SECTION 370.46. Waiting Period

(a) The waiting period is a delay in the start of health care coverage that:

(1) applies to a child who was covered by a health benefits plan at any time during the 90 days before the date of application for coverage; and

(2) extends for a period of 90-days after the last date on which the applicant was covered under a health benefits plan.

(b) Health Insurance, for purposes of this section, is not workers compensation or personal injury protection under an automobile insurance policy.

(c) The 90-day waiting period specified in subsection (a) of this section does not apply to a child under the following circumstances:

(1) The child lost health insurance coverage because:

(A) A change in employment resulted in the child's loss of employer-sponsored insurance (other than through full payment of the premium by the parent under COBRA);

(B) The employer stopped offering coverage of dependents (or any coverage) under an employer-sponsored health insurance plan;

(C) Insurance benefits under the Consolidated Omnibus Budget Reconciliation Act of 1985 (Pub. L. No. 99-272) terminated;

(D) The marital status of a parent of the child has changed;

(E) The child's parent dies;

(F) The child's eligibility and enrollment in Medicaid or another insurance affordability program was terminated; or

(G) Other circumstances similar to those described in this subparagraph that result in an involuntary loss of insurance coverage;

(2) The child had health insurance coverage provided by ERS, or CHIP in another state;

(3) The cost of family coverage that includes the child exceeds 9.5 percent of the household income;

(4) The child has access to group-based health insurance coverage and will participate in the premium payment reimbursement program administered by HHSC;

(5) The premium paid by the family for coverage of the child under the group health plan exceeded 5 percent of the household income;

(6) The child has special health care needs; or

(7) HHSC grants an exception to the waiting period under subsection (d) of this section.

(d) HHSC may grant an exception to the 90-day waiting period prescribed by this section if it determines good cause exists to grant an exception and either:

(1) An Applicant requests an exception:

(A) Prior to submission of an Application;

(B) At the time of Application; or

(C) As part of a request for review or reconsideration of a denial of eligibility under §370.52 of this subchapter (relating to Disposition of a Request for Review) or §370.54 of this subchapter (relating to Temporary Enrollment Pending Disposition of Review or Reconsideration); or

(2) HHSC reaches a determination that good cause exists based either on information provided by an Applicant or information otherwise obtained by HHSC.

Source Note: The provisions of this §370.46 adopted to be effective April 4, 2001, 26 TexReg 2519; amended 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 January 1, 2014, 38 TexReg 9477; amended to be effective June 1, 2014, 39 TexReg 3983