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5.2.1 Health Maintenance Organization (HMO)
The CSHCN Services Program does not reimburse providers for client copays.
The CSHCN Services Program considers payment for services specifically excluded or limited by HMOs, but a benefit of the CSHCN Services Program. An explanation of benefits (EOB) is required from the HMO. Payment of those services must not exceed the CSHCN Services Programs maximum allowable fees for those services.
The CSHCN Services Program does not provide assistance for:
• Supplement of payment made by HMOs to their providers, unlike other insurance.
•Services that are available through an HMO and were not provided by an HMO approved provider.
•Authorization and payment for services available through an HMO.
•Copayments to providers for services available through an HMO.
Providers may collect copays for CSHCN Services Program clients with private insurance. The CSHCN Services Program reimburses clients for medication copays only. Clients should call the TMHP-CSHCN Services Program Contact Center Client Line at 1-877-888-2350, which is available Monday through Friday, from 7 a.m. to 7 p.m., Central Time for additional information.
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