SECTION 370.321. Requirements and Exemptions

Cost-sharing requirements are based on a household's percentage of the Federal Poverty Level (FPL). Except for costs associated with unauthorized, non-emergency services provided to a member by out-of-network providers, the co-payments identified in this section are the only amounts a provider may collect from an applicant in regard to services provided to a member.

(1) An applicant may be required to pay any of the following costs of CHIP coverage for a member:

(A) an enrollment fee; and

(B) co-payments.

(2) HHSC determines the cost sharing amounts for enrollment in and services provided through CHIP. When determining cost sharing charges, HHSC will solicit public input by publishing proposed cost-sharing amounts and requesting comments. Cost sharing may be determined based on the maximum levels authorized under federal law and applied to income levels so as to minimize administrative costs.

(3) A member who is an American Indian/Alaska Native, as defined in 42 C.F.R. §457.10, is exempt from cost-sharing.

(4) HHSC or its designee notifies each MCO which of its members are exempt from cost-sharing.

(5) Co-payments do not apply, at any income level, to preventive health services, such as well-child or well-baby care visits and immunizations.

(6) A member's exemption from cost sharing is noted on the member's MCO Member Identification Card.

Source Note: The provisions of this §370.321 adopted to be effective September 1, 2003, 28 TexReg 7337; amended to be effective January 1, 2006, 30 TexReg 8674; amended to be effective March 1, 2012, 37 TexReg 1301; amended to be effective January 1, 2014, 38 TexReg 9477