PROVIDER MANUAL - Sendero Health Plans

Sendero Provider Manual Page 105 of 184
CH1 – Eligibility of Members
CH 1.1 HHSC Determines Eligibility
The Texas Health and Human Services Commission (HHSC) is responsible for determining CHIP eligibility.
For information regarding eligibility, contact HHSC CHIP hotline at 1-800-647-6558.
For other help, call Sendero Health Plans’ Customer Services at 1-855-526-7388.
CH 1.2 Role of Enrollment Broker
HHSC uses an Enrollment Broker to receive and process applications for CHIP. The enrollment broker cannot
authorize or determine eligibility. The role of the enrollment broker is to ensure that all required documentation
and forms are gathered. Once eligibility is determined by HHSC, the enrollment broker mails out welcome
letters and information on the available health plans in each area. The enrollment broker receives each
Member’s plan and primary care provider selection documentation and notifies health plans of their new
Members.
CH 1.3 General Eligibility for CHIP
Children under age 19 and whose family’s income is below 200% of the federal poverty level (FPL) are eligible
to enroll in the CHIP program if they do not qualify for STAR/Medicaid coverage. The four CHIP eligibility
categories are:
● At or below 100% of FPL
●101% to 150% of FPL
●151% to 185% of FPL
●186% to 200% of FPL
CHIP enrollment period is a twelve (12) month period. Prior to the end of the eligibility period, Members are
sent re-enrollment packets to complete and return to the enrollment broker. Determination of coverage is made
by the state Administrative Services Contractor. Members should complete the necessary forms and return as
soon as possible to the enrollment broker to prevent lapses in coverage. Physicians should encourage Members
to re-enroll.
Children of families with Group Health Insurance or Medicaid coverage for the children are NOT eligible for
the CHIP program.
Sendero Customer Services 1-855-526-7388 Network Management 1-855-895-0475
Health Services Dept.: 1-855-297-9191 (FAX 1-512-275-2862)