Texas Administrative Code
Title 26 - HEALTH AND HUMAN SERVICES
Part 1 - HEALTH AND HUMAN SERVICES COMMISSION
Chapter 351 - CHILDREN WITH SPECIAL HEALTH CARE NEEDS SERVICES PROGRAM
Section 351.3 - Eligibility for Services
Universal Citation: 26 TX Admin Code ยง 351.3
Current through Reg. 49, No. 38; September 20, 2024
(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 § 351.2(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 § 351.6 of this title (relating to Providers),
may be reimbursed for services as defined in § 351.2 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 § 351.13 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.
(C) Those applicants
or clients financially eligible for CHIP, Medicaid, or other programs with
eligibility income guidelines that meet the program's eligibility income
guidelines, and who also meet the program age and residency requirements, will
be considered financially eligible. The applicant, client, or family must
notify the program, if the applicant or client is no longer eligible for such
programs.
(8)
Determination of continuing eligibility for health care benefits. Financial
criteria for eligibility for health care benefits must be re-established at
least annually or as directed by statute. Medical or dental criteria must be
re-established at least annually (i.e., within 365 days from the first day of
the client's initial date of program eligibility or within 366 days during a
leap year). Clients for health care benefits will be notified of program
deadlines for re-establishment of eligibility. If an ongoing client for health
care benefits does not meet program deadlines for submitting information
required for the determination of continuing eligibility, the client's
eligibility for health care benefits will end. If the then former client
re-applies to the program after such lapse in eligibility and is determined
eligible for health care benefits, the former client will be considered a new
client. If the program has a waiting list for health care benefits, the new
client will be placed on the waiting list in order according to the date and
time the client is determined eligible for health care benefits.
(b) Eligibility for case management services. The program may provide or reimburse for case management services to persons in need of such services who are Texas residents and who are determined not to have another primary provider or funding source for such services. The program's case management services are focused on individuals (and their families) who are eligible, seeking eligibility, or potentially seeking eligibility for the program's health care benefits (this includes clients who are on the waiting list for health care benefits). However, the program may offer and provide case management services to individuals (and their families) who are not eligible or not seeking eligibility for the program's health care benefits.
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