PARKLAND HEALTHfirst - Parkland Community Health Plan, Inc.

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CHIP Eligibility CHIP KidsFirst Members Texas child residents who belong to families who are at or below 200% of the Federal Poverty Level may qualify for CHIP. Guardians can submit applications for their children ages 0-18 who have been uninsured for a minimum of 90 days. Once enrolled, their eligibility remains continuous for 12 months. The CHIP application process is separate and distinct from the enrollment process. During application, a family with uninsured children completes the CHIP application or calls the CHIP Help Line. CHIP is targeted to all families with uninsured children under the age of 19 who are Texas residents, U.S. citizens or legal permanent residents. The citizenship or immigration status of the parents does not affect the children's eligibility. When a family applies for CHIP, they will be linked to the appropriate children’s health insurance program based on family size, income, and citizenship status. Some families will be referred to Medicaid and some will be found eligible for CHIP. Families with CHIP-eligible children must complete an enrollment form in which they pick a health plan and Primary Care Provider and pay the applicable cost-sharing obligation. In areas covered by the Exclusive Provider Organization (EPO), the children will be enrolled in the EPO without any Primary Care Provider selection. This eligibility table is based on 2011 federal poverty income guidelines. Income Guidelines for CHIP/Children’s Medicaid* CHILDREN’S MEDICAID FAMILY MEMBERS (ADULTS PLUS CHILDREN) YEARLY FAMILY INCOME CHIP YEARLY FAMILY INCOME 1 $10,830 $21,660 2 $14,570 $29,140 3 $18,310 $36,620 4 $22,050 $44,100 5 $25,790 $51,580 6 $29,530 $59,060 7 $33,270 $66,540 8 $37,010 $74,020 *Families meeting these income guidelines might qualify. Some expenses such as childcare or adult care might be deductible (Information valid through 2011). .Eligible guidelines subject to change. Please refer to HHSC website for updated information. Pregnant Teens Please call Parkland KidsFirst as soon as you know that your Parkland KidsFirst patient is pregnant. She needs to apply immediately for services through the Medicaid and her baby will also likely be able to receive health coverage through Medicaid. Call Member Services toll-free at 1-888-814-2352. 57
Parkland CHIP Perinate and Parkland CHIP Perinate Newborn Members “CHIP Perinate” is a pregnant female CHIP Perinatal beneficiary who is identified before giving birth and is enrolled to receive covered services from Parkland Community Health Plan pursuant to the terms of the CHIP Perinatal Contract. “CHIP Perinate Newborn” means a CHIP Perinate who has been born alive. Parkland CHIP Perinate and Parkland CHIP Perinate Newborn members will need to meet the same income guideline requirements as indicated in the sections above, however, the 90 day waiting period and cost-sharing requirements will not apply to these members. Once the Parkland CHIP Perinate member is enrolled, eligibility remains continuous for 12 months. Eligibility for the Parkland CHIP Perinate member will end at the end of the month of the CHIP Perinate Newborn’s birth. Any time remaining in the first 12 months of continuous eligibility will be transferred to the CHIP Perinate Newborn. Eligibility will be continuous for the CHIP Perinate Newborn member for the remainder of the 12 months. CHIP Perinate members will be linked to any current CHIP member case. Both the CHIP Perinate member and CHIP members are required to be enrolled in the CHIP Perinate Health Plan through the CHIP Perinatal enrollment period. A CHIP Perinate (unborn child) who lives in a family with an income at or below 185% of the FPL will be deemed eligible for Medicaid and will receive 12 months of continuous coverage (beginning on the date of birth). A CHIP Perinate will continue to receive coverage through CHIP as a “CHIP Perinate Newborn” if born to a family with an income above 185% to 200% FPL.” CHIP Member Enrollment and Disenrollment Enrollment Application Parents and guardians can apply telephonically for CHIP coverage by contacting CHIP at 1-800-647-6558. Applicants can ask for a blank form or CHIP will print completed applications based on phone information and mail to the requesting party for signature and return. Applicants can download and complete application forms from the internet at www.chipmedicaid.com. Once enrolled, the CHIP eligibility remains continuous for 12 months. Eligibility determination is the responsibility of the HHSC Administrative Services Contractor. Enrollment Process Eligibility determination notices are sent to families determined eligible based on completed applications. The enrollment packet mailed to families contains: • Explanation of CHIP benefits • Comparison table showing value-added services by health plan • A place to indicate a child with special health care needs • A place to indicate whether a medical support order is applicable • How to pick a health plan, primary care provider , and the choice to pick a specialist as Primary Care Provider • Provider directories • Cost-sharing information specific to the income level of the family and payment coupon book for families with net income over 150% Federal Poverty Level • Simple form to track cost-sharing expenses relative to caps 58
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Parkland KIDSfirst, Parkland CHIP P
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Notification of Change in Provider
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CLAIMS SUBMISSION .................
Page 8 and 9:
Quick Reference Checklist This manu
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Plan specified services. However, c
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CHIP Covered Services PCHP provides
Page 14 and 15: • Surgical implants • Other art
Page 16 and 17: Outpatient Mental Health Services I
Page 18 and 19: • Out-of-network services not aut
Page 20 and 21: CHIP Perinatal Covered Services Cov
Page 22 and 23: 15 Covered Benefit CHIP Perinate Ne
Page 24 and 25: Covered Benefit CHIP Perinate Newbo
Page 30 and 31: • Personal comfort items includin
Page 32 and 33: • Donor non-medical expenses •
Page 34 and 35: SUPPLIES COVERED EXCLUDED COMMENTS/
Page 36 and 37: SUPPLIES COVERED EXCLUDED COMMENTS/
Page 38 and 39: Coordination between Physical and B
Page 40 and 41: in the provision of care and servic
Page 42 and 43: statement indicating that members s
Page 44 and 45: As the Primary Care Provider you mu
Page 46 and 47: Other Access Standards Service Stan
Page 48 and 49: Members Right to Select Network Oph
Page 50 and 51: HMO/Provider Coordination PCHP will
Page 52 and 53: 45 • describe the range of medica
Page 54 and 55: Coordination of Care The Primary Ca
Page 56 and 57: Coordination with Texas Department
Page 58 and 59: Presentation at Emergency Room afte
Page 60 and 61: If the complaint is received verbal
Page 62 and 63: Expedited Appeal can be made verbal
Page 66 and 67: • Information concerning the grie
Page 69 and 70: Parkland Community Health Plan Memb
Page 71 and 72: Pregnant Teens Please call Parkland
Page 73 and 74: your income. Co-payments do not app
Page 75 and 76: Member’s Right to Designate an OB
Page 77 and 78: 70 To report providers use this add
Page 79 and 80: 5. Network providers must report an
Page 81 and 82: To request to be a Specialist servi
Page 83 and 84: • OB/Gyn • Periodic Health Chec
Page 85 and 86: The table below provides HHSC Manag
Page 87 and 88: CHIP Cost Sharing Caps Members rece
Page 89 and 90: of these two dates: July 18, 2007,
Page 91 and 92: (DD) Diagnosis code by specific ser
Page 93 and 94: (PP) Attending physician ID (UB-04,
Page 95 and 96: (2) post-partum visits within 60 da
Page 97 and 98: CHIP Member Enrollment and Disenrol
Page 99 and 100: • In order to synchronize all CHI
Page 101 and 102: Provider Participation Requirements
Page 103 and 104: • Evidence of state licensure, an
Page 105 and 106: U1 U2 U3 Medically necessary delive
Page 107 and 108: PROCEDURE DESCRIPTION PROCEDURE COD
Page 109 and 110: provider actually treating the memb
Page 111 and 112: themselves appropriately and follow
Page 113 and 114: Medical Record Standards The medica
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1. History and Physical Examination
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WIC services include providing nutr
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As soon as the member knows they wi
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3) by the director to the employee
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In addition to the previously state
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Prior Authorization The CHIP Perina
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Appendix A Universal Referral/Prior
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Appendix B Consent for Disclosure 1
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PERMISSION TO RELEASE CONFIDENTIAL
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EXAMPLE FORM PRIVATE PAY AGREEMENT
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Appendix D Clinical Practice Guidel
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Appendix D - Continued Clinical Pra
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Appendix D - Continued Clinical Pra
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RATIONALE: Attention-Deficit/ Hyper
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Appendix G Urinary Tract Infections
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Follow-up • Follow-up urine cultu
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RATIONALE: Prevention of RSV Illnes
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RATIONALE: Treatment of Group A Str
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PARKLAND HEALTHfirst - Parkland Community Health Plan, Inc.

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