SECTION 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.

Source Note: 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