1 Tex. Admin. Code § 361.115 - Cost Sharing
(a) Monthly
premium requirements for the months after the eligibility certification month.
After HHSC establishes MBIC eligibility, HHSC or its designee sends the
recipient written notice of the monthly premium amount and the due date for the
monthly premium payment. HHSC provides a grace period of 60 days from the date
on which the monthly premium is past due for the recipient to pay the monthly
premium, in accordance with
42
U.S.C. 1396o(i)(3). If HHSC
does not receive a monthly premium payment within the grace period, then HHSC
terminates MBIC eligibility, effective the first day of the month after the
grace period ends.
(b) Monthly
premium requirements for the three months prior to the application month. As
described in §
361.119 of this chapter (relating
to Medical Effective Date), an applicant may receive MBIC coverage for up to
three months prior to the application month if the applicant meets the MBIC
eligibility requirements. A month prior to the application month is a
retroactive month. Prior to certifying MBIC eligibility for a retroactive
month, HHSC or its designee sends the applicant written notice of the monthly
premium amount for each eligible retroactive month and the due date for the
monthly premium payment. HHSC provides the applicant at least 60 days to submit
the premium payment for eligible retroactive months, in accordance with
42
U.S.C. 1396o(i)(3). HHSC or
its designee must receive, by the due date, a full premium payment for at least
one of the eligible retroactive months to certify MBIC eligibility for a
retroactive month. If HHSC or its designee receives a premium payment that is
less than the total amount due for all of the eligible retroactive months, then
HHSC or its designee applies the amount to the eligible retroactive months in
reverse chronological order.
(c)
Monthly premium amounts. HHSC determines the monthly premium amounts on a
sliding scale based on total monthly income as described in §
361.111(c)(3)(A)
of this chapter (relating to Income).
(1) For
a recipient who is not enrolled in employer-sponsored health insurance, HHSC
establishes full monthly premium amounts, up to the maximum amounts allowed by
federal law.
(2) For a recipient
who is enrolled in employer-sponsored health insurance and who receives premium
assistance from HHSC under §1906 of the Social Security Act (42 U.S.C.
1396e), HHSC establishes reduced monthly
premium amounts.
(d)
Monthly premium amounts for a family with more than one MBIC recipient. If
there is more than one MBIC recipient in a family, the family pays only one
monthly premium amount.
(e) Undue
hardship waivers. HHSC may, in its discretion, waive monthly premiums for undue
hardship. HHSC determines eligibility for the undue hardship waivers described
in paragraphs (1), (2), and (3) of this subsection based on information
provided at application or information provided as described in §
361.105 of this chapter (relating
to Applying and Providing Information). A recipient must apply for the undue
hardship waiver described in paragraph (4) of this subsection. HHSC does not
waive monthly premiums for any months prior to the application month.
(1) A recipient who is an American Indian or
Alaska Native as defined in
25
U.S.C. 1603(c),
25
U.S.C. 1603(f),
25 U.S.C.
1679(b) or who has been
determined eligible, as an Indian, pursuant to
42 C.F.R.
136.12 or Title V of the Indian Health Care
Improvement Act, to receive health care services is exempt from monthly
premiums for the duration of enrollment in MBIC.
(2) A recipient who is enrolled in
employer-sponsored health insurance, as determined by HHSC, and who does not
receive premium assistance from HHSC under §1906 of the Social Security
Act (42 U.S.C.
1396e) is exempt from monthly premiums for
MBIC as long as the recipient remains enrolled in employer-sponsored health
insurance and is not receiving premium assistance.
(3) A recipient residing in a federally
declared disaster area is exempt from monthly premiums for three months
beginning with the month in which the disaster is declared. A recipient may
only receive one undue hardship waiver per disaster.
(4) A recipient or authorized representative
may apply for an undue hardship waiver for loss of income.
(A) HHSC may grant an undue hardship waiver
for loss of income if the loss of income is due to:
(i) termination of employment because of a
layoff or business closing;
(ii) an
involuntary reduction in work hours;
(iii) a parent leaving the household because
of divorce or separation; or
(iv) a
parent's death.
(B) A
recipient who is determined by HHSC to be eligible for an undue hardship waiver
for loss of income may be exempt from monthly premiums for three
months.
(C) A recipient may only
receive one undue hardship waiver for loss of income per 12 months.
(D) An undue hardship waiver for loss of
income begins the first month for which HHSC or its designee did not receive a
premium payment for the recipient.
(f) Cost-share limits. A recipient is exempt
from monthly premiums for the remainder of the coverage period when the
cost-share expenditures for the recipient reach the cost-share limit. HHSC
determines the cost-share limit for a recipient, up to the maximum allowed by
42
U.S.C.
1396o(i)(2)(A).
(g) Tracking cost-share expenditures. For a
recipient without employer-sponsored health insurance, HHSC or its designee
determines when MBIC premium payments reach the cost-share limit. A recipient
with employer-sponsored health insurance must track cost-share expenditures on
the form provided by HHSC or its designee and report to HHSC or its designee
when the annual cost-share limit is reached. Eligible cost-share expenditures
include the monthly premiums for MBIC and cost sharing for employer-sponsored
health insurance. HHSC or its designee:
(1)
computes the cost-share limit for each recipient and informs the recipient of
the cost-share limit at enrollment;
(2) provides the recipient with a form for
keeping track of monthly premiums for MBIC and cost sharing for
employer-sponsored health insurance; and
(3) provides a refund if HHSC receives a
monthly premium payment that causes the recipient to exceed the cost-share
limit.
Notes
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