D—1210 Health Insurance

CHIP, CHIP Perinatal

Third-party resources (TPR) are sources of payment for medical expenses other than the recipient or Medicaid. TPR includes payments from private and public health insurance and from other liable third parties that can be applied toward the recipient’s medical expenses. Note: Separate dental or vision plans, auto, workers’ compensation, county medical discount cards, student accident or sports-related insurance are not considered TPRs.

Consider Medicare a TPR. Do not certify a Medicare recipient for CHIP or CHIP Perinatal.

CHIP

Families who have health insurance that costs less than 10% of the family's net income are not eligible for CHIP coverage. Families whose health insurance costs 10% or more of the family's net income are eligible for CHIP coverage; however, the family must drop the insurance before CHIP coverage begins. Children cannot be covered by CHIP and health insurance at the same time.

When the CHIP administrator determines the family's health insurance premium costs 10% or more of its net income, a Missing Information letter is sent to request proof of the insurance end date.

If the family:

• does not provide proof, then the child is not eligible for CHIP and the application is denied.
• provides proof of the insurance end date, the CHIP administrator ensures the CHIP coverage does not begin before the end date of the current private health insurance.

Acceptable verification of the private health insurance end date includes:

• health insurance ID card indicating the end date,
• letter from the employer indicating the end date, or
• the client's statement by phone or in writing.

At any time during the child's enrollment segment, if HHSC notifies the CHIP administrator that the child remains on health insurance or that the child has Medicare, the CHIP administrator takes appropriate action to disenroll the child.

Related Policy
Health Insurance Changes, D-1437
Health Insurance, D-1631.2
Exceptions to the Continuous Enrollment Period, D-1731

CHIP Perinatal

Pregnant women with any type of private health insurance are not eligible for perinatal coverage, even if the current health insurance does not provide maternity coverage. Pregnant women cannot be covered by perinatal and private health insurance at the same time. The 10% rule that applies to CHIP does not apply to CHIP perinatal.

Related Policy
Health Insurance Changes, D-1437
Exceptions to the Continuous Enrollment Period, D-1731

D—1220  Teacher Retirement System

CHIP

Children of participating employees of the Teacher Retirement System (TRS) may be enrolled in Active Care. Active Care is a private health insurance offered by TRS. TRS provides the CHIP administrator with a list of all participating school districts and/or schools annually. Upon identification that an employee is applying on behalf of his/her child, the CHIP administrator must determine whether the child is enrolled in the Active Care program. If the child is not enrolled in Active Care, the child may qualify for CHIP. If the child is enrolled in Active Care, the CHIP administrator applies the private health insurance rules before enrolling the child in CHIP.