|The Medicaid/Children's Health Insurance (CHIP) Division
of the Health and Human Services Commission and the Department of Human
Services (DHS) invite public comment on the proposed implementation of
Senate Bill 43, Seventy-seventh Legislature.
In addition to the project implementation plan outlined below, the
following attachments are included for review:
SB 43 requires major changes in Medicaid eligibility policy for
children under age 19. The law does not make any Medicaid eligibility
changes for children age 19 and 20. The legislation's primary focus is
to make children's Medicaid simpler and more like the CHIP program by
unifying the application process and streamlining eligibility approval
processes. The bill's Eligibility Transition provisions require the
elimination of gaps in coverage when children are moving between CHIP
and Medicaid. Two provisions in the bill -- the Health Care Orientation
requirement and the THSteps provisions -- require the development of new
processes and additional system and staff effort to ensure better
utilization of preventive care and the health care system in general.
The bill's requirements fall into four major areas:
- Application Simplification
- Continuous Eligibility and Eligibility Transition with CHIP
- Health Care Orientation (HCO)
- Participation in THSteps
Outline of Proposed Components and Processes
A. Application Simplification (Phase I)
- The TexCare Partnership (TCP) and the DHS children's Medicaid
application will become a joint application.
- DHS mailed-out applications or applications obtained in person
from DHS will omit the TCP 1-800 number at header and will omit the
U.S. DHHS civil rights number in the Rights and Responsibilities
section. Phone numbers for assistance and civil rights (at local DHS
office) will be addressed in DHS cover letter.
- These two differences recognize that sending families to TCP for
assistance with an application obtained from DHS is likely to be
confusing and that DHS local offices have an internal civil rights
process, unlike TCP.
- The assets questions and additional questions for Medicaid will be
included on the joint application and will not be asked as a second
step. This process and the additional questions and items will
improve and speed the processing of all applications, whether
applicants eventually enroll in CHIP or Medicaid.
- DHS applicants wanting TANF, Food Stamps or adult Medicaid will
still use the DHS form. If applicants want children's Medicaid in
addition to any of these other program benefits, they will complete
both the DHS and the TCP simplified children's health insurance
application. However, if applicants mail in ONLY the old DHS form
and intend to apply for children's Medicaid, DHS will process that
form for children's Medicaid eligibility.
- Any applications distributed in bulk in the community by DHS will
be the TCP application folder and will be mailed to TCP.
- The header on application will be "TexCare Partnership
- A social security number (SSN) or documentation of application for
a SSN will be required on the joint application. A SSN is considered
essential for a "seamless" application system between CHIP
and Medicaid and is also useful in improving child support and
medical support efforts (per Senate Bill 236).
- Assistance in applying for a SSN will be offered. Currently, about
75% of TCP applicants already provide SSNs on the submitted
- As an interim approach, TCP will discontinue/recycle existing TCP
application stock and start sending out the new joint application.
For an interim period, the application may be black and white with
updated instructions for SSN.
- The online application will be changed to be consistent with the
written application and the SSN change.
- TCP will continue to process any old stock applications. If a SSN
is not provided, the family will get a missing information letter
(similar to any of the other missing information letters).
- For Phase I, DHS mailed-out applications or applications provided
at DHS offices will be mailed to DHS. TCP applications will be
mailed to TCP. This process will be reviewed for Phase II.
- All of the above are interim steps to implement key provisions of
SB 43. Additional consolidation and changes may be made as Phase II
changes after field testing and further reengineering of TCP and/or
DHS business processes.
B. Medicaid Process Simplification and Continuous Eligibility
New DHS Policies
- Initial applications and renewals for children's Medicaid may be
processed by mail or telephone.
- Children under 19 are certified for 6-month periods, and remain
continuously eligible regardless of changes in household
composition, income and resources.
- A Medicaid renewal form asking the same questions as the CHIP form
will be sent to the family in the 4th month of their 6-month
continuous eligibility period. The form includes an option to state
there have been no changes and to return the form without completing
the entire renewal form.
- Applications may be accepted at any health
and human services agency.
- Applications may be filed at hospitals, county health departments,
and federally qualified health centers (FQHCs). List
- Each DHS region will contract with hospitals, health departments
and FQHCs to accept applications. Contracts will specify the length
of time by which the provider must get the applications to the DHS
office for processing.
- Documentation and verification procedures for children under 19
will be the same as the requirements for CHIP. Assets questions are
the same and do not require verification.
C. Eligibility Transition
DHS and Birch and Davis (the TCP administrative services contractor)
business processes will be reengineered to eliminate gaps in coverage
for children moving between CHIP and Medicaid. For families whose
eligibility periods "straddle" the January 1 start date, DHS
may manually extend Medicaid eligibility for 1-2 months as needed. For
families whose Medicaid continuous eligibility periods begin on or after
January 1, the system reprogramming will prevent system-caused gaps in
New DHS Policy
- Medicaid renewal packets will be mailed at the beginning of the
4th month of a child's 6-month eligibility period. Completion of the
renewal process by the middle of the 5th month will allow sufficient
time to "deem" (or automatically enroll) a child to CHIP
when he/she is no longer eligible for Medicaid due to income or
assets. Eligibility for Medicaid continues through the end of the
6th month. The family receives an enrollment packet as soon as the
deeming process occurs. If the enrollment packet is received at TCP
by the middle of the 6th month, enrollment in CHIP is effective the
first of the 7th month (no gap in health coverage).
- It will be important for families to promptly return Medicaid
renewal packets to DHS, and to promptly return the enrollment packet
to CHIP after deeming, to ensure no gap in coverage. If there is a
delay due to Birch & Davis or DHS error, Medicaid eligibility
may be extended 1 or 2 additional months to allow the family time to
complete the process and still retain coverage.
- Reminders will be mailed to families about importance of keeping
Medicaid coverage, and the availability of CHIP, at beginning of 5th
month if renewal form hasn't been received.
TCP / Birch and Davis System Changes - Eligibility Transition:
- A "Medicaid end date" field will be added to the daily
DHS electronic "deem to CHIP" file. This change will
better coordinate the ending date (for a child leaving Medicaid)
with the child's start date in CHIP.
- The existing TCP Enrollment Confirmation and Enrollment
packet/welcome letters will be revised to accommodate the change
- As of January 1, 2002, the TCP process will look for a SSN (or
proof of application to SSA for a SSN) for every applying child.
- For applications lacking a SSN, a missing information letter that
addresses both the need on the part of the family to submit SSN
information and that explains the reason for this change will be
- TCP will develop a process to assist families with SSN
- A reminder letter will be developed for families to forward SSN
(for those families that supplied verification of application for
- TCP will develop new CBO training materials to reflect the new SSN
requirement and provide training to CBOs on SSN application
D. Health Care Orientation (HCO) for Parents and Guardians of
- Generally, the HCO requirement is a one-time requirement.
- Only parents or guardians whose children are newly Medicaid
certified after January 1, 2002, are subject to the HCO requirement.
- Families with prior Medicaid coverage, but with gaps in service
greater than two years will need to meet the HCO requirement.
- Children who become eligible for Medicaid through an application
to the Social Security Administration for SSI or SSI-related
Medicaid programs are not subject to the HCO requirement.
- There will be multiple opportunities to meet the HCO requirement.
The parent or guardian may:
- attend an in-person HCO provided by THSteps or volunteer CBO
in a group setting, or in a one-on-one session in an office or
the caretaker's home;
- take the child to a THSteps medical check-up or for a
medical visit for any reason. Medical visits to an emergency
room will not qualify as an HCO (this system requires no extra
effort on the medical provider's part);
- get the HCO over the phone by THSteps staff and
concurrently in the mail as an insert in the DHS notification of
certification letter; or
- get the HCO in a DHS office with a DHS caseworker at the
time of application or at a face-to-face renewal visit.
- Although HCOs can be accomplished with CBOs, through medical
visits, medical check-ups, and at DHS offices, THSteps (including
MAXIMUS in contracted areas) is ultimately responsible for assuring
that caretakers receive the HCO.
- THSteps will offer the telephone HCO on the first telephone
contact with all parents and guardians, yet still encourage the
caretaker to make an appointment for a face-to-face HCO.
- It the parent or guardian does not complete the HCO requirement,
they may be required to renew the child's Medicaid in person at a
DHS office. If this occurs, he/she will receive the HCO from DHS at
that time, which will fulfil the one-time HCO requirement.
- Only medical visits and medical check-ups will fulfill the HCO
requirement; dental visits or dental check-ups will not fulfill this
- If the caretaker reports to THSteps or DHS that the child has been
to a medical appointment or THSteps medical check-up since the
initial certification for Medicaid, the HCO requirement will be
completed. DHS will verify the THSteps medical check-up visit at a
later date, through the claims processing system.
- When a THSteps worker assists a family in scheduling a medical
check-up appointment, or if a caretaker reports to the worker that
he/she has scheduled the medical check-up or a medical appointment,
the worker will credit the family as having completed the HCO.
- The HCO will be developed in English, Spanish, and Vietnamese.
Clients speaking other languages will be referred to the THSteps
call center for AT&T translation services. Caretakers with
hearing impairments can contact THSteps through the Relay Texas
- THSteps outreach staff and CBOs will coordinate with MAXIMUS
enrollment broker staff to include health plan-specific information
as an area-specific addendum to the statewide training curriculum.
This will allow the caretaker to attend only one HCO to learn about
THSteps, appropriate use of health insurance, and how to enroll in a
health plan, where appropriate.
- THSteps will test the HCO script in at least two areas of the
state (rural and urban) and make subsequent revisions to the script
before producing the final version for publication.
- DHS will begin mailing an updated Medicaid User's Guide to parents
and guardians statewide when it becomes available. Caretakers will
also receive a one-page summary of HCO content in their notification
letter, as well as a resource page of important phone numbers as a
handout at the time of the HCO.
- CBO participation in the HCO program will be on a voluntary basis.
- CBOs will designate a HCO contact person, who will attend a
train-the-trainer session. This contact person will be responsible
for assuring that other CBO staff and volunteers are trained before
E. Participation in THSteps
Proposed SB 43 Process
- Similar to the current THSteps process for TANF families, the SB
43 THSteps requirement will be applied to children starting at age
2. Children under age 2 typically have high compliance.
- Generally, children over age 2 are required to have an annual
THSteps medical check-up visit. Medical check-ups are not required
for ages 7 and 9.
- Following initial certification for Medicaid, THSteps staff will
contact the family (see HCO section) and encourage and assist (if
needed) the family to schedule a medical check-up visit for the
child or children.
- If no medical check-up is indicated on the DHS eligibility system
at the time the Medicaid renewal process begins, the family is
notified and given the opportunity to self-declare that the child
has had the medical check-up, the child is currently scheduled for
the medical check-up, or has good cause reason (using current
THSteps good cause policy) for not completing the medical check-up.
- Good cause reasons include:
- Medical - A medical provider may decide that for medical
reasons a check-up is not required (e.g., the child is ill or
has a chronic illness; doctor documentation of recent medical
check-up visit; or provider discretion based on health status of
the child, etc.)
- Religion - The family has a religious belief that does not
allow the child to have a medical check-up.
- No medical provider or transportation - There is no medical
provider or transportation available within the family's
- If the family indicates that the child has had the medical
check-up or is scheduled for the medical check-up, or had a good
cause reason, the DHS advisor updates the DHS eligibility system and
the family can renew Medicaid eligibility by mail.
- If the child is overdue for the medical check-up and there is no
self-declaration otherwise or a good cause exception, the family
will be required to renew Medicaid coverage in person at a DHS
Improvement to Data Systems:
The current data systems for capturing THSteps medical check-up
information do not adequately capture all completed medical check-ups.
This necessitates a flexible self-declaration process when the system
does not indicate a medical check-up. Planned improvements to data
- Improved data on Medicaid managed care claims.
- Manually verified medical check-up dates.
- Acceptance of data from other sources.
- Expansion of database to include filed as well as paid and