Revision 11-2; Effective June 1, 2011

§358.107. Coverage Groups.

(a) General. This section describes the groups of people who are categorically eligible for a Medicaid-funded program for the elderly and people with disabilities (MEPD) under the Texas State Plan for Medical Assistance.

(b) Mandatory coverage groups. In accordance with 42 CFR Part 435, Subpart B, the Texas Health and Human Services Commission (HHSC) determines eligibility for MEPD for a person who falls into at least one of the following mandatory coverage groups:

(1) Supplemental Security Income (SSI) eligible. In accordance with 42 CFR §435.120, this mandatory coverage group covers a person who is aged, blind, or disabled and is receiving SSI or deemed to be receiving SSI. The Social Security Administration (SSA) determines eligibility for SSI under Title XVI of the Social Security Act. If SSA determines that a person is eligible for SSI, HHSC accepts SSA's determination as an automatic determination of eligibility for Medicaid.

(2) Coverage for certain aliens. In accordance with 42 CFR §435.139, an alien, as defined in 42 CFR §435.406, is provided services necessary for the treatment of an emergency medical condition, as defined in 42 CFR §440.255.

(3) Disabled adult child. In accordance with §1634(c) of the Social Security Act (42 U.S.C. §1383c), this mandatory coverage group covers a person who:

(A) is at least 18 years of age;

(B) became disabled before 22 years of age;

(C) is denied SSI because of receipt of or an increase in Retirement, Survivors, and Disability Insurance (RSDI) disabled children's benefits received on or after July 1, 1987, and any subsequent increase; and

(D) meets current SSI criteria, excluding the RSDI benefit described in subparagraph (C) of this paragraph.

(4) Historical 1972 income disregard. In accordance with 42 CFR §435.134, this mandatory coverage group covers a person who:

(A) was receiving both public assistance and Social Security benefits in August 1972; and

(B) meets current SSI eligibility criteria, excluding from income the October 1972 cost-of-living adjustment (COLA) increase in Social Security benefits but not excluding subsequent COLA increases in Social Security benefits.

(5) Title II COLA disregard (Pickle). In accordance with 42 CFR §435.135(a) - (b), this mandatory coverage group covers a person who:

(A) has been denied SSI for any reason since April 1977; and

(B) meets current SSI eligibility criteria, excluding from countable income any Social Security COLA increases received after the person last received both SSI and Social Security benefits in the same month.

(6) Disabled widow's or widower's COLA disregard. In accordance with 42 CFR §435.137, this mandatory coverage group covers a person who:

(A) is 50 to 60 years of age;

(B) is ineligible for Medicare;

(C) was denied SSI due to an increase in a disabled widow's or widower's and surviving divorced spouse's RSDI; and

(D) meets SSI eligibility criteria, excluding from countable income the RSDI benefit and any subsequent COLA increases in RSDI.

(7) Early age widow's or widower's COLA disregard. In accordance with 42 CFR §435.138, this mandatory coverage group covers a disabled person who was denied SSI due to early receipt of Social Security widow's or widower's benefits and:

(A) is at least 60 years of age;

(B) is not eligible for Medicare; and

(C) meets current SSI eligibility criteria, excluding from countable income the RSDI benefit and any subsequent COLA increases in RSDI.

(8) SSI denied children. In accordance with §1902(a)(10)(A)(i)(II) of the Social Security Act (42 U.S.C. §1396a(a)(10)(A)(i)(II)), this mandatory coverage group covers a person who:

(A) is under 18 years of age;

(B) was receiving SSI on August 22, 1996;

(C) was subsequently denied SSI because of the change in disability criteria implemented by the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (Public Law 104-193); and

(D) meets SSI eligibility criteria, including the disability criteria in effect before August 22, 1996.

(c) Optional coverage groups. In accordance with 42 CFR Part 435, Subpart C, HHSC determines Medicaid eligibility for MEPD for a person who falls into an optional coverage group described in this subsection. Although federal regulations may allow other optional coverage groups, HHSC does not provide benefits to a member of an optional coverage group unless the group is included in the Texas State Plan for Medical Assistance.

(1) Institutional. In accordance with 42 CFR §435.211, this optional coverage group covers a person who would be eligible for SSI, as specified in 42 CFR §435.230, if the person were not in an institutional setting.

(2) Institutional special income limit. In accordance with 42 CFR §435.236, this optional coverage group covers a person who has lived in an institutional setting for at least 30 consecutive days, as described in §358.433 of this chapter (relating to Special Income Limit), and is eligible under the special income limit.

(3) §1915(c) waiver program. In accordance with 42 CFR §435.217, this optional coverage group covers a person who would be eligible for Medicaid if institutionalized, but is living in the community and receiving services under a §1915(c) waiver program.

(d) Other. In accordance with the Texas State Plan for Medical Assistance, HHSC determines Medicaid eligibility for MEPD for a person who meets the criteria for one of the following services:

(1) Primary home care services. This is a person who needs primary home care services and meets the criteria established in §1929(b)(2)(B) of the Social Security Act (42 U.S.C. §1396t(b)(2)(B)) but is not otherwise eligible for Medicaid.

(2) Program of All-Inclusive Care for the Elderly (PACE). In accordance with 42 CFR Part 460, this is a person who is enrolled in a PACE program under a PACE program agreement.

(3) Susan Walker v. Bayer Corporation services. A person who has received payments from the class action settlement of Susan Walker v. Bayer Corporation may be eligible for Medicaid as a result of excluding from countable resources the payments from the settlement.

(e) Retroactive coverage. In accordance with 42 CFR §435.914, HHSC may determine eligibility for retroactive coverage:

(1) for up to three months before the date of application for:

(A) an applicant;

(B) a person who has been denied SSI;

(C) a deceased person, if a representative for the deceased person requests that HHSC determine eligibility for retroactive coverage; and

(D) a person eligible under the SSI-denied-children coverage group in subsection (b)(8) of this section; and

(2) for up to two months before the month in which an SSI recipient's Medicaid coverage automatically begins.

(f) Medicare Savings Program. In accordance with 42 U.S.C. §1396a(a)(10)(E) for this mandatory coverage group, HHSC may determine eligibility for a person who meets the criteria in Chapter 359 of this title (relating to Medicare Savings Program) for a Medicare Savings Program, which uses Medicaid funds to help the person pay for all or some of the person's out-of-pocket Medicare expenses, such as premiums, deductibles, or coinsurance.

(g) Medicaid Buy-In Program. In accordance with §1902(a)(10)A)(ii)(XIII) of the Social Security Act (42 U.S.C. §1396a(a)(10)(A)(ii)(XIII)) for this optional coverage group, HHSC may determine eligibility for a person with a disability who is working and earning income and meets the criteria established in Chapter 360 of this title (relating to Medicaid Buy-In Program).

(h) Medicaid Buy-In for Children. In accordance with §1902(cc) of the Social Security Act (42 U.S.C. §1396a(cc)) for this optional coverage group, HHSC may determine eligibility for a child with a disability who meets the criteria established in Chapter 361 of this title (relating to Medicaid Buy-In for Children Program).

Revision 19-4; Effective December 1, 2019

The Social Security Administration (SSA) administers the SSI program. In Texas, persons found eligible for SSI cash payment are automatically eligible for Medicaid. SSA notifies the state through an automated interface called the State Data Exchange System (SDX). Once received, the person is certified for Medicaid and sent a Your Texas Benefits Medicaid card.

SSI appears as type of assistance ME-SSI (TP 13) in TIERS.

Related Policy

SSI Applications, B-7100
MEPD Eligibility Pending a Decision of SSI Application, B-7300
Interstate Requests for Assistance, D-3610
SSI Recipient Visiting in Texas, D-3660
Co-Payment for SSI Cases, H-6000

Revision 12-3; Effective September 1, 2012

Certain aliens with an emergency medical condition who meet all SSI criteria, except citizenship, may be eligible for Medicaid coverage for the medical emergency. Coverage is for the duration of the emergency period. It is not considered as a "prior" medical, though prior months may be covered.

Automated System Program Identifier

TIERS – ME-A and D Emergency

Revision 09-4; Effective December 1, 2009

Medicaid eligibility for the aged, blind and disabled is directly related to receipt of SSI in most states. Loss of SSI payments can result in loss of Medicaid coverage. To preserve Medicaid coverage for certain groups of persons who lose SSI payments, Congress enacted special Medicaid continuation provisions. Persons denied SSI due to certain increases in Social Security benefits may continue to be eligible for Medicaid coverage. SSA informs HHSC through automated files to help locate potential eligible persons who may apply for continued Medicaid.

A-2310 Disabled Adult Children (DAC)

Revision 11-4; Effective December 1, 2011

This applies to persons denied SSI after July 1, 1987, and who meet SSI eligibility criteria when qualifying RSDI disabled adult children's benefits are excluded from countable income (OBRA 1986). These persons were denied SSI benefits because of an increase in or receipt of RSDI disabled children's benefits. These persons may continue to be eligible for Medicaid if they:

• are at least 18;
• become disabled before they are 22;
• are denied SSI benefits because of entitlement to or an increase in RSDI disabled children's benefits received on or after July 1, 1987, and any subsequent increase; and
• meet current SSI criteria, excluding the children's benefit specified above.

Automated System Program Identifier

TIERS – ME-Disabled Adult Child

Note: Based on SSA information, adult disabled child benefits generally end if the person gets married. There are exceptions such as marriage to another adult disabled child. This is an SSA requirement and not part of MEPD policy.

A-2320 Historical 1972 Income Disregard

Revision 11-4; Effective December 1, 2011

This applies to persons who were receiving both public assistance and Social Security benefits in August 1972. These persons must meet current SSI or MEPD eligibility criteria, with the exclusion from income of the amount of the October 1972, 20% Social Security cost of living adjustment (COLA) increase.

Automated System Program Identifier

TIERS – ME-Pickle

A-2330 Pickle

Revision 11-4; Effective December 1, 2011

This applies to persons denied SSI cash benefits for any reason since April 1977. They must meet all current SSI eligibility criteria, with the exclusion of any Social Security COLA increases received since they were eligible for and entitled to both SSI and Social Security benefits in the same month. The earliest COLA increase that can be excluded is the increase received in July 1977. There are two files received from SSA for Title II COLA denials. The 503 file identifies "Pickle" potentials and is received late November of each year. The Lynch vs. Rank file is usually received mid-December.

Automated System Program Identifier

TIERS – ME-Pickle

A-2340 Widow(er)s

Revision 11-4; Effective December 1, 2011

This applies to persons age 60 to 65 who are ineligible for Medicare and who are denied SSI due to excess widow/widower's RSDI benefits. They must meet SSI eligibility criteria, with the exclusion of their RSDI benefit and any subsequent COLA increases from countable income (OBRA 1987).

Automated System Program Identifier

TIERS – ME-Early Age Widow(er)

This applies to persons age 50 to 60 who are ineligible for Medicare and who are denied SSI due to excess disabled widow/widower's and surviving divorced spouse's RSDI benefits. They must meet SSI eligibility criteria, with the exclusion of their RSDI benefit and any subsequent COLA increases from countable income (OBRA 1990).

Historically this also applies to persons denied SSI due to a recomputation of their Social Security disabled widows/widowers benefits for January 1984. They must meet SSI eligibility criteria, with the exclusion of the recomputation increase and any subsequent Social Security COLA increases from countable income. Persons had to have filed an application before July 1, 1998, to be eligible under this program. Enrollment for this program ended June 30, 1998 (OBRA 1985).

Automated System Program Identifier

TIERS – ME-Disabled Widow(er)

A-2350 Reserved for Future Use

Revision 19-4; Effective December 1, 2019

 

Revision 09-4; Effective December 1, 2009

This optional coverage group covers a person who would be eligible for SSI, if the person were not in an institutional setting.

Revision 16-1; Effective March 1, 2016

The special income limit applies to persons who will reside in a Medicaid-approved long-term care facility or who apply for certain Home and Community-Based Services (HCBS) waiver programs. Countable income must be equal to or less than the special income limit established by HHSC (see Appendix XXXI, Budget Reference Chart). A person must live in one or more Medicaid-certified long-term facilities at least 30 consecutive days to be eligible under the special income limit. The following are included in this group:

• Persons of any age in Medicaid-certified nursing facilities who meet medical necessity
• Persons of any age in Medicaid-certified sections of state supported living centers and private facilities for persons with intellectual disabilities
• Persons age 65 and over in Medicaid-approved sections of state hospitals (institutions for mental diseases)
• Persons applying for certain HCBS waiver programs who are not already Medicaid eligible under another coverage group covered by the waiver and who meet the waiver eligibility criteria.

Automated System Program Identifier
TIERS – ME-Nursing Facility; ME-State School; ME-Non-State Group Home; ME-State Group Home; ME-State Hospital; ME-Waivers

Revision 16-1; Effective March 1, 2016

Home and Community-Based Services (HCBS) waiver programs may have limited enrollment and are an alternative to institutionalization. A person can enroll in only one HCBS waiver at a time, but may be on the interest list for multiple HCBS waivers. Persons applying for certain HCBS waiver programs who are not already Medicaid eligible under another coverage group covered by the waiver and who meet the waiver eligibility criteria may be Medicaid eligible using the special income limit.

For additional information about HCBS waiver programs, including interest lists, see Intellectual or Developmental Disabilities (IDD) – Long-term Care.

Descriptions for some of the Home and Community-Based Services waiver programs follow in this section.

A-3310 Community Living Assistance and Support Services (CLASS)

Revision 16-1; Effective March 1, 2016

A person may be eligible for services through CLASS if the person:

• is residing in the community;
• is age 65 or older or, if less than 65, receives a Social Security Administration (SSA), Supplemental Security Income (SSI), or Railroad Retirement (RR) disability benefit or has a disability determination by HHSC, which is required;
• has an ICF/IID Level of Care (LOC) VIII;
• has an approved plan of care or service plan;
• has a service begin date no later than 30 days from certification; and
• is eligible for Medicaid using the special income limit.

Automated System Program Identifier

TIERS – ME-Waivers

A-3320 Deaf Blind with Multiple Disabilities (DBMD)

Revision 16-1; Effective March 1, 2016

A person may be eligible for services through DBMD if the person:

• is residing in the community;
• is 65 or older or, if less than 65, receives a Social Security Administration (SSA), Supplemental Security Income (SSI), or Railroad Retirement (RR) disability benefit or has a disability determination by HHSC, which is required;
• has an ICF/IID Level of Care (LOC) VIII;
• has an approved plan of care or service plan;
• has a service begin date no later than 30 days from certification; and
• is eligible for Medicaid using the special income limit.

Automated System Program Identifier

TIERS – ME-Waivers

A-3330 Home and Community-based Services (HCS)

Revision 16-1; Effective March 1, 2016

A person may be eligible for services through HCS if the person:

• is residing in the community;
• is age 65 or older or, if less than 65, receives a Social Security Administration (SSA), Supplemental Security Income (SSI), or Railroad Retirement (RR) disability benefit or has a disability determination by HHSC, which is required;
• has an ICF/IID Level of Care (LOC) VIII;
• has an approved plan of care or service plan;
• has a service begin date no later than 30 days from certification; and
• is eligible for Medicaid using the special income limit.

Automated System Program Identifier

TIERS – ME-Waivers

A-3340 Youth Empowerment Services (YES)

Revision 16-1; Effective March 1, 2016

A person may be eligible for services through YES if the person:

• is residing in the community;
• is at least age 3, but less than age 19;
• receives a Social Security Administration (SSA), Supplemental Security Income (SSI), or Railroad Retirement (RR) disability benefit or has a disability determination by HHSC, which is required;
• meets clinical level of care criteria;
• has an approved individual plan of care (IPC);
• has a service begin date no later than 30 days from certification; and
• is eligible for Medicaid using the special income limit.

Note: This program is administered by the Department of State Health Services. For additional information, go to www.dshs.state.tx.us.

Automated System Program Identifier

TIERS – ME-Waivers

A-3350 Medically Dependent Children Program (MDCP)

Revision 16-1; Effective March 1, 2016

A person may be eligible for services through MDCP if the person:

• is residing in the community;
• is less than age 21;
• receives a Social Security Administration (SSA), Supplemental Security Income (SSI), or Railroad Retirement (RR) disability benefit or has a disability determination by HHSC, which is required;
• has an MN;
• has an approved plan of care or service plan;
• has a service begin date no later than 30 days from certification; and
• is eligible for Medicaid using the special income limit.

Automated System Program Identifier

TIERS – ME-Waivers

A-3360 Reserved for Future Use

Revision 16-1; Effective March 1, 2016

A-3370 Texas Home Living (TxHmL)

Revision 18-1; Effective March 1, 2018

A person may be eligible for services through TxHmL if the person:

• is residing in the community;
• has an ICF/IID Level of Care (LOC) VIII;
• has an approved plan of care or service plan; and
• is currently a Medicaid recipient.

Eligibility is not determined using the special income limit.

Automated System Program Identifier

TIERS shows this as ME-Pickle, ME-Disabled Adult Child, etc. HHSC puts the person on TxHmL.

A-3380 STAR+PLUS Waiver (SPW)

Revision 16-1; Effective March 1, 2016

The SPW provides for the managed care delivery of home and community-based Medicaid services in addition to all other services provided through STAR+PLUS.

Revision 16-1; Effective March 1, 2016

This program covers children with disabilities up to the age of 19 with family income up to 300 percent of the federal poverty level. A family may have to pay a monthly premium as a condition of eligibility. The MBIC program began Jan. 1, 2011. For more information, see Chapter N, Medicaid Buy-In for Children.

Automated System Program Identifier

TIERS – ME-MBIC
TA 88

Revision 16-1; Effective March 1, 2016

Texans with disabilities who work can apply for health insurance benefits even if their income exceeds traditional Medicaid limits. A person may have to pay a monthly premium as a condition of eligibility. For more information on the Medicaid Buy-In Program, see Chapter M, Medicaid Buy-In Program.

Automated System Program Identifier

TIERS – ME-MBI
TA 87

Revision 11-4; Effective December 1, 2011

Those who may be eligible for CAS services are persons who are not eligible under a Medicaid program and have a functional need for Medicaid Primary Home Care (PHC) services. The intent of the program is to delay or prevent the need for institutional care; therefore, countable income must be equal to or less than HHSC's special income limit. Eligible persons do not receive regular Medicaid benefits; they receive only PHC services. The program has its statutory basis in §1929(b) of the Social Security Act. This program historically was called Waiver Five and later 1929(b).

Automated System Program Identifier

TIERS – ME-Community Attendant and CC-CCAD-Community Attendant

Revision 20-4; Effective December 1, 2020

The PACE program serves the frail elderly and features a comprehensive service delivery system and integrated Medicare and Medicaid financing. Those who may be eligible for PACE services are people 55 years and older, with chronic medical problems and functional impairments who meet criteria for MN and are eligible for Medicaid (see §1905(a)(26) of the Social Security Act (enacted in Section 4802 of the Balanced Budget Act of 1997)).

Automated System Program Identifier

TIERS – ME-Waivers

A-4310 General

Revision 12-4; Effective December 1, 2012

In addition to the creation of the SSI program, Public Law 92-603 extended Medicaid benefits to cover the three-month time period before the month an application is filed with the Social Security Administration for SSI, if unpaid or reimbursable medical bills are incurred during the prior months.

Medicaid coverage also is extended to cover the three-month time period before the month an application is filed with MEPD for an ongoing MEPD program. For example, if an individual applies for ME – Nursing Facility, the eligibility specialist explores three months prior coverage.

People are potentially eligible for coverage in the prior months, regardless of their eligibility for the month of application and ongoing is approved or denied.

Note: This provision does not provide prior coverage for an application for which no MEPD program is available.

For specific program coverage, see Section G-7100, Prior Coverage for SSI Applicants, Section G-7200, Prior Coverage for Medical Assistance Only (MAO) Applicants, Section G-7210, Prior Coverage for Deceased Applicants, and Section G-7300, Prior Coverage for Aliens.

A-4320 Two Months Prior

Revision 11-4; Effective December 1, 2011

Public Law 104-193, Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA), Section 3502.4, changed policy for retroactive Medicaid coverage for persons found eligible for SSI. Effective July 1997, HHSC automatically adds Medicaid coverage for the month prior to the first month of SSI cash payment due (20 CFR §416.501). The person may apply with HHSC for coverage for the two preceding months if there are unpaid or reimbursable medical bills and the person meets all Medicaid eligibility requirements in those months.

Automated System Program Identifier

TIERS – ME-SSI Prior

A-4330 Deceased Individuals

Revision 12-4; Effective December 1, 2012

Medicaid coverage is extended to a deceased person, if a bona fide agent files an application with MEPD on behalf of a deceased person. The three-month time period is the three months prior to the month the application is received by MEPD.

Revision 11-4; Effective December 1, 2011

Persons residing in a community-based living arrangement, such as their home or a hospital, may elect to participate in the Texas Medicaid Hospice Program if they are eligible for full Medicaid benefits. This means that they qualify as an SSI recipient (ME-Temp Manual SSI or ME-SSI) or an MEPD recipient in the community (certified under ME-Pickle, ME-Disabled Adult Child or ME-Early Aged Widow(er)).

Persons whose only eligibility is MC-SLMB, MC-QMB and MC-QDWI may not participate in the Texas Medicaid Hospice Program because they receive only limited Medicaid coverage. However, they may be entitled to receive Medicare hospice services.

For a list of programs, see the TIERS Policy and Procedures Guide, Section A-6, Type Program Lists in the Texas Integrated Eligibility Redesign System (TIERS) in the Texas Works Handbook.

Revision 18-1; Effective March 1, 2018

A Medicaid recipient may elect to receive hospice services in a Medicaid-certified nursing facility (NF) or intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID). In order to receive Medicaid hospice services, the person must meet all eligibility criteria for MEPD in a long-term care facility, including confinement in one or more Medicaid-certified long-term care facilities for 30 consecutive days. Form 3071, Individual Election/Cancellation/Update, substitutes for the medical necessity determination when hospice is elected.

The hospice provider informs the eligibility specialist of the possibility of hospice election by a recipient. When the recipient (or authorized representative) signs and dates Form 3071, the hospice provider contacts the eligibility specialist, providing the effective date that the recipient is starting/electing hospice services. The hospice provider follows up this contact by sending Form 3071 to the contractor for Medicaid claims, with a copy to the eligibility specialist.

For Medicaid hospice residents in long-term care facilities, the hospice provider is responsible for collecting the applied income, and the nursing facility manages the patient trust fund. The hospice provider is responsible for completing Form 3071 in the event of any change in the hospice provider, cancellation of the hospice election, and death. There is normally no need for the eligibility specialist to take any action in response to any of these changes. The automated system receives this information through interfacing with the Service Authorization System Online (SASO) and communication with HHSC. If the eligibility worker becomes aware of the death of the recipient, manual denial of the case should be taken.

Revision 11-4; Effective December 1, 2011

QMBs are entitled to Medicare Part A (either with or without payment of premiums) with income usually counted according to the SSI rules at or below the federal poverty guidelines. States determine QMB eligibility, and Medicaid pays all Medicare-related expenses for QMBs (premiums, deductibles and coinsurance). Many SSI beneficiaries meet the QMB eligibility factors. Persons may be eligible under both a Medicaid or Community Attendant Services program and the QMB program (Public Law 100-360). For more information on the QMB program, see Section Q-2000, Qualified Medicare Beneficiaries (QMB) – MC-QMB.

Automated System Program Identifier
TIERS – MC-QMB

Revision 13-4; Effective December 1, 2013

Persons eligible for this program do not receive regular Medicaid benefits. Medicaid will pay the Medicare Part B premiums for SLMB. The person must be entitled to enroll in Medicare Part A and must meet all of the eligibility requirements for QMB status, except for income less than 120 percent of the federal poverty level. Persons may be eligible under both a Medicaid or Community Attendant Services program and the SLMB program (see Section 4501(b) of the OBRA, 1990). For more information on the SLMB program, see Section Q-3000, Specified Low-Income Medicare Beneficiaries (SLMB) – MC-SLMB.

Automated System Program Identifier
TIERS – MC-SLMB

Note: For TIERS, the following programs cannot be dually eligible for SLMB: ME-Pickle; ME-SSI Prior; ME-Temp Manual SSI; ME-SSI; ME-Disabled Adult Child (DAC); MC-SLMB; MC-QMB; and ME-A and D Emergency. Even though ME-Pickle and ME-DAC recipients may meet SLMB eligibility requirements, the Medicare Part B premium is already paid by the state of Texas based on their prior SSI eligibility and the continuation of that Medicaid coverage. The only requirement to test for SLMB is if the Pickle or DAC eligibility will be denied.

Revision 14-2; Effective June 1, 2014

Persons eligible for this program do not receive regular Medicaid benefits. QIs must meet the eligibility criteria for the Qualified Medicare Beneficiary (QMB) Program, except the income limits are higher. Medicaid will pay the Medicare Part B premiums for QIs. These persons must be entitled to be enrolled in Medicare Part A and have countable income of at least 120 percent but less than 135 percent of the current federal poverty level. Eligibility is determined for each calendar year.QI recipients cannot be certified under any other Medicaid-funded program and receive QI benefits simultaneously (Public Law 105-33, Balanced Budget Act of 1997). For more information on the QI program, see Section Q-5000, Qualifying Individuals (QIs).

Automated System Program Identifier

TIERS – MC-QI-1

Note: Even though ME-Pickle and ME-Disabled Adult Child (DAC) recipients may meet QI-1 eligibility requirements, the Medicare Part B premium is already paid by the state of Texas through the Pickle or DAC Medicaid program eligibility. The only requirement to test for QI-1 is if the Pickle or DAC eligibility will be denied.

Revision 14-2; Effective June 1, 2014

Persons eligible for this program do not receive regular Medicaid benefits and must be disabled working individuals entitled to Medicare Part A (hospital coverage). Medicaid will pay the Medicare Part A premiums for QDWIs. These persons must be entitled to enroll in Medicare Part A, not otherwise certified under any other Medicaid-funded program, have countable income of no more than 200% of the federal poverty guidelines, have countable resources of no more than twice the SSI resource limit and be referred by SSA (Public Law 101-239, OBRA 1989). For more information on the QDWI program, see Section Q-6000, Qualified Disabled and Working Individuals (QDWI) – MC-QDWI.

Automated System Program Identifier

TIERS – MC-QDWI

Revision 18-1; Effective March 1, 2018

Medicare is a federal program under Title XVIII of the Social Security Act and is administered by the Social Security Administration (SSA). Medicare provides health care benefits for individuals age 65 or older, under age 65 with certain disabilities, and any age with permanent kidney failure (called end-stage renal disease).

Those younger than 65 will receive Medicare after getting Social Security disability benefits for at least two years.

There are exceptions to the two-year waiting period, including:

• a chronic renal disease that requires a kidney transplant or maintenance dialysis (SSA determines if an individual with a chronic renal disease diagnosis meets the requirements for the exception to the waiting period); or
• Lou Gehrig's disease (amyotrophic lateral sclerosis).

Medicare is available to an individual who has paid into the Medicare trust account through payroll taxes sometimes called the Federal Income Contributions Act (FICA). Most employers are required to withhold FICA taxes, but there are some exceptions. Federal government employees have been eligible to participate in Social Security only since 1984. As a result, some older employees have opted to remain with the former Civil Service Retirement System. Some state and local government employee retirement plans also are not covered by Social Security.

If an individual receives Medicare, they are either:

• 65 years old or older; or
• determined disabled by SSA.

Medicare is divided into four parts:

• Medicare Part A (Hospital Insurance) – Helps pay for inpatient care in a hospital, skilled nursing facility or hospice, and for home health care if certain conditions are met. Most people do not have to pay a monthly premium for Medicare Part A because they or a spouse paid Medicare taxes while working in the U.S. If the Part A premium is not automatically free, an individual still may be able to enroll and pay a premium.
• Medicare Part B (Medical Insurance) – Helps pay for medically necessary doctors’ services and other outpatient care. It also pays for some preventive services (like flu shots), and some services that keep certain illnesses from getting worse. Most individuals pay the standard monthly Medicare Part B premium.
• Medicare Part C (Medicare Advantage Plans) – Individuals must be enrolled in both Part A and Part B. These plans are available through Medicare-approved private insurance companies. The plans cover all of the Part A and Part B services and, in most cases, include Part D Prescription Drug Coverage as well. Some plans offer additional services, such as vision, hearing, dental, and health and wellness programs. Individuals pay a monthly premium and co-payments that are usually lower than the coinsurance and deductibles under the original Medicare. Actual costs and benefits vary by plan.
• Medicare Part D (Medicare Prescription Drug Coverage) provides prescription drug coverage. Individuals can add Part D by joining a Medicare Prescription Drug Plan (PDP). Individuals must pay a deductible and usually pay coinsurance each time services are received. The PDPs are available through private insurance companies approved by Medicare. Costs and benefits vary by plan.

Premiums

In most cases, the Part B and Part D premiums are deducted from the Social Security or Railroad Retirement check. The recipient is responsible for calendar-year deductibles and co-pay liabilities for both Parts A and B.

The Part C premium is handled by the private company that offers the benefit as a Medicare Advantage Plan. The Medicare Advantage Plan has its own benefits and coverage that differs from the traditional Medicare benefits. Medicare pays a fixed amount every month to the companies offering Medicare Advantage Plans. These companies must follow rules set by Medicare. However, each Medicare Advantage Plan can charge different out-of-pocket costs and have different rules for how one gets services.

Extra help for Part D (Medicare Prescription Drug Coverage) is available for people with Medicare who have limited income and resources. If eligible for extra help, Medicare will pay for almost all prescription drug costs. Extra help provides a subsidy based on the amount of income and resources an individual has.

Full Subsidy Benefits from Extra Help:

• Full premium assistance up to the premium subsidy amount
• Nominal cost sharing up to out-of-pocket threshold
• No coverage gap

Other Low Income Subsidy Benefits from Extra Help:

• Sliding scale premium assistance
• Reduced deductible
• Reduced coinsurance
• No coverage gap

Individuals who have Medicare and Medicaid or who are eligible for the Medicare Savings Program (MSP) do not need to apply for extra help through the SSA.

Individuals can apply for extra help or get more information about extra help subsidy by calling Social Security at 800-772-1213 (TTY 800-325-0778) or visiting www.socialsecurity.gov.

Revision 11-4; Effective December 1, 2011

To ensure that Medicaid recipients who are entitled to Medicare receive maximum health care protection, the state pays for certain recipients' Medicare Part B premiums. This process is called buy-in. For those persons who have dual entitlement, Medicare becomes the payer of first resort, with Medicaid paying deductibles and co-insurance for Medicaid-covered services.

If recipients in ME-Nursing Facility, ME-State School, ME-Waivers and ME-Community Attendant are not eligible for QMB or SLMB, they are not eligible for buy-in.

 

A-9210 Eligibility Requirements for Medicare Buy-In

Revision 11-4; Effective December 1, 2011

Recipients are eligible for buy-in if they are:

• 65 or older and U.S. citizens;
• 65 or older and lawfully admitted aliens who have lived in the U.S. five consecutive years;
• under 65 and have received or been eligible to receive Social Security or Railroad Retirement disability benefits for 24 consecutive months; or
• under 65 and qualify for Medicare Part A because of chronic renal disease.

If recipients in ME-Nursing Facility, ME-State School, ME-Waivers and ME-Community Attendant are not eligible for QMB or SLMB, they are not eligible for buy-in.

 

A-9220 Time Frames for Medicare Buy-In Enrollment

Revision 13-4; Effective December 1, 2013

Persons who have Medicare Part B coverage at the time they are certified for Medicaid are enrolled as follows:

• SSI and Temporary Assistance for Needy Families (TANF) recipients are enrolled for buy-in effective the first month they receive a cash payment.
• ME-Pickle recipients who are RSDI pass-on recipients are enrolled in continuous buy-in.
  
  Example: The recipient was denied SSI on Dec. 31 due to a cost of living increase. The recipient applied for ME-Pickle in February and was certified eligible on March 5. Medical effective date is Jan. 1. Medicare Part B buy-in is effective Jan. 1. The recipient will be reimbursed by SSA for any premiums withheld from the recipient's RSDI check.
   
• ME-Disabled Adult Child (DAC) recipients who are RSDI pass-on recipients are enrolled in continuous buy-in.
  
  Example: The recipient was denied SSI on Dec. 31 due to a cost of living increase. The recipient applied for ME-DAC in March and was certified eligible on April 10. Medical effective date is Jan. 1. Medicare Part B buy-in is effective Jan. 1. The recipient will be reimbursed by SSA for any premiums withheld from the recipient’s RSDI check.
   
• ME-Nursing Facility, ME-State School, ME-Waivers, ME-Non-State Group Home and ME-State Group Home recipients who are QMB-eligible, whose certification was accomplished as a program transfer, and whose certification has no break in Medicaid coverage are eligible for continuous buy-in.
  
  Example: The MQMB recipient has SSI and RSDI income and enters a nursing facility in January. SSI is denied effective Feb. 28. The recipient qualifies for QMB and Medicaid. The medical effective date for MQMB is March 1. The recipient is entitled to continued Medicare buy-in and is reimbursed for any premium withheld from the RSDI check.
   
• Recipients who are denied in error and are recertified have continuous enrollment for buy-in. This is true except for those recipients in ME-Nursing Facility who are not eligible for QMB benefits.
  
  Example: The MQMB recipient is enrolled in Medicaid, ME-Nursing Facility. During the first year's review process, the recipient was denied due to excess resources effective Jan. 31. During a subsequent application in March, the eligibility specialist discovers the recipient should not have been denied in January and grants a medical effective date of Feb. 1, reopening the case. The recipient is entitled to continued Medicare buy-in and is reimbursed for any premium withheld from the RSDI check.
   
• ME-Nursing Facility recipients who are also QMB-eligible are enrolled for buy-in effective the month of their eligibility for QMB benefits.
  
  Example: The recipient is certified for ME-Nursing Facility and is also eligible for MQMB. Certification is Jan. 15, and the MQMB effective date is Feb. 1. Medicare buy-in is effective Feb. 1. The recipient will be reimbursed by SSA for any premiums withheld after the effective date of buy-in.
   
• Recipients eligible for QMB who do not have Medicare Part B coverage at the time of Medicaid certification are enrolled in buy-in when they meet Medicare criteria. These recipients remain on the buy-in rolls while they are eligible for Medicare, Medicaid and QMB benefits.

When a recipient is enrolled in buy-in, SSA stops charging for Part B premiums. Usually this occurs the month after SSA has acknowledged receiving the recipient's name as an addition to the buy-in rolls. If premiums have been withheld from the monthly benefit, the recipient's check should reflect an upward adjustment by the third month after the month of certification.

Address questions about the buy-in status of a recipient who has been certified for at least three months to:

CCC_Data_Integrity_Program@hhsc.state.tx.us