SECTION 370.303. Completion of Enrollment

(a) To complete CHIP enrollment, an applicant must:

(1) select and indicate on the enrollment form a health care MCO and a dental MCO for all eligible children;

(2) select a PCP and a dental home, and place the names on the enrollment form;

(3) if applicable, indicate if an eligible child has special health care needs based on criteria in the member guide;

(4) sign and return the enrollment form; and

(5) pay any applicable enrollment fee on or before the due date.

(b) If an applicant does not pay an applicable enrollment fee as described in subsection (a) of this section, the child is not enrolled in CHIP.

(c) Notwithstanding subsections (a) and (b) of this section, if an application is for a child enrolled in Medicaid transitioning to CHIP after being determined ineligible for Medicaid before the end of the child's Medicaid certification period, the child may be enrolled in CHIP prior to payment of the enrollment fee. However, if the enrollment fee is not paid on or before the due date, the child is disenrolled.

(d) An applicant may select a PCP, dental home, health care MCO, and dental MCO by mail, telephone, or facsimile. Unless the application is for a perinate receiving expedited enrollment in accordance with §370.401 of this chapter (relating to Perinates), the applicant will have 30 calendar days from the date the enrollment packet is mailed to choose a health care MCO, dental MCO, PCP, and dental home. If the applicant does not choose a health care MCO, dental MCO, PCP, or dental home within the time period established by HHSC, HHSC or its designee will assign one using the default assignment methodologies described in this section.

(e) PCP assignment. If an applicant has not selected a PCP, the health care MCO will assign one using an algorithm that considers:

(1) the child's established history with a PCP, as demonstrated by encounter history with the provider in the preceding year, if available;

(2) the geographic proximity of the child's home address to the PCP;

(3) whether the provider serves as a PCP to other members of the child's household;

(4) limitations on default assignment, such as PCP restrictions on age, gender, and capacity; and

(5) other criteria approved by HHSC.

(f) Dental home assignment. If an applicant has not selected a dental home, the dental MCO will assign one using an algorithm that considers:

(1) the child's established history with a dental home, as demonstrated by encounter history with the provider in the preceding year, if available;

(2) the geographic proximity of the child's home address to the dental home;

(3) whether the provider serves as the dental home to other members of the child's household;

(4) limitations on default assignment, such as dental home restrictions on age and capacity; and

(5) other criteria approved by HHSC.

(g) MCO assignment. If an applicant has not selected a health care MCO or dental MCO, HHSC or its administrative services contractor will assign one using an algorithm that considers the child's history, including PCP or dental home when possible. If this is not possible, HHSC or its administrative services contractor will equitably distribute members among qualified MCOs, using an algorithm that considers one or more of the following factors:

(1) whether the child was previously enrolled in the MCO in Medicaid or CHIP;

(2) whether other members of the child's household are enrolled in the MCO in Medicaid or CHIP;

(3) MCO performance;

(4) the greatest variance between the percentage of elective and default enrollments (with the percentage of default enrollments subtracted from the percentage of elective enrollments);

(5) capitation rates;

(6) market share; and

(7) other criteria determined by HHSC.

(h) Modified default enrollment process. HHSC has the option to implement a modified default enrollment process for MCOs when contracting with a new MCO or implementing managed care in a new service area, or when it has placed an MCO on full or partial enrollment suspension.

(i) Request to change dental home or PCP. There is no limit on the number of times a member can request to change his or her dental home or PCP. A member can request a change in writing or by calling the MCO's toll-free member hotline.

Source Note: The provisions of this §370.303 adopted to be effective September 1, 2003, 28 TexReg 7337; amended to be effective January 1, 2006, 30 TexReg 8666; amended to be effective September 1, 2007, 32 TexReg 5359; amended to be effective March 1, 2012, 37 TexReg 1301; amended to be effective July 8, 2012, 37 TexReg 4854; amended to be effective January 1, 2014, 38 TexReg 9477; amended to be effective June 1, 2014, 39 TexReg 3983; amended to be effective October 9, 2016, 41 TexReg 7711