PARKLAND HEALTHfirst - Parkland Community Health Plan, Inc.

CHIP Cost Sharing Caps
Members receive a guide from CHIP when they join. Included in the guide is a tear-out form that can be used
to track CHIP expenses. To ensure that members do not exceed their cost-sharing limit, guardians must keep
track of CHIP-related expenses on the form. The enrollment packet welcome letter informs the member exactly
what their cost-sharing cap is, based on family income. Members can contact The CHIP Help Line at 1-800-
647-6558 to verify their yearly limit. When members reach their yearly cap, they can send the form to the CHIP
Enrollment Broker and they will inform Parkland KIDSfirst and we will issue a new member ID card. This new
card will show that no co-payments are due when the member receives services.
Co-payment and Cost Sharing for CHIP Perinatal Members
Co-payment and cost sharing requirements do not apply to members enrolled in the CHIP Perinatal. This
requirement has been waived for this population. The member ID card for these members will not reflect copayment
information.
Billing CHIP Members
Except as specifically indicated in the CHIP benefit descriptions, a provider cannot bill or require payment,
other than co-pay, from members for CHIP covered services. Providers cannot bill, or take recourse against
members for denied or reduced claims for services that are within the amount, duration and scope of benefits of
Texas CHIP.
Parkland KIDSfirst providers are responsible for collecting, at the time of service, any applicable CHIP copayments
or deductibles in accordance with CHIP cost-sharing limitations. KIDSfirst providers shall not
charge:
1. Co-payments or deductibles to CHIP members of Native American Tribes or Alaskan Natives, or members
participating in Parkland CHIP Perinate and Parkland CHIP Perinate Newborn;
2. Co-payments or deductibles to a CHIP member with an ID card that indicates the member has met his or
her cost-sharing obligation for the balance of their term of coverage; and
3. Co-payments for well-child or well-baby visits or immunizations.
Co-payments are the only amounts that KIDSfirst providers can collect from CHIP members, except for costs
associated with unauthorized non-emergency services provided to a member by out-of-network providers for
non-covered services. Co-payment requirements do not apply to Parkland CHIP Perinate or Parkland CHIP
Perinate Newborn members. PCHP will initiate and maintain any action necessary to stop a PCHP provider or
employee, agent, assign, trustee, or successor-in-interest from maintaining an action against HHSC, an HHS
Agency, or any member to collect payment from HHSC, an HHS Agency, or any member above an allowable
co-payment or deductible, excluding payment for services not covered by CHIP.
Member Acknowledgement / Private Pay Agreement/
If a Parkland KIDSfirst, Parkland CHIP Perinate or Parkland CHIP Perinate Newborn member decides to go to
a provider that is not within the PCHP network or chooses to get services that have not been authorized or are
not a covered benefit, the member must document his/her choice by signing the Private Pay Agreement
(Appendix C) and the Member Acknowledgement form.
A provider can bill a client for a claim denied as not being medically necessary or not a part of a covered
preventive, family planning, or immunization service if any of the following conditions are met:
• A specific service or item is provided at the request of the client.
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