1 Tex. Admin. Code § 370.325 - Cost-Sharing Cap

(a) The aggregate annual Children's Health Insurance Program (CHIP) cost-sharing cap is based on household income (as defined in § 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 § 42 C.F.R. 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.

Notes

1 Tex. Admin. Code § 370.325

The provisions of this §370.325 adopted to be effective September 1, 2003, 28 TexReg 7337; Amended to be effective January 1, 2006, 30 TexReg 8674; Amended to be effective September 1, 2007, 32 TexReg 5359; Amended to be effective January 30, 2011, 36 TexReg 240; Amended to be effective March 1, 2012, 37 TexReg 1301; Amended to be effective January 1, 2014, 38 TexReg 9477; Amended to be effective June 1, 2014, 39 TexReg 3983