The Texas Health and Human Services Commission (HHSC) proposes an amendment to Subchapter A, Program Administration, §370.4, Definitions. HHSC proposes to repeal Subchapter B, Division 5, Review and Reconsideration/Eligibility Denials and Temporary Enrollment, §§370.50 - 370.54. Simultaneously, HHSC proposes new review and reconsideration rules in new Subchapter E, Review and Reconsideration Process; Complaint Process, §§370.411, 370.413, 370.415, 370.417, 370.419, 370.421, 370.423, 370.425, 370.427, 370.429, 370.431, 370.433, and 370.435.

HHSC also proposes new Subchapter C, Enrollment, Disenrollment, and Renewal of Membership, Division 1, TexCare Partnership Enrollment, §§370.301, 370.303, 370.305, 370.307, and 370.309; Division 2, Cost Sharing Requirements, §§370.321, 370.323, and 370.325; Division 3, Reporting Changes in Status During the Enrollment Period, §§370.331, 370.333, and 370.335; Division 4, Disenrollment Process, §§370.341, 370.343, 370.345, 370.347, 370.349, 370.351, and 370.353; Division 5, Member Rights and Privacy Protections, §§370.361 and 370.363; and Division 6, Renewal Process, §§370.371, 370.373, 370.375, 370.377, 370.379, and 370.381.

Background and Summary of Factual Basis for the Rules

Chapter 62, Health and Safety Code, establishes the State Child Health Plan (CHIP) authorized under Title XXI of the federal Social Security Act, 42 U.S.C. §§1397aa, et seq. Section 62.051, Health and Safety Code, designates HHSC as the agency responsible for developing the state-designed child health plan program for Texas, making policy for the program, and adopting rules as necessary to implement Chapter 62. Section 62.104 directs HHSC to develop eligibility screening and enrollment procedures for CHIP.

Chapter 63, Health and Safety Code, authorizes health benefits coverage for certain children who are ineligible for CHIP, authorized under Chapter 62, or the state Medicaid program. HHSC is directed to develop and implement this plan, which to the extent possible must provide benefits comparable to the plan established under Chapter 62.

Section-by-Section Summary

Subchapter A of the proposed rules governs CHIP program administration. Section 370.4 provides definitions for terms used in the CHIP program and is amended to include additional terms used in proposed new Subchapter C, Enrollment, Disenrollment, and Renewal of Membership and proposed new Subchapter E, Review and Reconsideration Process; Complaint Process. The definitions have been renumbered to reflect the additional terms. HHSC proposes to repeal Division 5, Review and Reconsideration/Eligibility Denials and Temporary Enrollment, and to replace it with proposed Subchapter E, Review and Reconsideration Process; Complaint Process, §§370.411, 370.413, 370.415, 370.417, 370.419, 370.421, 370.423, 370.425, 370.427, 370.429, 370.431, 370.433, and 370.435. The proposed new Subchapter E, Review and Reconsideration Process; Complaint Process, consolidates the eligibility, enrollment, and health services matters review process. Section 370.411 identifies the matters that are subject to review by TCP and reconsideration by HHSC and explains the circumstances in which there is no right of review or reconsideration; §370.413 explains when an applicant or member may request reconsideration by HHSC. Section 370.415 describes the notice that TCP is required to provide once it makes an adverse eligibility or enrollment determination. Section 370.417 explains how an applicant or member may request a review of an adverse eligibility or enrollment determination. Conduct of the review is set forth in §370.419. Section 370.421 and §370.423 set forth the timelines for review and for reconsideration, respectively. Section 370.425 explains when TCP will grant continuation of enrollment pending review of a disenrollment decision. Temporary and retroactive enrollment is discussed in §370.427. Section 370.429 identifies what constitutes a health services matter. Section. 370.431 describes a member's right to file a complaint concerning an adverse health services determination made by a health plan provider under Chapter 20A and article 21.58A of the Insurance Code. Section 370.433 states the requirement that investigation and resolution of complaints concerning adverse health services matters must be concluded in accordance with the medical needs of the child. Section 370.435 addresses situations in which these rules may conflict with state insurance statutes and regulations.

Proposed new Subchapter C governs enrollment, disenrollment, and renewal of membership in CHIP. Division 1 addresses enrollment issues. Section 370.301 identifies the contents of the CHIP enrollment packet. Section 370.303 explains how to complete the enrollment process. Section 370.305 governs the enrollment process for children with complex special health care needs. Section 370.307 explains CHIP's continuous enrollment period. Section 370.309 explains what happens if an enrollment packet is submitted that is incomplete or missing required information. Division 2 of proposed new Subchapter C governs cost-sharing requirements. Sections 370.321, 370.323, and 370.325 explain the cost-sharing requirements, the exemptions to cost-sharing, and the annual cost-sharing cap.

Division 3 of proposed new Subchapter C governs reporting changes in status during an enrollment period. Section 370.331 explains what happens if a member reports change in status that lower the budget group's percentage of federal poverty level income guidelines. Section 370.333 explains what will happen when a member reports that she is pregnant. Section 370.335 discusses changes to a member's health plan. Division 4 governs the disenrollment process. The reasons for disenrollment are described in §370.341. Section 370.343 sets forth the notice requirement for the disenrollment process. Disenrollment based on self-reported changes in status is discussed in §370.345. Section 370.347 explains the disenrollment process for failure to meet monthly cost-sharing obligations. Section 370.349 and §370.351 describe the good cause exceptions to disenrollment. Section 370.353 governs reinstatement of a member disenrolled for failure to meet monthly cost-sharing obligations.

Division 5, §370.361 and §370.363 address members' rights and privacy protections. Division 6 governs the renewal process. Section 370.371 explains when the renewal process begins and describes TCP's notification procedures. Section 370.373 explains how to complete renewal forms. Section 370.375 governs enrollment fees and monthly premiums due at renewal. Incomplete renewal applications are discussed in §370.377. Section 370.379 describes denials of eligibility during renewal. Incomplete renewal applications are discussed in §370.381.

The enrollment rules describe current TexCare partnership business practices related to enrollment policy for the Children's Health Insurance Program (CHIP). These business processes reflect the requirements of the State Child Health Plan under Chapter 62 of the Health and Safety Code as implemented by HHSC and TCP, the third party administrator for CHIP enrollment.

Chapter 62 authorizes, under certain circumstances, that HHSC take steps to limit enrollment in the CHIP program should available funds be insufficient to sustain enrollment levels. This proposed rule does not implement any enrollment caps or open-enrollment periods. As indicated above, this rule describes current HHSC enrollment policy and TCP business practices. In the event that any limits on CHIP enrollment should become necessary, HHSC will publish those proposed rules separately.

Fiscal Note

Don Green, Chief Financial Officer, has determined that for the first five years that the proposed rules are in effect, there will be no new or additional fiscal impact to the state or federal government. The proposed rules describe and will incorporate into state rules existing HHSC enrollment policies and the related business practices of the TexCare Partnership, HHSC's contractor for enrollment and other administrative services. The cost of these services has already been incurred by HHSC through the implementation of Senate Bill 445, 76th Legislature (1999), the legislation authorizing the state child health plan. No additional costs will be borne by local governments as a result of the rules other than costs borne by local governments that contract with the HHSC to provide health care benefits or community-based outreach services, nor is there any anticipated negative impact on revenues of state or local government.

Public Benefit

Mr. Green has also determined that during the first five years that the proposed rules are in effect, the public will benefit from adoption of the rules by making low-cost insurance for children of low-income families more accessible and clarifying the enrollment, disenrollment, and renewal processes. The public will also benefit from the clarification of the review and reconsideration processes for adverse eligibility and enrollment determinations and the explanation of the complaint procedure for adverse health services matters determinations.

Small and Micro-business Impact Analysis

The proposed rules will not result in additional costs to persons required to comply with the rules other than the cost of insurance premiums for families with cost-sharing obligations under the CHIP program, nor do the rules have any anticipated adverse affect on small or micro-businesses. The rules will not negatively affect local employment.

Regulatory Analysis

HHSC has determined that none of the proposed rules is a "major environmental rule" as defined by §2001.0225, Government Code. "Major environmental rule" is defined to mean a rule the specific intent of which is to protect the environment or reduce risks to human health from environmental exposure and that may adversely and materially affect the economy, a sector of the economy, productivity, competition, jobs, the environment, or the public health and safety of the state or a sector of the state. None of the proposed rules is specifically intended to protect the environment or reduce risks to human health from environmental exposure.

Takings Impact Assessment

HHSC has evaluated the takings impact of the proposed rules under §2007.043, Government Code. HHSC has determined that this action does not restrict or limit an owner's right to his or her property that would otherwise exist in the absence of governmental action and therefore does not constitute a taking. The proposed rules are administrative and do not impose any new regulatory requirements. The proposed rules are reasonably taken to fulfill requirements of state law.

Public Comment

Public comment may be submitted in writing to Carlotta Vann, Health and Human Services Commission, by mail addressed to P.O. Box 13247, Austin, Texas 78711, or e-mail at Carlotta.Vann@hhsc.state.tx.us, or by facsimile to (512) 794-5136. Comments must be submitted by 5:00 p.m., Central Time, May 6, 2002. Further information may be obtained by calling Carlotta Vann at (512) 685-3170.

Public Hearing

HHSC has scheduled a public hearing to accept public testimony regarding the proposed rules. The hearing will be held from 2:30 to 4:30 p.m., Central Time, on April 16, 2002, in the Public Hearing Room of the Brown-Heatly State Office Building, 4900 North Lamar Boulevard, Austin, Texas. Persons requiring further information, special assistance, or accommodations should contact Anita Garcia at (512) 794-6838.

Subchapter A. PROGRAM ADMINISTRATION