CHAPTER 62. CHILD HEALTH PLAN FOR CERTAIN LOW-INCOME CHILDREN - Texas Statutes

HEALTH AND SAFETY CODE

TITLE 2. HEALTH

SUBTITLE C. PROGRAMS PROVIDING HEALTH CARE BENEFITS AND SERVICES

CHAPTER 62. CHILD HEALTH PLAN FOR CERTAIN LOW-INCOME CHILDREN

SUBCHAPTER A. GENERAL PROVISIONS

Sec. 62.001. OBJECTIVE OF THE STATE CHILD HEALTH PLAN. The

principal objective of the state child health plan is to provide

primary and preventative health care to low-income, uninsured

children of this state, including children with special health

care needs, who are not served by or eligible for other state

assisted health insurance programs.

Added by Acts 1999, 76th Leg., ch. 235, Sec. 1, eff. Aug. 30,

1999.

Sec. 62.002. DEFINITIONS. In this chapter:

(1) "Commission" means the Health and Human Services Commission.

(2) "Commissioner" means the commissioner of health and human

services.

(3) "Health plan provider" means an insurance company, health

maintenance organization, or other entity that provides health

benefits coverage under the child health plan program. The term

includes a primary care case management provider network.

(4) "Net family income" means the amount of income established

for a family after reduction for offsets for child care expenses,

in accordance with standards applicable under the Medicaid

program.

Added by Acts 1999, 76th Leg., ch. 235, Sec. 1, eff. Aug. 30,

1999. Amended by Acts 2003, 78th Leg., ch. 198, Sec. 2.45, eff.

Sept. 1, 2003.

Amended by:

Acts 2007, 80th Leg., R.S., Ch.

1353, Sec. 1, eff. June 15, 2007.

Sec. 62.003. NOT AN ENTITLEMENT; TERMINATION OF PROGRAM. (a)

This chapter does not establish an entitlement to assistance in

obtaining health benefits for a child.

(b) The program established under this chapter terminates at the

time that federal funding terminates under Title XXI of the

Social Security Act (42 U.S.C. Section 1397aa et seq.), as

amended, unless a successor program providing federal funding for

a state-designed child health plan program is created.

(c) Unless the legislature authorizes the expenditure of other

revenue for the program established under this chapter, the

program terminates on the date that money obtained by the state

as a result of the Comprehensive Settlement Agreement and Release

filed in the case styled The State of Texas v. The American

Tobacco Co., et al., No. 5-96CV-91, in the United States District

Court, Eastern District of Texas, is no longer available to

provide state funding for the program.

Added by Acts 1999, 76th Leg., ch. 235, Sec. 1, eff. Aug. 30,

1999.

Sec. 62.004. FEDERAL LAW AND REGULATIONS. The commissioner

shall monitor federal legislation affecting Title XXI of the

Social Security Act (42 U.S.C. Section 1397aa et seq.) and

changes to the federal regulations implementing that law. If the

commissioner determines that a change to Title XXI of the Social

Security Act (42 U.S.C. Section 1397aa et seq.) or the federal

regulations implementing that law conflicts with this chapter,

the commissioner shall report the changes to the governor,

lieutenant governor, and speaker of the house of representatives,

with recommendations for legislation necessary to implement the

federal law or regulations, seek a waiver, or withdraw from

participation.

Added by Acts 1999, 76th Leg., ch. 235, Sec. 1, eff. Aug. 30,

1999.

SUBCHAPTER B. ADMINISTRATION OF CHILD HEALTH PLAN PROGRAM

Sec. 62.051. DUTIES OF COMMISSION. (a) The commission shall

develop a state-designed child health plan program to obtain

health benefits coverage for children in low-income families. The

commission shall ensure that the child health plan program is

designed and administered in a manner that qualifies for federal

funding under Title XXI of the Social Security Act (42 U.S.C.

Section 1397aa et seq.), as amended, and any other applicable law

or regulations.

(b) The commission is the agency responsible for making policy

for the child health plan program, including policy related to

covered benefits provided under the child health plan. The

commission may not delegate this duty to another agency or

entity.

(c) The commission shall oversee the implementation of the child

health plan program and coordinate the activities of each agency

necessary to the implementation of the program, including the

Texas Department of Health, Texas Department of Human Services,

and Texas Department of Insurance.

(d) The commission shall adopt rules as necessary to implement

this chapter. The commission may require the Texas Department of

Health, the Texas Department of Human Services, or any other

health and human services agency to adopt, with the approval of

the commission, any rules that may be necessary to implement the

program. With the consent of another agency, including the Texas

Department of Insurance, the commission may delegate to that

agency the authority to adopt, with the approval of the

commission, any rules that may be necessary to implement the

program.

(e) The commission shall conduct a review of each entity that

enters into a contract under Section 62.055 or Section 62.155, to

ensure that the entity is available, prepared, and able to

fulfill the entity's obligations under the contract in compliance

with the contract, this chapter, and rules adopted under this

chapter.

(f) The commission shall ensure that the amounts spent for

administration of the child health plan program do not exceed any

limit on those expenditures imposed by federal law.

Added by Acts 1999, 76th Leg., ch. 235, Sec. 1, eff. Aug. 30,

1999.

Sec. 62.052. DUTIES OF TEXAS DEPARTMENT OF HEALTH. (a) The

commission may direct the Texas Department of Health to:

(1) implement contracts with health plan providers under Section

62.155;

(2) monitor the health plan providers, through reporting

requirements and other means, to ensure performance under the

contracts and quality delivery of services;

(3) monitor the quality of services delivered to enrollees

through outcome measurements including:

(A) rate of hospitalization for ambulatory sensitive conditions,

including asthma, diabetes, epilepsy, dehydration,

gastroenteritis, pneumonia, and UTI/kidney infection;

(B) rate of hospitalization for injuries;

(C) percent of enrolled adolescents reporting risky health

behavior such as injuries, tobacco use, alcohol/drug use, dietary

behavior, physical activity, or other health related behaviors;

and

(D) percent of adolescents reporting attempted suicide; and

(4) provide payment under the contracts to the health plan

providers.

(b) The commission, or the Texas Department of Health under the

direction of and in consultation with the commission, shall adopt

rules as necessary to implement this section.

Added by Acts 1999, 76th Leg., ch. 235, Sec. 1, eff. Aug. 30,

1999.

Sec. 62.053. DUTIES OF TEXAS DEPARTMENT OF HUMAN SERVICES. (a)

Under the direction of the commission, the Texas Department of

Human Services may:

(1) accept applications for coverage under the child health plan

and implement the child health plan program eligibility screening

and enrollment procedures;

(2) resolve grievances relating to eligibility determinations;

and

(3) coordinate the child health plan program with the Medicaid

program.

(b) If the commission contracts with a third party administrator

under Section 62.055, the commission may direct the Texas

Department of Human Services to:

(1) implement the contract;

(2) monitor the third party administrator, through reporting

requirements and other means, to ensure performance under the

contract and quality delivery of services; and

(3) provide payment under the contract to the third party

administrator.

(c) The commission, or the Texas Department of Human Services

under the direction of and in consultation with the commission,

shall adopt rules as necessary to implement this section.

Added by Acts 1999, 76th Leg., ch. 235, Sec. 1, eff. Aug. 30,

1999.

Sec. 62.054. DUTIES OF TEXAS DEPARTMENT OF INSURANCE. (a) At

the request of the commission, the Texas Department of Insurance

shall provide any necessary assistance with the development of

the child health plan. The department shall monitor the quality

of the services provided by health plan providers and resolve

grievances relating to the health plan providers.

(b) The commission and the Texas Department of Insurance may

adopt a memorandum of understanding that addresses the

responsibilities of each agency in developing the plan.

(c) The Texas Department of Insurance, in consultation with the

commission, shall adopt rules as necessary to implement this

section.

Added by Acts 1999, 76th Leg., ch. 235, Sec. 1, eff. Aug. 30,

1999.

Sec. 62.055. CONTRACTS FOR IMPLEMENTATION OF CHILD HEALTH PLAN.

(a) It is the intent of the legislature that the commission

maximize the use of private resources in administering the child

health plan created under this chapter. In administering the

child health plan, the commission may contract with a third party

administrator to provide enrollment and related services under

the state child health plan.

(b), (c) Repealed by Acts 2003, 78th Leg., ch. 198, Sec.

2.156(a)(1).

(d) A third party administrator may perform tasks under the

contract that would otherwise be performed by the Texas

Department of Health or Texas Department of Human Services under

this chapter.

(e) The commission shall:

(1) retain all policymaking authority over the state child

health plan;

(2) procure all contracts with a third party administrator

through a competitive procurement process in compliance with all

applicable federal and state laws or regulations; and

(3) ensure that all contracts with child health plan providers

under Section 62.155 are procured through a competitive

procurement process in compliance with all applicable federal and

state laws or regulations.

Added by Acts 1999, 76th Leg., ch. 235, Sec. 1, eff. Aug. 30,

1999. Amended by Acts 2003, 78th Leg., ch. 198, Sec. 2.43,

2.156(a)(1), eff. Sept. 1, 2003.

Sec. 62.056. COMMUNITY OUTREACH CAMPAIGN; TOLL-FREE HOTLINE.

(a) The commission shall conduct a community outreach and

education campaign to provide information relating to the

availability of health benefits for children under this chapter.

The commission shall conduct the campaign in a manner that

promotes enrollment in, and minimizes duplication of effort

among, all state-administered child health programs.

(b) The community outreach campaign must include:

(1) outreach efforts that involve school-based health clinics;

(2) a toll-free telephone number through which families may

obtain information about health benefits coverage for children;

and

(3) information regarding the importance of each conservator of

a child promptly informing the other conservator of the child

about the child's health benefits coverage.

(c) The commission shall contract with community-based

organizations or coalitions of community-based organizations to

implement the community outreach campaign and shall also promote

and encourage voluntary efforts to implement the community

outreach campaign. The commission shall procure the contracts

through a process designed by the commission to encourage broad

participation of organizations, including organizations that

target population groups with high levels of uninsured children.

(d) The commission may direct that the Department of State

Health Services perform all or part of the community outreach

campaign.

(e) The commission shall ensure that information provided under

this section is available in both English and Spanish.

Added by Acts 2007, 80th Leg., R.S., Ch.

1353, Sec. 2, eff. June 15, 2007.

Sec. 62.058. FRAUD PREVENTION. The commission shall develop and

implement rules for the prevention and detection of fraud in the

child health plan program.

Added by Acts 1999, 76th Leg., ch. 235, Sec. 1, eff. Aug. 30,

1999.

Sec. 62.0582. THIRD-PARTY BILLING VENDORS. (a) A third-party

billing vendor may not submit a claim with the commission for

payment on behalf of a health plan provider under the program

unless the vendor has entered into a contract with the commission

authorizing that activity.

(b) To the extent practical, the contract shall contain

provisions comparable to the provisions contained in contracts

between the commission and health plan providers, with an

emphasis on provisions designed to prevent fraud or abuse under

the program. At a minimum, the contract must require the

third-party billing vendor to:

(1) provide documentation of the vendor's authority to bill on

behalf of each provider for whom the vendor submits claims;

(2) submit a claim in a manner that permits the commission to

identify and verify the vendor, any computer or telephone line

used in submitting the claim, any relevant user password used in

submitting the claim, and any provider number referenced in the

claim; and

(3) subject to any confidentiality requirements imposed by

federal law, provide the commission, the office of the attorney

general, or authorized representatives with:

(A) access to any records maintained by the vendor, including

original records and records maintained by the vendor on behalf

of a provider, relevant to an audit or investigation of the

vendor's services or another function of the commission or office

of attorney general relating to the vendor; and

(B) if requested, copies of any records described by Paragraph

(A) at no charge to the commission, the office of the attorney

general, or authorized representatives.

(c) On receipt of a claim submitted by a third-party billing

vendor, the commission shall send a remittance notice directly to

the provider referenced in the claim. The notice must include

detailed information regarding the claim submitted on behalf of

the provider.

(d) The commission shall take all action necessary, including

any modifications of the commission's claims processing system,

to enable the commission to identify and verify a third-party

billing vendor submitting a claim for payment under the program,

including identification and verification of any computer or

telephone line used in submitting the claim, any relevant user

password used in submitting the claim, and any provider number

referenced in the claim.

(e) The commission shall audit each third-party billing vendor

subject to this section at least annually to prevent fraud and

abuse under the program.

Added by Acts 2003, 78th Leg., ch. 198, Sec. 2.44(a), eff. Jan.

1, 2006.

Sec. 62.059. HEALTH INSURANCE PREMIUM ASSISTANCE PROGRAM FOR

CHILDREN ELIGIBLE FOR CHILD HEALTH PLAN. (a) In this section,

"group health benefit plan" means a plan described by Section

1207.001, Insurance Code.

(b) The commission shall identify children, otherwise eligible

to enroll in the state child health plan under this chapter, who

are eligible to enroll in a group health benefit plan.

(c) For a child identified under Subsection (b), the commission

shall determine whether it is cost-effective to enroll the child

in the group health benefit plan under this section. The

commission may determine cost-effectiveness on an aggregate basis

for the premium assistance program as a whole.

(d) If the commission determines that it is cost-effective to

enroll the child in the group health benefit plan, the commission

shall:

(1) inform the child and the child's parent or guardian of the

availability of the premium assistance program under this

section;

(2) offer, as an optional alternative to enrollment in the

commission's state child health plan program, a premium

assistance payment to assist with the employee's or member's

share of the required premiums for the group health benefit plan

that is available to the child; and

(3) provide written notice to the issuer of the group health

benefit plan in accordance with Chapter 1207, Insurance Code.

(e) The commission shall determine the amount of the premium

assistance payment. The premium assistance payment shall be paid

only for the reimbursement of the employee's or member's share of

required premiums for coverage of a child enrolled in the group

health benefit plan.

(f) The premium assistance payment paid under Subsection (e) may

provide assistance for the payment of a group health benefit plan

premium that includes the child's parent or other individuals who

are members of the child's family.

(g) The commission may not provide for the payment of any

deductible, copayment, coinsurance, or other cost-sharing

obligation for the child or another individual enrolled in a

group health benefit plan under Subsection (f).

(h) Repealed by Acts 2003, 78th Leg., ch. 198, Sec. 2.07(b).

(i) Redesignated as subsec. (h) by Acts 2003, 78th Leg., ch. 11,

Sec. 1.

Added by Acts 2001, 77th Leg., ch. 1165, Sec. 1, eff. Aug. 31,

2001. Amended by Acts 2003, 78th Leg., ch. 11, Sec. 1, eff. Sept.

1, 2003; Acts 2003, 78th Leg., ch. 198, Sec. 2.07(b), eff. Sept.

1, 2003.

Amended by:

Acts 2005, 79th Leg., Ch.

728, Sec. 11.125, eff. September 1, 2005.

Sec. 62.060. HEALTH INFORMATION TECHNOLOGY STANDARDS. (a) In

this section, "health information technology" means information

technology used to improve the quality, safety, or efficiency of

clinical practice, including the core functionalities of an

electronic health record, an electronic medical record, a

computerized health care provider order entry, electronic

prescribing, and clinical decision support technology.

(b) The commission shall ensure that any health information

technology used by the commission or any entity acting on behalf

of the commission in the child health plan program conforms to

standards required under federal law.

Added by Acts 2009, 81st Leg., R.S., Ch.

1120, Sec. 2, eff. September 1, 2009.

SUBCHAPTER C. ELIGIBILITY FOR COVERAGE UNDER CHILD HEALTH PLAN

Sec. 62.101. ELIGIBILITY. (a) A child is eligible for health

benefits coverage under the child health plan if the child:

(1) is younger than 19 years of age;

(2) is not eligible for medical assistance under the Medicaid

program;

(3) is not covered by a health benefits plan offering adequate

benefits, as determined by the commission;

(4) has a family income that is less than or equal to the income

eligibility level established under Subsection (b); and

(5) satisfies any other eligibility standard imposed under the

child health plan program in accordance with 42 U.S.C. Section

1397bb, as amended, and any other applicable law or regulations.

(b) The commission shall establish income eligibility levels

consistent with Title XXI, Social Security Act (42 U.S.C. Section

1397aa et seq.), as amended, and any other applicable law or

regulations, and subject to the availability of appropriated

money, so that a child who is younger than 19 years of age and

whose net family income is at or below 200 percent of the federal

poverty level is eligible for health benefits coverage under the

program. In addition, the commission may establish eligibility

standards regarding the amount and types of allowable assets for

a family whose net family income is above 150 percent of the

federal poverty level.

(b-1) The eligibility standards adopted under Subsection (b)

related to allowable assets:

(1) must allow a family to own at least $10,000 in allowable

assets; and

(2) may not in calculating the amount of allowable assets under

Subdivision (1) consider:

(A) the value of one vehicle that qualifies for an exemption

under commission rule based on its use;

(B) the value of a second or subsequent vehicle that qualifies

for an exemption under commission rule based on its use if:

(i) the vehicle is worth $18,000 or less; or

(ii) the vehicle has been modified to provide transportation for

a household member with a disability;

(C) if no vehicle qualifies for an exemption based on its use

under commission rule, the first $18,000 of value of the highest

valued vehicle; or

(D) the first $7,500 of value of any vehicle not described by

Paragraph (A), (B), or (C).

(c) The commissioner shall evaluate enrollment levels and

program impact every six months during the first 12 months of

implementation and at least annually thereafter and shall submit

a finding of fact to the Legislative Budget Board and the

Governor's Office of Budget and Planning as to the adequacy of

funding and the ability of the program to sustain enrollment at

the eligibility level established by Subsection (b). In the event

that appropriated money is insufficient to sustain enrollment at

the authorized eligibility level, the commissioner shall:

(1) suspend enrollment in the child health plan;

(2) establish a waiting list for applicants for coverage; and

(3) establish a process for periodic or continued enrollment of

applicants in the child health plan program as the availability

of money allows.

Added by Acts 1999, 76th Leg., ch. 235, Sec. 1, eff. Aug. 30,

1999. Amended by Acts 2003, 78th Leg., ch. 198, Sec. 2.46, eff.

Sept. 1, 2003.

Amended by:

Acts 2007, 80th Leg., R.S., Ch.

1353, Sec. 3, eff. June 15, 2007.

Sec. 62.1011. VERIFICATION OF INCOME. The commission shall

continue employing methods of verifying the net income of the

individuals considered in the calculation of an applicant's net

family income. The commission shall verify income under this

section unless the applicant reports a net family income that

exceeds the income eligibility level established under Section

62.101(b).

Added by Acts 2007, 80th Leg., R.S., Ch.

1353, Sec. 4, eff. June 15, 2007.

Sec. 62.1015. ELIGIBILITY OF CERTAIN CHILDREN; DISALLOWANCE OF

MATCHING FUNDS. (a) In this section, "charter school,"

"employee," and "regional education service center" have the

meanings assigned by Section 2, Article 3.50-7, Insurance Code.

(b) A child of an employee of a charter school, school district,

other educational district whose employees are members of the

Teacher Retirement System of Texas, or regional education service

center may be enrolled in health benefits coverage under the

child health plan. A child enrolled in the child health plan

under this section:

(1) participates in the same manner as any other child enrolled

in the child health plan; and

(2) is subject to the same requirements and restrictions

relating to income eligibility, continuous coverage, and

enrollment, including applicable waiting periods, as any other

child enrolled in the child health plan.

(c) The cost of health benefits coverage for children enrolled

in the child health plan under this section shall be paid as

provided in the General Appropriations Act. Expenditures made to

provide health benefits coverage under this section may not be

included for the purpose of determining the state children's

health insurance expenditures, as that term is defined by 42

U.S.C. Section 1397ee(d)(2)(B), as amended, unless the Health and

Human Services Commission, after consultation with the

appropriate federal agencies, determines that the expenditures

may be included without adversely affecting federal matching

funding for the child health plan provided under this chapter.

Added by Acts 2001, 77th Leg., ch. 1187, Sec. 1.04, eff. Sept. 1,

2001. Amended by Acts 2003, 78th Leg., ch. 198, Sec. 2.47, eff.

Sept. 1, 2003.

Sec. 62.102. CONTINUOUS COVERAGE. (a) Subject to a review

under Subsection (b), the commission shall provide that an

individual who is determined to be eligible for coverage under

the child health plan remains eligible for those benefits until

the earlier of:

(1) the end of a period not to exceed 12 months, beginning the

first day of the month following the date of the eligibility

determination; or

(2) the individual's 19th birthday.

(b) During the sixth month following the date of initial

enrollment or reenrollment of an individual whose net family

income exceeds 185 percent of the federal poverty level, the

commission shall:

(1) review the individual's net family income and may use

electronic technology if available and appropriate; and

(2) continue to provide coverage if the individual's net family

income does not exceed the income eligibility limits prescribed

by this chapter.

(c) If, during the review required under Subsection (b), the

commission determines that the individual's net family income

exceeds the income eligibility limits prescribed by this chapter,

the commission may not disenroll the individual until:

(1) the commission has provided the family an opportunity to

demonstrate that the family's net family income is within the

income eligibility limits prescribed by this chapter; and

(2) the family fails to demonstrate such eligibility.

(d) The commission shall provide written notice of termination

of eligibility to the individual not later than the 30th day

before the date the individual's eligibility terminates.

Added by Acts 1999, 76th Leg., ch. 235, Sec. 1, eff. Aug. 30,

1999. Amended by Acts 2003, 78th Leg., ch. 198, Sec. 2.48, eff.

Sept. 1, 2003.

Amended by:

Acts 2005, 79th Leg., Ch.

899, Sec. 3.01, eff. August 29, 2005.

Acts 2007, 80th Leg., R.S., Ch.

1353, Sec. 5, eff. June 15, 2007.

Sec. 62.103. APPLICATION FORM AND PROCEDURES. (a) The

commission, or the Texas Department of Human Services at the

direction of and in consultation with the commission, shall adopt

an application form and application procedures for requesting

child health plan coverage under this chapter.

(b) The form and procedures must be coordinated with forms and

procedures under the Medicaid program to ensure that there is a

single consolidated application to seek assistance under this

chapter or the Medicaid program.

(c) To the extent possible, the application form shall be made

available in languages other than English.

(d) The commission may permit application to be made by mail,

over the telephone, or through the Internet.

Added by Acts 1999, 76th Leg., ch. 235, Sec. 1, eff. Aug. 30,

1999. Amended by Acts 2001, 77th Leg., ch. 584, Sec. 1.

Sec. 62.104. ELIGIBILITY SCREENING AND ENROLLMENT. (a) The

commission, or the Texas Department of Human Services at the

direction of and in consultation with the commission, shall

develop eligibility screening and enrollment procedures for

children that comply with the requirements of 42 U.S.C. Section

1397bb, as amended, and any other applicable law or regulations.

The procedures shall ensure that Medicaid-eligible children are

identified and referred to the Medicaid program.

(b) The Texas Integrated Enrollment Services eligibility

determination system or a compatible system may be used to screen

and enroll children under the child health plan.

(c) The eligibility screening and enrollment procedures shall

ensure that children who appear to be Medicaid-eligible are

identified and that their families are assisted in applying for

Medicaid coverage.

(d) A child who applies for enrollment in the child health plan,

who is denied Medicaid coverage after completion of a Medicaid

application under Subsection (c), but who is eligible for

enrollment in the child health plan, shall be enrolled in the

child health plan without further application or qualification.

(e) The commission shall report semi-annually to the committees

of both houses of the legislature with jurisdiction over the

child health plan:

(1) the number of individuals referred for Medicaid application

under this section who are enrolled in the Medicaid program; and

(2) the number of individuals who are denied coverage under the

Medicaid program because they failed to complete the application

process.

(f) A determination of whether a child is eligible for child

health plan coverage under the program and the enrollment of an

eligible child with a health plan provider must be completed, and

information on the family's available choice of health plan

providers must be provided, in a timely manner, as determined by

the commission. The commission must require that the

determination be made and the information be provided not later

than the 30th day after the date a complete application is

submitted on behalf of the child, unless the child is referred

for Medicaid application under this section.

(g) In the first year of implementation of the child health

plan, enrollment shall be open. Thereafter, the commission may

establish enrollment periods.

Added by Acts 1999, 76th Leg., ch. 235, Sec. 1, eff. Aug. 30,

1999.

Sec. 62.105. COVERAGE FOR QUALIFIED ALIENS. The commission

shall provide coverage under the state Medicaid program and under

the program established under this chapter to a child who is a

qualified alien, as that term is defined by 8 U.S.C. Section

1641(b), if the federal government authorizes the state to

provide that coverage. The commission shall comply with any

prerequisite imposed under the federal law to providing that

coverage.

Added by Acts 1999, 76th Leg., ch. 235, Sec. 1, eff. Aug. 30,

1999.

SUBCHAPTER D. CHILD HEALTH PLAN

Sec. 62.151. CHILD HEALTH PLAN COVERAGE. (a) The child health

plan must comply with this chapter and the coverage requirements

prescribed by 42 U.S.C. Section 1397cc, as amended, and any other

applicable law or regulations.

(b) In developing the covered benefits, the commission shall

consider the health care needs of healthy children and children

with special health care needs.

(c) In developing the plan, the commission shall ensure that

primary and preventive health benefits do not include

reproductive services, other than prenatal care and care related

to diseases, illnesses, or abnormalities related to the

reproductive system.

(d) The child health plan must allow an enrolled child with a

chronic, disabling, or life-threatening illness to select an

appropriate specialist as a primary care physician.

(e) In developing the covered benefits, the commission shall

seek input from the Public Assistance Health Benefit Review and

Design Committee established under Section 531.067, Government

Code.

(f) The commission, if it determines the policy to be

cost-effective, may ensure that an enrolled child does not,

unless authorized by the commission in consultation with the

child's attending physician or advanced practice nurse, receive

under the child health plan:

(1) more than four different outpatient brand-name prescription

drugs during a month; or

(2) more than a 34-day supply of a brand-name prescription drug

at any one time.

Added by Acts 1999, 76th Leg., ch. 235, Sec. 1, eff. Aug. 30,

1999. Amended by Acts 2003, 78th Leg., ch. 198, Sec. 2.49, eff.

Sept. 1, 2003.

Sec. 62.152. APPLICATION OF INSURANCE LAW. To provide the

flexibility necessary to satisfy the requirements of Title XXI of

the Social Security Act (42 U.S.C. Section 1397aa et seq.), as

amended, and any other applicable law or regulations, the child

health plan is not subject to a law that requires:

(1) coverage or the offer of coverage of a health care service

or benefit;

(2) coverage or the offer of coverage for the provision of

services by a particular health care services provider, except as

provided by Section 62.155(b); or

(3) the use of a particular policy or contract form or of

particular language in a policy or contract form.

Added by Acts 1999, 76th Leg., ch. 235, Sec. 1, eff. Aug. 30,

1999.

Sec. 62.153. COST SHARING. (a) To the extent permitted under

42 U.S.C. Section 1397cc, as amended, and any other applicable

law or regulations, the commission shall require enrollees to

share the cost of the child health plan, including provisions

requiring enrollees under the child health plan to pay:

(1) a copayment for services provided under the plan;

(2) an enrollment fee; or

(3) a portion of the plan premium.

(b) Subject to Subsection (d), cost-sharing provisions adopted

under this section shall ensure that families with higher levels

of income are required to pay progressively higher percentages of

the cost of the plan.

(c) If cost-sharing provisions imposed under Subsection (a)

include requirements that enrollees pay a portion of the plan

premium, the commission shall specify the manner in which the

premium is paid. The commission may require that the premium be

paid to the Texas Department of Health, the Texas Department of

Human Services, or the health plan provider.

(d) Cost-sharing provisions adopted under this section may be

determined based on the maximum level authorized under federal

law and applied to income levels in a manner that minimizes

administrative costs.

Added by Acts 1999, 76th Leg., ch. 235, Sec. 1, eff. Aug. 30,

1999. Amended by Acts 2003, 78th Leg., ch. 198, Sec. 2.50, eff.

Sept. 1, 2003.

Sec. 62.154. WAITING PERIOD; CROWD OUT. (a) To the extent

permitted under Title XXI of the Social Security Act (42 U.S.C.

Section 1397aa et seq.), as amended, and any other applicable law

or regulations, the child health plan must include a waiting

period and may include copayments and other provisions intended

to discourage:

(1) employers and other persons from electing to discontinue

offering coverage for children under employee or other group

health benefit plans; and

(2) individuals with access to adequate health benefit plan

coverage, other than coverage under the child health plan, from

electing not to obtain or to discontinue that coverage for a

child.

(b) A child is not subject to a waiting period adopted under

Subsection (a) if:

(1) the family lost coverage for the child as a result of:

(A) termination of employment because of a layoff or business

closing;

(B) termination of continuation coverage under the Consolidated

Omnibus Budget Reconciliation Act of 1985 (Pub. L. No. 99-272);

(C) change in marital status of a parent of the child;

(D) termination of the child's Medicaid eligibility because:

(i) the child's family's earnings or resources increased; or

(ii) the child reached an age at which Medicaid coverage is not

available; or

(E) a similar circumstance resulting in the involuntary loss of

coverage;

(2) the family terminated health benefits plan coverage for the

child because the cost to the child's family for the coverage

exceeded 10 percent of the family's net income;

(3) the child has access to group-based health benefits plan

coverage and is required to participate in the health insurance

premium payment reimbursement program administered by the

commission; or

(4) the commission has determined that other grounds exist for a

good cause exception.

(c) A child described by Subsection (b) may enroll in the child

health plan program at any time, without regard to any open

enrollment period established under the enrollment procedures.

(d) The waiting period required by Subsection (a) must:

(1) extend for a period of 90 days after the last date on which

the applicant was covered under a health benefits plan; and

(2) apply 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 under the child health plan.

Added by Acts 1999, 76th Leg., ch. 235, Sec. 1, eff. Aug. 30,

1999. Amended by Acts 2003, 78th Leg., ch. 198, Sec. 2.51(a),

(b), eff. Sept. 1, 2003.

Amended by:

Acts 2007, 80th Leg., R.S., Ch.

1353, Sec. 6, eff. June 15, 2007.

Sec. 62.155. HEALTH PLAN PROVIDERS. (a) The commission, or the

Texas Department of Health at the direction of and in

consultation with the commission, shall select the health plan

providers under the program through a competitive procurement

process. A health plan provider, other than a state administered

primary care case management network, must hold a certificate of

authority or other appropriate license issued by the Texas

Department of Insurance that authorizes the health plan provider

to provide the type of child health plan offered and must

satisfy, except as provided by this chapter, any applicable

requirement of the Insurance Code or another insurance law of

this state.

(b) A managed care organization or other entity shall seek to

obtain, in the organization's or entity's provider network, the

participation of significant traditional providers, as defined by

commission rule, if that organization or entity:

(1) contracts with the commission or with another agency or

entity to operate a part of the child health plan under this

chapter; and

(2) uses a provider network to provide or arrange for health

care services under the child health plan.

(c) In selecting a health plan provider, the commission:

(1) may give preference to a person who provides similar

coverage under the Medicaid program; and

(2) shall provide for a choice of at least two health plan

providers in each service area.

(d) The commissioner may authorize an exception to Subsection

(c)(2) if there is only one acceptable applicant to become a

health plan provider in the service area.

Added by Acts 1999, 76th Leg., ch. 235, Sec. 1, eff. Aug. 30,

1999. Amended by Acts 2003, 78th Leg., ch. 198, Sec. 2.52, eff.

Sept. 1, 2003.

Sec. 62.156. HEALTH CARE PROVIDERS. Health care providers who

provide health care services under the child health plan must

satisfy certification and licensure requirements, as required by

the commission, consistent with law.

Added by Acts 1999, 76th Leg., ch. 235, Sec. 1, eff. Aug. 30,

1999.

Sec. 62.157. TELEMEDICINE MEDICAL SERVICES AND TELEHEALTH

SERVICES FOR CHILDREN WITH SPECIAL HEALTH CARE NEEDS.

Text of section as added by Acts 2001, 77th Leg., ch. 959, Sec. 5

(a) In providing covered benefits to a child with special health

care needs, a health plan provider must permit benefits to be

provided through telemedicine medical services and telehealth

services in accordance with policies developed by the commission.

(b) The policies must provide for:

(1) the availability of covered benefits appropriately provided

through telemedicine medical services and telehealth services

that are comparable to the same types of covered benefits

provided without the use of telemedicine medical services and

telehealth services; and

(2) the availability of covered benefits for different services

performed by multiple health care providers during a single

telemedicine medical services and telehealth services session, if

the commission determines that delivery of the covered benefits

in that manner is cost-effective in comparison to the costs that

would be involved in obtaining the services from providers

without the use of telemedicine medical services and telehealth

services, including the costs of transportation and lodging and

other direct costs.

(c) In developing the policies required by Subsection (a), the

commission shall consult with:

(1) The University of Texas Medical Branch at Galveston;

(2) Texas Tech University Health Sciences Center;

(3) the Texas Department of Health;

(4) providers of telemedicine hub sites in this state;

(5) providers of services to children with special health care

needs; and

(6) representatives of consumer or disability groups affected by

changes to services for children with special health care needs.

Added by Acts 2001, 77th Leg., ch. 959, Sec. 5, eff. June 14,

2001.

Sec. 62.157. TELEMEDICINE MEDICAL SERVICES.

Text of section as added by Acts 2001, 77th Leg., ch. 1255, Sec.

4

(a) In providing covered benefits to a child, a health plan

provider must permit benefits to be provided through telemedicine

medical services in accordance with policies developed by the

commission.

(b) The policies must provide for:

(1) the availability of covered benefits appropriately provided

through telemedicine medical services that are comparable to the

same types of covered benefits provided without the use of

telemedicine medical services; and

(2) the availability of covered benefits for different services

performed by multiple health care providers during a single

session of telemedicine medical services, if the commission

determines that delivery of the covered benefits in that manner

is cost-effective in comparison to the costs that would be

involved in obtaining the services from providers without the use

of telemedicine medical services, including the costs of

transportation and lodging and other direct costs.

(c) In developing the policies required by Subsection (a), the

commission shall consult with the telemedicine advisory

committee.

(d) In this section, "telemedicine medical service" has the

meaning assigned by Section 57.042, Utilities Code.

Added by Acts 2001, 77th Leg., ch. 1255, Sec. 4, eff. June 15,

2001.

Sec. 62.158. STATE TAXES. The commission shall ensure that any

experience rebate or profit-sharing for health plan providers

under the child health plan is calculated by treating premium,

maintenance, and other taxes under the Insurance Code and any

other taxes payable to this state as allowable expenses for

purposes of determining the amount of the experience rebate or

profit-sharing.

Added by Acts 2003, 78th Leg., ch. 198, Sec. 2.53, eff. Sept. 1,

2003.

Sec. 62.159. DISEASE MANAGEMENT SERVICES. (a) In this section,

"disease management services" means services to assist a child

manage a disease or other chronic health condition, such as heart

disease, diabetes, respiratory illness, end-stage renal disease,

HIV infection, or AIDS, and with respect to which the commission

identifies populations for which disease management would be

cost-effective.

(b) The child health plan must provide disease management

services or coverage for disease management services in the

manner required by the commission, including:

(1) patient self-management education;

(2) provider education;

(3) evidence-based models and minimum standards of care;

(4) standardized protocols and participation criteria; and

(5) physician-directed or physician-supervised care.

Added by Acts 2003, 78th Leg., ch. 589, Sec. 1, eff. June 20,

2003.