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

Current through Reg. 49, No. 28; July 12, 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.