Processing CHIP Applications and Renewals

1
Processing CHIP Applications and Renewals

• In the New Eligibility System

November 3,2006 Version 2.3
2
Agenda
1. Introduction
2. CHIP Process Overview
3. Getting Started
3. Application Review
4. Wrap-Up
3
Introduction

• Medical coverage for CHIP and Childrens Medicaid
  begins once the client successfully completes
  each of the following phases
• Application
• Eligibility
• Enrollment
• This training focuses on the policies and
  procedures for each phase in the Childrens
  Health Insurance process.
• Note For more information about completing the
  application, please review the Instructions for
  Completing the CHIP and Childrens Medicaid
  Application training _at_ www.chipmedicaid.org/cbo/ap
  p_process.htm

4
Childrens Insurance Process Overview
Phase 1 Application
Phase 2 Eligibility
Phase 3 Enrollment

• (CHIP/Applicant)
• Six months continuous eligibility
• If CHIP, select health plan and pay enrollment
  fee, if applicable

• (CHIP)
• Eligibility Determination
• If CHIP, TAA processes
• If Medicaid, HHSC processes

• (Applicant)
• Complete Application
• Sign and date application
• Attach Verification

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Objective

• Provide an understanding of the CHIP process for
• New applications including eligibility
  determination and enrollment
• Renewals
• Cost-sharing
• Provide an overview of the CHIP change reporting
  requirements
• Provide an overview of the Complaints and Request
  for Review Processes

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Application Phase
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• Texas Access Alliance (TAA)
• Administers the Childrens Health Insurance
  Program (CHIP) for Texas
• Processes applications and verification
  information for Childrens Medicaid and CHIP
• Refers children potentially eligible for Medicaid
  to the Health and Human Services Commission
  (HHSC)
• Enrolls children in CHIP

8
Who Can Apply

• The following individuals have case authority to
  apply for CHIP
• Parents
• Other custodial parent, including step-parent
• Grandparent or other relative
• Independent children
• The individual must be living with and caring for
  the child

Case Authority authority to apply, renew or
make changes to a CHIP case
9
Who Qualifies for CHIP?

• Children who are
• US citizens or qualifying non-citizens with valid
  proof of immigration/alien status
• Living in the state of Texas
• Ineligible for Medicaid
• Under age 19
• Note A child is eligible for CHIP through the
  month of his/her
• 19th birthday.

10
How to Apply

• Families can apply for benefits using the
• Application for Childrens Health Insurance
  Program (CHIP) and Childrens Medicaid
• Form H1010, Application for Assistance
• Integrated Application (used in the pilot areas
  Travis and Hays Counties)
• Access
• www.CHIPmedicaid.org and download the
  application
• www.yourtexasbenefits.com
• Note If the family wants to apply for food
  stamps, Temporary Assistance for Needy Families
  (TANF), Medicaid for adults or other HHSC
  services, Form H1010 or the Integrated
  Application is required

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How to Apply

• Families file an application for Childrens
  Medicaid or CHIP by
• Mail HHSC P.O. Box 14200 Midland, TX 79711-9901
• Fax [phone](toll free)
• Internet Access
• www.CHIPmedicaid.org (download, print, complete
  and sign)
• Phone
• 1-800-647-6558 or 1-877-543-7669 (1-877-KIDS-NOW)
• 2-1-1
• 1-800-735-2988 (Relay Texas)
• HHSC Benefits Office
• To find the nearest benefits office, visit
  www.yourtexasbenefits.com/wps/themes/html/SSPortal
  /officeLocator/results.html

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Complete Application

• Before eligibility can be determined, the family
  must submit a complete application
• A complete application has the following
• All data fields completed
• Signature included
• Verification attached
• Income
• Expenses
• Childrens U.S. citizenship or immigration status

13
Incomplete Application

• The family receives a missing information notice
  when the application is incomplete, i.e.,
• Data fields (all or some) are blank
• Signature is not included
• Verification is not attached
• Attached to the missing information notice is
  Form M5017c, How to Provide Missing Information,
  explains the information the applicant must
  verify with written documentation and the
  information the applicant may verify by phone

14
Timeframes Application Processing

• When the application is complete and verification
  received, TAA
• screens the children for Childrens Medicaid and
  CHIP using an automated system
• refers the application for children potentially
  eligible for Medicaid to HHSC for processing
• continues processing the application for children
  who are CHIP eligible

15
Timeframes File Date

• File Date
• Date HHSC or TAA receives an application that
  contains, at a minimum, the applicants name,
  address, and signature

16
Timeframes Processing

• Processing Timeframes
• Up to 45 calendar days from the file date to
  complete the eligibility process and render a
  decision
• Applications denied on the 45th day for failure
  to provide information may be reopened without
  submitting a new application when the family
  provides the missing information (within 60 days
  from the file date). Note The date the
  information is provided becomes the new file date

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Eligibility Phase
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Eligibility Points

• Family Size/Budget Group
• Eligible child and his/her siblings under 19
• Parents (natural/adoptive) or step-parents living
  in the home
• Spouse of the married child and their mutual
  child(ren)
• Independent children
• Includes members of the household whose income
  and resources are used to determine a childs
  eligibility for CHIP

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Eligibility Points

• Citizenship/Immigration Status
• CHIP provides coverage to
• U.S. citizens
• Legal Permanent Residents (LPR) ineligible for
  Medicaid
• LPRs who meet the requirements for Medicaid but
  are over the income and/or resource limits for
  Medicaid

Note Verification of a childs Legal Permanent
Residents status is required at application only
unless the INS document is expired at renewal.
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Eligibility Points

• Social Security Enumeration
• At application, family must provide SSN or proof
  of application (Forms SSA 2583 or SSA 5028) for
  all eligible children
• Exceptions
• Children six months or younger
• Independent child whose representative is
  currently going or will go through the courts to
  obtain proof of identity and age for the child
  prior to obtaining an SSN

21
Eligibility Points

• Residency
• Meet the residency requirement if
• the family lives in Texas, and
• intends to make Texas their home
• Note A Texas residence on the application
  meets the intent to make Texas their home rule

22
Eligibility Points

• Family Assets - Test
• 5000 asset limit for families with income above
  150 FPL
• Note The family must complete a CHIP Asset
  Questionnaire if countable liquid assets and
  vehicle values exceed 5000
• Count assets of all members included in the
  family size/budget group
• Families with income at or below 150 FPL are not
  subject to asset test

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Eligibility Points

• Countable Assets
• Liquid assets
• Vehicles
• Liquid assets are assets that can be readily
  converted to cash, for example
• Cash
• Bank accounts
• Cash value of stocks, bonds and savings
  certificates
• List of countable assets not all-inclusive

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Eligibility Points

• Vehicles

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Eligibility Points

• Family Income - Limits
• Gross income must be below 200 of the Federal
  Poverty Level (FPL)
• Consider the income of any person included in the
  family size/budget group
• Note The earnings of a child attending school
  are exempt
• No deductions allowed however, applicant must
  provide verification to determine if the children
  qualify for Medicaid
• Verify all countable income at application and
  renewal
• Enhanced data broker screening on all new
  applications and renewals

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Eligibility Points

• Family Income Countable Income
• Wages
• Self-employment
• Social Security (retirement, survivor and
  disability)
• Child support
• Alimony
• Unemployment
• Veterans Affairs (VA) benefits
• List of countable income not all-inclusive

 
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Eligibility Points

• Family Income Countable Income
• Convert income to a monthly amount if not
  received monthly
• Use conversion factors below to convert income to
  a monthly amount

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Eligibility Points

• Third Party Insurance
• Children cannot be covered by CHIP and other
  health insurance at the same time
• Families with private insurance that cost gt 10
  of the familys gross income must drop the
  insurance before CHIP coverage can begin
• Families with private insurance that cost lt 10
  of the familys gross income are not eligible for
  CHIP coverage

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Verification Requirements

• Calling CHIP and providing the information over
  the phone is acceptable for

• Applicants information
• Childs information
• Parent or step-parent information
• Current or previous private insurance information
  (except cost)
• Social Security Numbers
• Assets (make,model, year and/or vehicles value,
  money in bank accounts or on hand)
• Expenses

See Form M5017c for details
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Verification Requirements

• Written verification is required for
• US citizenship
• Immigration status
• Identity (Note The head of households
  signature on the application meets this
  requirement)
• Income
• Expenses
• Termination of private health insurance
• Cost of current or previous private health
  insurance
• Conflicting information

See Form M5017c for details
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Verification Requirements

• Written verification is required for
• Dependent care costs
• Child support and alimony payments
• Payments to dependents outside the home
• Note CHIP does not allow deductions of any
  kind however, the expenses above are allowable
  deductions for Childrens Medicaid and may help
  the family qualify. If the family does not
  provide verification of the expense, the
  deduction is not allowed.

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Eligibility Summary

• Children must be tested for Medicaid prior to
  CHIP. This processing change may require some
  families to provide information not requested in
  the past
• If the children are determined potentially
  eligible for Medicaid, TAA refers the application
  to HHSC for an eligibility determination
• If the children are determined eligible for CHIP,
  TAA begins the enrollment process
• CHIP coverage cannot begin unless the family
  successfully completes the next phase Enrollment

33
Enrollment Phase
34
Enrollment Coverage Periods

• Eligible children receive six months of
  continuous coverage, regardless of any change in
  income or resources, unless the child
• Is added to an existing CHIP account
• Is pregnant (may receive two additional months if
  the pregnancy terminates in the 6th month of
  coverage)
• Is covered by Medicaid
• Is determined eligible for Medicaid
• Is covered by private insurance
• Turns 19
• Moves out of state
• Dies
• Coverage ends the last day of the sixth month
• 90-day uninsured or waiting period before CHIP
  coverage can begin unless good cause exists

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New Enrollment Waiting Period

• Waiting period is based on the date the child is
  determined eligible for CHIP
• If eligibility is determined
• On or before the 15th of the month, the three
  month period begins the month eligibility is
  determined
• Example Ernest is determined eligible for CHIP
  May 2. His three month waiting period is May
  through July
• After the 15th through the last day of the month,
  the three month period begins the first day of
  the next month
• Example Ernest is determined eligible for CHIP
  May 23. His three month waiting period is June
  through August

36
New Enrollment Waiting Period

• Exceptions to the 90 waiting period
• Child added to an active CHIP account
• Child disenrolled for failure to renew, but
  successfully completes the renewal process by
  cut-off in the 7th month (grace period)
• Child no longer covered by CHIP/SKIP in another
  state
• Child denied Medicaid and deemed to CHIP
• Child whose previous health coverage cost gt10 of
  the familys gross income

37
New Enrollment Waiting Period

• Exceptions to the 90 day waiting period
• Child who lost insurance coverage due to one of
  the following
• Parents employment terminated due to layoff,
  reduction in force or business closure
• Parents benefits under the Consolidated Omnibus
  Budget Reconciliation Act of 1984 (COBRA)
  terminated
• Child is no longer covered by the Texas Employee
  Retirement System (ERS)
• Dependent coverage terminated by parents
  employer
• Change in parents marital status

38
New Enrollment Completion

• Once eligibility is determined and a potential
  start date is established, the family receives a
  CHIP welcome letter, enrollment/transfer form,
  and payment coupon
• The family must take the following steps to
  complete the Enrollment Phase
• Select a health plan, if applicable
• Select a primary care physician
• Complete the enrollment form (written or by
  phone) by the due date
• Pay the enrollment fee by the due date, if
  required
• Note The child will not be enrolled in CHIP
  unless the family completes the steps above.

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Enrollment Coverage Periods

• CHIP coverage begins the earliest month after the
• CHIP application is fully processed and
  eligibility has been determined, and
• Enrollment process is complete including receipt
  and processing of the enrollment fee, if
  applicable
• CHIP coverage is prospective and relative to
  cut-off
• Cut-off each month is approximately 10 calendar
  days from the end of the month

40
Enrollment Coverage Periods

• For the examples below, assume the 90 day
  waiting period is March through May. The family
  must return the enrollment form and pay the
  enrollment by cut-off in the third month of the
  waiting period.
• Example Frances Milner returns the CHIP
  enrollment form and fee on May 14th. May cut-off
  is May 19th. Her children will be enrolled in
  CHIP effective June 1st.
• Example Frances returns the CHIP enrollment
  form on May 10th and the enrollment fee on May
  26th,after cut-off. Her children will enroll in
  CHIP effective July 1st.

41
Enrollment Confirmation Notice

• Families receive an enrollment confirmation
  notice when the enrollment process is complete
• The notice informs the family of the following
• Enrollment start date for the eligible children
• Health plan selected and the plans phone number
• Cost for insurance (co-payments)
• A Medical Payments Form is included with the
  notice for families to track medical expenses and
  return when the expenses meet the cost share cap
• Familys annual cost-share limit
• Once met, the family has no cost sharing
  responsibilities
• Family receives new cards that show no
  co-payments are due for services

42
Processing CHIP Renewals
43
Renewal Process

• Similar to the new application process
• The family must
• Complete and return a CHIP renewal application
• Have the childrens continued eligibility for
  CHIP determined
• Complete the enrollment process
• The mailing of the renewal packet begins the
  Renewal Process

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Renewal Packet

• Mailed between the 1st 5th of the 4th month of
  coverage
• Contains a CHIP Renewal Application pre-populated
  with some of the clients information and a
  letter requesting proof of current income and
  expenses
• Informs family that an enrollment fee may be
  required for continued enrollment

45
Renewal Application

• The family is required to
• Review the information on the renewal application
  which is pre-populated
• Update any information as necessary
• Attach current income and expense verifications
• Sign and date the application
• Review health plan options, if applicable
• Return the renewal application by the due date

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Renewal Applications/Reminder Notices

• Renewal application is due within 15 days of
  receipt
• Up to two reminder notices mailed if the renewal
  application is not received by the due date
• First reminder notice sent when the renewal
  application is not received by the 25th day of
  the fourth month
• Second reminder notice sent when the renewal
  application is not received by the 10th day of
  the the fifth month
• A 30 day grace period allowed for renewal
  applications received and processed between
  cut-off in the 6th month of coverage and cut-off
  in the following month without a 90-day waiting
  period

47
Renewal Eligibility Process

• Upon receiving the renewal application and
  required verification, TAA determines if the
  child continues to qualify for CHIP or if a
  referral to Medicaid is necessary
• Children who continue to qualify for CHIP are
  eligible to enroll in a new six month period
  pending payment of the enrollment fee, if one is
  applicable
• The family receives a CHIP welcome letter,
  enrollment/transfer form, and payment coupon

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Enrollment Fee Extension

• If the family is required to pay an enrollment
  fee and CHIP does not receive payment before
  cut-off in the 6th month of coverage, the family
  receives
• One additional month of coverage (first month of
  the new six month period)
• A second notice explaining
• The Enrollment fee has not been received
• Payment is due within 10 days of the notice
• The child will be disenrolled and the case
  suspended, if payment is not received and
  processed before cut-off in the first month of
  the new six month period

49
Break in Coverage

• If payment is received and processed before
  cut-off in the second month of the new six month
  period, coverage continues without interruption
• If payment is received and processed after
  cut-off in the second month of the new six month
  period, the children could experience a one to
  three month break in coverage

50
Continued Enrollment Examples

• For the following examples, assume that October
  is the last month of the current six month period
  and cut-off is October 15th.
• Example 1 Enrollment fee paid timely
• Frances Milner completes the renewal process
  timely and submits the CHIP enrollment fee on
  October 3rd. TAA processes the payment on
  October 13th. Since the enrollment fee was
  received and processed before October cut-off,
  Ms. Milners children will continue enrollment in
  CHIP beginning November 1st.
• Example 2 Enrollment fee paid after cut-off in
  6th month and before cut-off in the 1st month of
  the new six month period
• Samuel Jackson completes the renewal process
  timely and submits the CHIP enrollment fee on
  October 14th. TAA processes the payment on
  October 21st. Although the payment was mailed
  before cut-off, CHIP did not receive or process
  the payment before that date. The Jacksons CHIP
  coverage will be extended for the month of
  November which will be the first month of their
  new six month period.

51
Continued Enrollment Examples

• For the following examples, assume that October
  is the last month of the current six month period
  and cut-off is October 15th. Cut-off for the
  following four months is November 15th, December
  16th, January 17th and February 15th.
• Example 3 Enrollment fee paid after cut-off in
  the first month and before cut-off in the second
  month of the new six month period
• Gil Scott completes the renewal process timely
  but does not pay the enrollment fee until
  December 7th. CHIP receives and processes the
  payment on December 16th.
• The enrollment fee was not received or processed
  before cut-off in October therefore, the Scotts
  coverage was extended through November and
  suspended for December pending receipt of the
  enrollment fee.
• Since the enrollment fee was received before
  cut-off in what would have been the second month
  of the new six month period, CHIP will reinstate
  the case effective December and the Scotts will
  receive the months remaining in the new six month
  period(November through April).

52
Continued Enrollment Examples

• For the following examples, assume that October
  is the last month of the current six month period
  and cut-off is October 15th. Cut-off for the
  following four months is November 15th, December
  16th, January 17th and February 15th.
• Example 4 Enrollment fee paid between cut-off
  in the third and fourth months
• Babs Streisand completes the renewal process
  timely and submits the CHIP enrollment fee on
  January 22nd. CHIP receives and processes the
  payment on February 5th.
• The enrollment fee was not received or processed
  before cut-off in October CHIP extended the
  Streisand coverage through November and suspended
  coverage for December, January and February
  pending receipt of the enrollment fee.
• Since the enrollment fee was received before
  cut-off in February, which would have been the
  fourth month of the new six month period, CHIP
  will reinstate the case and the Streisands will
  receive a new six month coverage period beginning
  February.

53
Enrollment Confirmation Notice

• Families receive an enrollment confirmation
  notice when the enrollment process is complete
• The notice informs the family of the following
• Enrollment start date for the eligible children
• Health plan selected and the plans phone number
• Cost for insurance (co-payments)
• A Medical Payments Form is included with the
  notice for families to track medical expenses and
  return when the expenses meet the cost share cap
• Familys annual cost-share limit
• Once met, the family has no cost sharing
  responsibilities
• Family receives new cards that show no
  co-payments are due for services

54
Referral from CHIP to Medicaid

• At renewal, CHIP refers all children found to be
  potentially eligible for Medicaid to HHSC
• CHIP notifies the family of the childs
  disenrollment from CHIP and referral to Medicaid
• Upon receipt of the referral from CHIP, HHSC
  determines the childs eligibility for Medicaid
• If eligible, the childs Medicaid coverage begins
  the month following the last month of CHIP
  coverage

55
Process Overview for CHIP Applications
56
Cost-sharing
57
Cost-Sharing

• Families must share in the cost of their
  childrens health insurance coverage if their
  income is above 133 FPL
• Enrollment fees
• Due at initial enrollment and at renewal
• Based on the familys gross income
• No monthly billing
• Co-pays for doctor visits, prescriptions, etc.
• American Indians and Native Alaskans are exempt
• Effective January 2006

58
Enrollment fees
59
Co-Pays
Co-pay Schedule Based on Familys Gross Income
60
Dental Benefits

• Expanded benefit for families that timely
• Renew
• Pay enrollment fees
• Three-Tiered Approach
• Tier I therapeutic service up to 200
• Tier II therapeutic services up to 300
• Tier III therapeutic services up to 400
• Preventive service up to 175 for all Tiers
• Effective April 2006

61
Dental Benefits

• Most children begin at Tier I the first year of
  coverage, moving to Tier II the second year and
  Tier III, the third year
• Children that begin at Tier II the first year of
  coverage
• American Indians or Alaskan natives
• Enrollees w/income lt 133 FPL
• Enrollees deemed from Medicaid to CHIP w/no gap
  in coverage
• Families who made payments during January 2004
  and October 2004
• Families move to Tier III the second year of
  coverage
• Under no circumstances will a child begin at Tier
  III

62
Complaints and Requests for Review
63
Complaint Process

• To file a complaint, the family can
• Call toll-free 1-800-647-6558 or 1-877-543-7669
• Fax a written statement to toll free
  1-877-542-5951
• Mail a written statement to
• CHIP
• P O Box 14400
• Midland, TX 79711-9904
• CHIP sends a written response within 15 working
  days of receiving the complaint

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Request for Review

• If eligibility is denied, the family may request
  a review based on specific grounds such as
• Family believes a mistake was made in calculating
  their income/family size
• Enrollment
• Current insurance payment causing economic
  hardship
• Current insurance benefits less comprehensive
  than CHIP
• Must submit request in writing within 30 days
  from the date of the notification letter
• Letter can simply state I request a review
  because I believe you made a mistake

65
Request for Review

• CHIP has 10 working days from receipt of request
  to respond
• Family has 15 days from CHIP response letter to
  request an HHSC Administrative Review only if
  CHIP denies the request for review
• CHIP notifies HHSC of the Administrative Review
  request within 5 days
• HHSC has 15 working days to complete the
  Administrative Review and notify the family of
  its decision

66
Retroactive/Temporary Enrollments

• When a family files a Request for Review
• At application, the children are not eligible for
  temporary eligibility or enrollment
• At renewal, the children may be eligible for
  temporary enrollment if the family requests
  continued coverage
• Allowed once during each term of coverage
• Continues through the end of the six month
  period, if successful
• Disenrolled at the end of the next possible
  month, if unsuccessful
• There is no retroactive enrollment for CHIP

67
Retroactive/Temporary Enrollments

• When the family disagrees with basic program
  policy and files a Request for Review, temporary
  enrollment in CHIP will not be granted in the
  following situations
• Child currently enrolled in Medicaid
• Child is over 19 years of age
• Child no longer lives in Texas
• Family does not want to be referred to Medicaid
• Income varies still more than 200 FPL
• Family pays lt 10 of their gross income for
  insurance

68
Processing Changes
69
Changes

• The family must report
• change of address
• when an enrolled child leaves the home or dies
• when an enrolled child is institutionalized
• addition of a child to the home, if the family
  wants CHIP for the child
• change in income, if the family wants their
  cost-sharing responsibilities re-evaluated
• The family can call, mail or fax the reported
  change(s) to CHIP

70
Additional Information
71
Resources

• Texas Works Handbook
• www.dads.state.tx.us/handbooks/TexasWorks/
• Texas Administrative Code
• http//info.sos.state.tx.us/pls/pub/readtacext.V
  iewTAC?tac_view4ti1pt15ch370
• HHSC website
• www.hhsc.state.tx.us/
• CHIP/Childrens Medicaid
• www.chipmedicaid.org/index.htm

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Contact Information
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• Thank you for your participation!