the aggregate annual CHIP cost-sharing cap for the household and informing the applicant of the amount at enrollment;

(2) providing the applicant with a form for keeping track of each CHIP member's co-payments and enrollment fee payment;

(3) notifying the affected dental MCO and health care MCO within two business days of receiving notice from the applicant that a household has reached the aggregate annual CHIP cost-sharing cap; and

(4) informing HHSC that an applicant is owed a refund in the form of a warrant issued by the State Comptroller's Office, if the applicant notifies HHSC's designee that the household has exceeded its aggregate annual CHIP cost-sharing cap and an enrollment fee has been received from the household that is in excess of the CHIP cost-sharing cap.

(b) On notification by HHSC's designee that a household has reached its aggregate annual CHIP cost-sharing cap, an MCO will issue a new MCO Member Identification Card reflecting the absence of a co-payment requirement.

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