B-1100, Texas Administrative Code Rules

Revision 09-4; Effective December 1, 2009

§358.505. Application Process Overview.

(a) The Texas Health and Human Services Commission (HHSC) gives anyone the opportunity to apply for a Medicaid-funded program for the elderly and people with disabilities (MEPD), in accordance with 42 CFR §435.906. A person can apply for MEPD by submitting:

(1) an application for assistance to HHSC; or

(2) an application for Supplemental Security Income (SSI) to the Social Security Administration.

(b) Under the application submittal process described in subsection (a)(1) of this section, a person must follow the requirements in §358.515 of this subchapter (relating to Application Requirements) to obtain an eligibility determination from HHSC.

(c) In accordance with 42 CFR §435.120 and §435.909(b)(1), an application for SSI as described in subsection (a)(2) of this section serves as an application for MEPD. A person receiving or deemed to be receiving SSI derives eligibility for MEPD from the person's SSI eligibility and does not require an eligibility determination from HHSC.

§358.510. Authorized Representative.

In accordance with 42 CFR §435.908, an authorized representative may accompany, assist, and represent an applicant or recipient in the application or eligibility redetermination process.

§358.515. Application Requirements.

(a) To apply for a Medicaid-funded program for the elderly and people with disabilities (MEPD) under the application submittal process described in §358.505(a)(1) and (b) of this subchapter (relating to Application Process Overview), and in accordance with 42 CFR §435.907, an applicant, authorized representative, or someone acting responsibly for the applicant (if the applicant is incompetent or incapacitated) must:

(1) use the application prescribed by the Texas Health and Human Services Commission (HHSC) and complete it according to HHSC instructions:

(A) in writing, using a paper application obtained via telephone, Internet request, or other means;

(B) online, using the application process available over the Internet;

(C) over the telephone, through the State's toll-free telephone number; or

(D) in person, by visiting an HHSC benefits office;

(2) provide all requested information according to HHSC instructions; and

(3) sign the application for assistance under penalty of perjury.

(b) If someone helps an applicant or authorized representative complete the application for assistance, the name of the person completing the form must appear as requested on the application.

(c) If HHSC sends an applicant or authorized representative a request for missing information or verification documents, or both, the applicant or authorized representative must provide the requested information to HHSC by the due date given in the request, or eligibility may be denied.

§358.520. Date of Application.

(a) The date of application is the date on which:

(1)the Texas Health and Human Services Commission receives an application for assistance in accordance with subsection (c) of this section; or

(2) an application for Supplemental Security Income is filed with the Social Security Administration.

(b) If an application for assistance is received after the close of business, the date of application is the next working day.

(c) For purposes of determining the date of application for an application for assistance received under subsection (a)(1) of this section:

(1) an application received via fax or mail must contain, at a minimum, the applicant's name, address, and valid signature; and

(2) an application received via telephone or the Internet:

(A) must contain, at a minimum, the applicant's name and address; and

(B) the applicant must provide a valid signature within 45 days after the date of application.

§358.525. Previously Completed Application for Assistance.

An application for assistance remains valid for 90 days after a date of denial, if the Texas Health and Human Services Commission denies eligibility. An applicant may use his or her previously completed application to reapply during the 90-day period, in accordance with HHSC instructions.

§358.530. Eligibility Determination.

(a) Time frame for determination. After an applicant or authorized representative provides all information and verification documents requested, the Texas Health and Human Services Commission (HHSC) makes an eligibility determination within the following time frames, in accordance with 42 CFR §435.911:

(1) by the 90th day after the date of application if the applicant is applying on the basis of a disability;

(2) by the 45th day after the date of application for all other applicants; or

(3) beyond the time frames established in paragraphs (1) and (2) of this subsection under unusual circumstances, such as those set forth in 42 CFR §435.911.

(b) Basis for determination. HHSC decides whether an applicant meets the eligibility criteria for a Medicaid-funded program for the elderly and people with disabilities based on:

(1) a complete, signed, and dated application for assistance;

(2) information obtained from an interview, if an interview occurred; and

(3) required verification documents.

§358.545. Eligibility Redetermination.

(a) In accordance with 42 CFR §435.916, the Texas Health and Human Services Commission (HHSC) redetermines a person's eligibility for a Medicaid-funded program for the elderly and people with disabilities (MEPD):

(1) at least every 12 months;

(2) after HHSC receives information about a change in the person's circumstances, such as living arrangement, income, or resources, that may affect MEPD eligibility; and

(3) at the appropriate time based on an anticipated change in the person's circumstances.

(b) If the result of an eligibility redetermination causes an adverse action, HHSC:

(1) gives timely and adequate notice of the proposed action to terminate, discontinue, or suspend MEPD eligibility;

(2) gives timely and adequate notice to reduce or discontinue MEPD services; and

(3) informs the person of the right to request a hearing to appeal the adverse action in accordance with 42 CFR Part 431, Subpart E and HHSC's fair hearing rules in Chapter 357 of this title (relating to Hearings).

B-2000, Responsibilities of an Eligibility Specialist

B-2100, Reporting Abuse and Neglect

Revision 09-4; Effective December 1, 2009

HHSC staff are mandated to report abuse or neglect that threatens the health or welfare of a child or an elderly or disabled adult. Staff must report instances of:

  • physical or mental injury;
  • sexual abuse;
  • exploitation; and
  • neglect.

Report such instances to the Department of Family and Protective Services. The toll-free number to report abuse is 800-252-5400.

For reports of domestic violence, abuse or neglect of adults, inform the person or his or her authorized representative of the report unless you believe informing them would place the person at risk of serious harm.

B-2200, Conflict of Interest

Revision 09-4; Effective December 1, 2009

An eligibility specialist has an obligation to avoid even the appearance of impropriety or conflict of interest when determining Medicaid eligibility. The eligibility specialist must not work on or review an ongoing case nor assist an applicant or recipient to receive benefits if the applicant or recipient is a relative (by blood or marriage), roommate, dating companion, supervisor or someone under the specialist's supervision. The specialist may not determine their eligibility for Medicaid. The specialist may provide anyone with an application for Medicaid and may inform anyone how and where to apply. The specialist may help anyone gather documents to verify eligibility and need for Medicaid, but must not take any other role in determining eligibility.

The specialist must consult with the supervisor if the applicant or recipient is a friend or acquaintance. Generally, the specialist should not work on cases or applications involving these individuals, but the degree and nature of the relationship should be taken into account.

B-2300, Eligibility Determination

Revision 09-4; Effective December 1, 2009

Verify all eligibility factors according to the verification and documentation requirements for each factor.

Document all factors of eligibility in the case record to substantiate the decisions made on all applications and redeterminations before certifying, recertifying, denying or taking any other action on a person's eligibility and/or co-payment.

B-2400, Documentation Standards

Revision 11-4; Effective December 1, 2011

Documentation standards are contained in this handbook. Specific documentation and verification standards can be found in Appendix XVI, Documentation and Verification Guide. Appendix XVI provides documentation expectations and suggested sources for obtaining information that have proven to result in quality, accurate cases.

When supervisor approval is suggested, written or documented, verbal contact is acceptable. Requirements for documenting telephone contacts are contained in Appendix XVI.

Documentation standards include the date and name/signature of the MEPD eligibility specialist on all recording documents and case actions.

See Section B-8440, Streamlining Methods.

B-2500, Explaining Policy vs. Giving Advice

Revision 09-4; Effective December 1, 2009

Explaining policy is appropriate. The law requires that Medicaid rules, policies and procedures be freely available to the public. The rules governing MEPD are contained in the Texas Administrative Code (TAC), Title 1, Part 15, Chapters 358, 359 and 360. This handbook also contains the MEPD rules, as well as policies, procedures and examples. Both the TAC and MEPD Handbook are available online. MEPD eligibility specialists act properly in explaining the rule or policy that applies to an applicant's or recipient’s situation, and in referencing the applicable rule or handbook sections.

Giving advice is contrary to HHSC policy. Giving advice includes suggesting options for how to become eligible or how to avoid Medicaid estate recovery, as well as expressing any opinion of what is preferable or more advantageous to the applicant or recipient. Giving advice is contrary to HHSC policy because it:

  • usually constitutes the unauthorized practice of law (which can subject the eligibility specialist to legal penalties);
  • encroaches on the contractual relationship that may exist between the applicant or recipient and attorney or financial advisor; and
  • can subject the eligibility specialist to personal liability for giving advice that is incorrect or that fails to take into account issues other than eligibility (attorneys and financial planners take into account other issues, such as tax laws, in giving estate planning advice relating to Medicaid eligibility).

The approach taken by MEPD eligibility specialists should be to explain policy but not to make recommendations. If an MEPD eligibility specialist is asked for advice, an appropriate response would be to provide the policy that applies to the situation, and to otherwise decline the request. The MEPD eligibility specialist should explain that agency policy prohibits giving advice, and may suggest that the applicant or recipient seek the assistance of an attorney or other estate planning professional of their own choosing.

Excess Income

See Appendix XVI, Documentation and Verification Guide, and Appendix XXXVI, Qualified Income Trusts (QITs) and Medicaid for the Elderly and People with Disabilities (MEPD).

If an applicant is income ineligible in an institutional living arrangement, Appendix XXXVI may be shared with applicants and their representatives to assist them in understanding the purpose of and requirements for a QIT.

To prevent allegations that MEPD staff are engaging in the unauthorized practice of law, the following instructions are provided. Use the instructions on the chart regarding the appropriate actions to take and the actions to avoid.

MEPD Staff

May May Not
Provide applicants or their representatives with a copy of Appendix XXXVI for informational purposes only. Tell applicants or their representatives that they need a QIT.
Provide applicants or their representatives with applicable policy and procedures. Recommend specific actions applicants or their representatives should take to become eligible for Medicaid.
Refer applicants or their representatives to the following allowable referral list:
  • local legal aid office,
  • local Area Agency on Aging,
  • National Academy of Elder Law Attorneys,
  • local bar association or lawyer referral service,
  • Advocacy Inc., or
  • State Bar of Texas for a list of attorneys who practice elder law in the area.
Tell applicants or their representatives whether or not they must have an attorney to establish a QIT.

Recommend that an applicant or representative consult with a specific attorney or organization. (See allowable referral list.)

Speak with their supervisor or regional services attorney about any questions they have regarding the use of Appendix XXXVI. Recommend that an applicant or representative call an HHSC attorney for legal advice.

Excess Resources

See Appendix XVI, Documentation and Verification Guide.

If excess resources can be designated as burial funds, allow the individual the opportunity to do so. See Section F-4227, Burial Funds.

If a person is determined ineligible because of excess funds in a joint account, allow an opportunity to disprove the presumed ownership of all or part of the funds. The person also must be allowed to disprove ownership of joint accounts that currently do not affect eligibility but may in the future. See Section F-4121, Joint Bank Accounts.

B-2600, Medicaid Estate Recovery Program Notification Requirements

Revision 18-1; Effective March 1, 2018

Medicaid Estate Recovery Program (MERP) is not part of the eligibility determination process for Medicaid.

MERP recovers from a Medicaid recipient’s estate the cost of Medicaid assistance paid for an individual who:

1) was age 55 or older at the time Medicaid services were received; and
2) initially applied for certain types of long-term care (LTC) services on or after March 1, 2005.

Individuals whose estate may be subject to MERP recovery include:

  • an applicant for a Medicaid program that covers these LTC services; or
  • a recipient who requests a change to a Medicaid program that covers these LTC services.

Individuals applying for or receiving these LTC services must be informed about MERP.

A signed Form 8001, Medicaid Estate Recovery Program Receipt Acknowledgement, or documentation the Form 8001 was provided, must be in the case record of each applicant whose estate is subject to MERP recovery.

 

B-2610 Types of MEPD Groups Subject to MERP

Revision 18-1; Effective March 1, 2018

On March 1, 2005, Texas implemented MERP in compliance with federal Medicaid and state laws. The program is managed by HHSC. Under this program, the state may file a claim against the estate of a deceased Medicaid recipient who: 1) was age 55 or older when Medicaid services were received; and 2) first applied for certain long-term care services and supports on or after March 1, 2005. The most complete, current and accurate source of information regarding MERP is the HHS website: Medicaid Estate Recovery Program. MERP Claims include the cost of Medicaid assistance paid for the following services:

  • nursing facilities;
  • intermediate care facilities for individuals with an intellectual disability or related conditions (ICF/IID), which include state supported living centers;
  • Home and Community-Based Services waiver programs. See Chapter O, Waiver Programs, Demonstration Projects and All-Inclusive Care;
  • Community Attendant Services; and
  • related hospital and prescription drug services.

Notes:

  • A person who is placed on an interest list for a Home and Community-Based Services waiver program is not considered to be an applicant.
  • As of Jan. 1, 2010, states are prohibited from recovering the value of Medicare cost-sharing paid under Medicare savings programs as a result of the Medicare Improvements for Patients and Providers Act (MIPPA) signed into law on July 15, 2008.

 

B-2620 HHSC MERP Notification Requirements

Revision 18-1; Effective March 1, 2018

HHSC staff must inform anyone requesting Medicaid assistance for long-term services and supports that may be subject to MERP recovery. Complete the following to document this requirement:

  • Form 8001, Medicaid Estate Recovery Program Receipt Acknowledgement, is mailed with all Form H1200 application requests received on or after March 1, 2005.
  • Ensure the signed MERP Receipt Acknowledgement (Form 8001) is imaged in the case record.
  • Include the MERP documentation with SSI monitoring requirements outlined in Section B-7100, SSI Monitoring.
  • Record information (name, address, telephone number) of any of the following individuals representing the applicant:
    • guardian of the person or guardian of the estate of the applicant;
    • agent under a durable power of attorney or a medical power of attorney;  or
    • if none of the above individuals are known, family members acting on behalf of the applicant.
  • If a signed MERP Receipt Acknowledgement form is not returned by the applicant/recipient, send Form 8001 and document in case comments that the MERP information was sent to inform the recipient about MERP and the potential for estate recovery.  Include in the documentation the date the form was sent to the recipient.

If a Form H1746-A, MEPD Referral Cover Sheet, has a mark in the box "MERP shared," do not send MERP notifications to the individual. The agency making the referral has shared MERP information with the individual.

The MERP notification requirement applies to any individual, age 55 or older, who is applying for Medicaid assistance for long-term care services and supports that are subject to MERP on or after March 1, 2005, either through an application or program transfer. Individuals transferring to long-term care services and supports subject to MERP must have documentation of Form 8001 in the case record. If there is no documentation in the case record, send Form 8001 and follow documentation guidelines outlined in this section.

Example: Mr. Andy Allen applied for a Medicare Savings Program (MSP) before Nov. 1, 2004, and was certified, but did not receive Form 8001 since Mr. Allen was on an MSP before March 1, 2005. Mr. Allen entered a nursing facility this month and requested a program transfer. Based on Section B-7450, Medicaid Certified Person Enters Nursing Facility or Home and Community-Based Services Waiver Program, the program transfer is complete, and Form 8001 is sent to Mr. Allen. Staff document in case comments the date the Form H8001 was mailed.

B-3000, Applications

B-3100, Application Process

Revision 20-2; Effective June 1, 2020

For Medicaid for the Elderly and People with Disabilities (MEPD), the application for assistance is based on one of the following versions of Form H1200:

  • Form H1200, Application for AssistanceYour Texas Benefits, for all MEPD programs;
  • Form H1200-EZ, Application for Assistance — Aged and Disabled, for Medicare Savings Programs (MSP) programs;
  • Form H1200-PFS, Medicaid Application for Assistance (for Residents of State Facilities) Property and Financial Statement, for state supported living centers, state hospitals, and state centers;
  • Form H1200-MBI, Application for Benefits — Medicaid Buy-In, for the MBI program only; or
  • Form H1200-MBIC, Application for Benefits — Medicaid Buy-In for Children (MBIC), for the MBIC program only.

If requested, give the applicant a receipt (Form H1800, Receipt for Application/Medicaid Report/Verification/Report of Change) to verify they provided an application. An applicant may request Form H1800 by fax or mail. Mail the receipt to the applicant’s listed address.

Related Policy

Date of Application, B-4000
Previous Completed Application, B-5000
Notices and Forms, M-9000
Notices and Forms, N-9000

B-3200, Application Requirements

Revision 09-4; Effective Dec. 1, 2009

Federal law requires that anyone who wishes to apply for a Medicaid program be allowed to file an application without delay, regardless of the person's ultimate eligibility for assistance.

An application form must be mailed within two working days from the receipt of the request for an application.

Use an application form to test eligibility for all Medicaid programs for which a person meets the criteria. A separate application form is not required for each of the different Medicaid programs for the elderly and persons with disabilities.

Consider the application complete with a name, address and signature.

B-3210 Who May Complete an Application for Assistance

Revision 23-2; Effective June 1, 2023

A person who may complete or sign an application for an applicant may not be on the list of people to whom the Texas Health and Human Services Commission (HHSC) can release the applicant’s individually identifiable health information. See section C-5000, Personal Representatives, for people who may receive or authorize the release of an applicant's individually identifiable health information under Health Insurance Portability and Accountability Act (HIPAA) privacy regulations.

An authorized representative may accompany, help and represent an applicant or recipient in the application or eligibility redetermination process.

Anyone may help the applicant, guardian, power of attorney or authorized representative complete an application form. If someone helps complete the application for assistance, the name of the person completing the form must appear as requested on the application.

See section B-3220, Who May Sign an Application for Assistance, to determine who may sign an application for assistance form. The requirements for signing a redetermination form are the same as the requirements for signing an application.

See section C-1100, Responsibility of Applying.

Most applicants in an institutional setting such as a nursing facility are signed into the facility by someone else. An application and information from the applicant or the person(s) having knowledge of the applicant's financial circumstances are required.

B-3220 Who May Sign an Application for Assistance

Revision 16-3; Effective Sept. 1, 2016

An individual who may complete or sign an application for an applicant may not be on the list of people to whom HHSC can release the applicant’s individually identifiable health information. See section C-5000, Personal Representatives, for individuals who may receive or authorize the release of an applicant’s individually identifiable health information under HIPAA privacy regulations.

An applicant, authorized representative or someone acting responsibly for the applicant (if the applicant is incompetent or incapacitated) may sign an application for assistance. The application for assistance must be signed under penalty of perjury.

If an applicant has a guardian, the guardian must:

  • sign the application for assistance;
  • obtain a copy of the guardianship papers; and
  • work with the guardian in the eligibility process.

If an application is signed by someone other than the applicant or the applicant’s guardian, power of attorney, family member, or a friend who is knowledgeable of the applicant’s finances, the individual must provide a Form H1003, Appointment of an Authorized Representative (PDF), signed by the applicant, or evidence of:

  • authority to complete and sign an application on behalf of an applicant;
  • the individual’s relationship to the applicant; and
  • responsibility for the applicant’s care.

If an applicant makes an "X" on the signature line for applicant/recipient, a witness must sign on the witness signature line.

B-3221 Valid Signatures

Revision 24-1; Effective March 1, 2024

All applications and renewals must be signed under the penalty of perjury statement.

Valid signatures include only the following:

  • a traditional written signature;
  • a faxed written signature;
  • an electronic signature submitted through YourTexasBenefits.com;
  • an electronic signature submitted through an account transfer from the Marketplace; and
  • a telephonic signature submitted by calling 2-1-1.

YourTexasBenefits.com

Applications submitted online through YourTexasBenefits.com by a person or authorized representative (AR) are considered electronically signed. A traditional written signature is not required before the person can be certified.

Federal Marketplace Applications

The Marketplace sends a person's information electronically to HHSC through an account transfer. Applications from the Marketplace are received by staff in the same way as an application from YourTexasBenefits.com and are considered electronically signed. 

Other Electronic Signatures

Other electronic signatures not specifically mentioned above, including those captured or copied by electronic devices, are not valid signatures. 

Calling 2-1-1

A person may apply for Medicaid by calling 2-1-1. A person or AR may complete and sign an application over the phone by:

  • providing their information over the phone to a customer care representative (CCR); and
  • signing the application telephonically by stating their name and agreeing to the penalty of perjury statement read by the CCR.

The CCR enters and submits the information provided by the person or AR through YourTexasBenefits.com.

Unsigned Applications

An application or renewal form is considered invalid when:

  • it is received without a signature below the penalty of perjury statement; or
  • the agency receives an application without a signature and does not accept the application by giving the application an established file date. 

Staff must return the application with a letter and a self-addressed return envelope explaining that the application must be signed before the agency can establish a file date.

If the agency receives and accepts an application without a signature and the application is given an established file date in error, the date the application is received is considered a valid file date. Staff must send Form H1020, Request for Information or Action (PDF), along with the signature page requesting a signature. If the person applying for Medicaid fails to provide a signed application by the final due date, staff must deny the application for failure to provide information.

Related Policy

Processing Deadlines, B-6400
Who May Sign an Application for Assistance, B-3220

B-3230 Receipt of Duplicate or Identical Applications

Revision 20-3; Effective Sept. 1, 2020

Duplicate Application

An application filed after another application has already been filed is a duplicate application if it:

  • does not include a request for a new program (i.e.: a type of program not requested on the initial application or a type of program not currently received by the applicant); and
  • is not needed for a redetermination of the active program(s).

Example: An application is received on January 2 and a second application for the same program is received on January 5. The second application is considered a duplicate application.

If a duplicate application is received while the first application is being processed:

  • treat the duplicate application as a report of change; and
  • assign to the eligibility staff currently processing the case.

If a duplicate application is received after the first application has been processed, review the application to ensure the person is not applying for a different type of program and that a redetermination is not due. If a new program is not being requested:

  • consider the duplicate application as a report of change; and
  • assign as a change indicating "duplicate application."

If the person is applying for a new program, the application is not a duplicate application. Process the application as a new request for assistance.

Identical Application

An identical application is an exact copy of an application previously submitted by an applicant.

Example: An application is received by fax on January 2 and an exact copy of the same application (with the same signature and date of the previously submitted application) is received by mail on January 5. The second application is considered an identical application.

Required Action on Identical Application Received

If an identical application is received, write "Identical Application" on the front page of the application and route for imaging. The identical application will be imaged and added to the electronic case record. No other action is needed.

B-3240 Electronic Correspondence

Revision 22-3; Effective September 1, 2022

At any time, an applicant, recipient, or authorized representative (AR) for a case may view available eligibility correspondence electronically through YourTexasBenefits.com instead of receiving them by mail. By selecting this option, applicable forms and notices are posted to the recipient’s or AR’s YourTexasBenefits.com case account. A text message or an e-mail reminder is sent to the recipient each time a new form or notice is posted to their account. The recipient may print a copy of the correspondence from their YourTexasBenefits.com account or request a paper copy be mailed to them. Forms and notices that are not available electronically will continue to be mailed to the recipient or AR.

Related Policy

Notices, R-1300

B-3300, Authorized Representative

Revision 21-1; Effective March 1, 2021

An authorized representative (AR) is a person who is familiar with the applicant and knowledgeable of the applicant’s financial affairs.

An applicant, person receiving benefits, head of household (HOH), or someone with legal authority to act on their behalf (e.g., legal guardian or power of attorney) may designate a person or organization as an AR.

When applying for benefits, an AR must be verified using one of the following:

If a person or organization submits an application on behalf of an applicant and indicates they wish to be the AR but the application is not signed by the applicant, send correspondence to both the unverified AR and the applicant to request the verification.

For the AR to be verified, either the AR or the applicant must return the completed Form H1003 within 10 days (or 39 days from the file date). All missing information listed on the Form H1020 must also be returned timely. If the AR verification is not received by the due date, do not designate an AR.

The AR designation is effective from the date the AR is verified until:

  • the applicant or recipient notifies HHSC that the AR is no longer authorized to act on their behalf;
  • the AR notifies HHSC that they no longer wish to act as the AR for the applicant or recipient;

    Note: The AR will not be able to do this during the redetermination process if the AR is the person completing and signing the redetermination.
     
  • there is a change in the legal authority (i.e., legal guardianship or power of attorney) on which the AR’s designation is based; or
  • the applicant or recipient designates a new AR to act on their behalf. If there is an existing AR designated on a case, the person or organization most recently designated as the AR will replace the existing AR on the case.

Requests to end the designation of an AR must include the signature of the applicant, the recipient or the AR as appropriate.

Note: An AR is not automatically a personal representative.

An AR is designated at the case level to have access to all benefit information for that case. A verified AR may:

  • sign an application on behalf of an applicant;
  • complete and submit a renewal form;
  • receive copies of notices or renewal forms in the preferred language selected on the application, and other communications from HHSC;
  • designate a health plan; and
  • act on behalf of the applicant or the recipient in all other matters with HHSC.

The applicant, recipient or AR may also request that the AR receive the recipient’s Medicaid ID card and enrollment-related agency correspondence.

Mailing Address for AR

When processing the application, obtain the AR’s complete mailing address if not included on the application form. Record the AR’s address on the TIERS Data Collection page, Household – Authorized Representative. If the applicant cannot provide a complete mailing address for the AR, do not pend the case. Record the applicant’s mailing address as the AR’s address in TIERS.

When an applicant or recipient and their designated AR have the same mailing address, correspondence will be sent only to the AR.

When an applicant or recipient has a legal guardian, correspondence will be sent only to the guardian, even if the applicant or recipient and the guardian have different mailing addresses.

Applicants, recipients or ARs who have chosen to receive eligibility correspondence electronically will continue to receive correspondence electronically.

Related Policy

Who May Complete an Application for Assistance, B-3210
Who May Sign an Application for Assistance, B-3220
Prior Coverage for Deceased Applicants, G-7210

B-3400, General Procedures

Revision 21-4; Effective December 1, 2021

If an applicant or authorized representative (AR) contacts HHSC to initiate an application and appears to be eligible for SSI, refer the person or AR to the Social Security Administration (SSA). If the person or AR wishes to file an application with HHSC, provide the appropriate cover letter, application for assistance and Form H0025, HHSC Application for Voter Registration.

Explain that eligibility is determined based on:

  • a completed, signed and dated application for assistance;
  • information obtained from the completed form, the applicant and AR, tape matches and interviews if needed; and
  • required verification documents.

When determining eligibility for a person in an institutional setting using the special income limit, the eligibility determination cannot be disposed in the system of record until the person has resided in an institutional setting for at least 30 consecutive days.  The person must also have an approved level of care (LOC) for an intermediate care facility for persons with intellectual disabilities (ICF/IID)  or an approved medical necessity (MN) with a nursing facility LOC. 

Do not approve medical assistance for a person in an institutional setting unless the person has been in a Medicaid facility for at least 30 days and has an approved LOC or MN determination.

Related Policy

Institutional Living Arrangement, B-6300
Voter Registration, C-7000
Assessment and SPRA, J-4000
 

 

B-3500, Coordination with the Federal Marketplace

Revision 24-1; Effective March 1, 2024

Eligibility determinations for Medicaid must be coordinated with the federal Marketplace. A person who applies for health care coverage through the Marketplace at HealthCare.gov is also assessed for Medicaid eligibility. If the Marketplace assessment does not show the person may be eligible for Medicaid, the person can still request their information be transferred to HHSC for a full eligibility determination.

The Marketplace assesses a person as:

  • potentially eligible for Medicaid based on Modified Adjusted Gross Income (MAGI) rules; or
  • potentially eligible for Medicaid on a non-MAGI basis if the person is 65 or older or reports having a disability or blindness.

If the assessment shows the person may be eligible for Medicaid, the person’s application information is transferred to HHSC.

HHSC must evaluate the person’s eligibility for Medicaid without requiring a new application.

B-3510 Applications Received from the Marketplace

Revision 24-1; Effective March 1, 2024

The federal Marketplace sends a person’s application information to HHSC through an electronic interface when:

  • the Marketplace assessment shows the person may be eligible for Medicaid; or
  • the person requests a full eligibility determination for Medicaid.

The electronic transfer of application information is called an account transfer. The account transfer includes information provided by the person on the Marketplace application and information verified by the Marketplace.

The account transfer process generates a PDF application with the information the Marketplace provides. Verifications completed by the Marketplace are included in the Verifications section of the PDF. Like an application from YourTexasBenefits.com, enter applicant information into the appropriate logical unit of work (LUW) following the verification policies. This includes any required documentation about blanks or discrepancies on the PDF application.

B-3520 Verifications Provided by the Marketplace

Revision 24-1; Effective March 1, 2024

Medical Programs

Marketplace account transfer PDFs also include a Verifications section. Enter information from the verification section as follows:

  • If the Marketplace verified the person's Social Security number (SSN) or citizenship status using data from the Social Security Administration (SSA), accept the information as Verified by SSA.
  • If the Marketplace verified the person's alien status using data from the Department of Homeland Security (DHS), accept the information as Verified by DHS.
  • If the Marketplace verified other eligibility criteria, such as income or resources, per HHSC verification policy, accept the information as verified. 

All other applicant information must be verified as required by the applicable HHSC verification policy. Do not request additional verification for information verified by the Marketplace per HHSC verification policy.

Related Policy

Documentation and Verification Guide, Appendix XVI

B-4000, Date of Application

Revision 20-2; Effective June 1, 2020

The file date of an application is the date the Texas Health and Human Services Commission (HHSC) receives an application form containing the applicant’s name, address and appropriate signature.  This is day zero in the application process.

For electronically filed applications, the file date is the date the applicant clicks the “Submit Application” button in YourTexasBenefits.com.

For applications received after the close of business or on days when HHSC is closed, including weekends and holidays, the file date is the next business day.

If an application is denied in error, the original file date of the application must be protected no matter how old the application for assistance.

Within 10 calendar days from receipt of an application, send Form H1236, Notification of Receipt of Application, to the nursing facility or ICF/IID where a person resides or intends to reside. If requested, provide the applicant a receipt (Form H1800, Receipt for Application/Medicaid Report/Verification/Report of Change (PDF)) to verify an application was received. An applicant may request Form H1800 by fax or mail. Mail the receipt to the applicant’s listed address.

Related Policy

Previously Completed Application, B-5000
Application Due Dates, B-6410

B-5000, Previously Completed Application

Revision 20-4; Effective December 1, 2020

A previously completed application for assistance is valid for 90 days. It may be used to reopen the application or renewal in the following situations.

Failure to Provide Requested Information

  • An application is denied for failure to provide information and all requested information is provided within 90 days of the date of denial.
  • A renewal is denied for failure to provide information and all requested information is provided after the date of denial but within 90 days of the last day of the last benefit month.  

Reopen and re-evaluate eligibility using the information provided and the previously submitted application or renewal form. A written request to reopen is not required.

The date all the information and verification that was originally requested is provided is the new file date. If additional information is needed to make an accurate eligibility determination based on the new file date, request the needed information following regular policy and process.

Failure to Provide Verification of Level of Care (LOC) or Medical Necessity (MN)

If an application is denied for failure to provide verification of LOC or MN and all other eligibility criteria are met:

  • Reopen and re-evaluate eligibility using the previously submitted application if verification of LOC or MN is received within 90 days of the date of denial. A written request to reopen is not required. The date the verification is received is the new file date.
  • If additional information is needed to make an accurate eligibility determination based on the new file date, request the needed information following regular policy and processes.

Application or Renewal Denied for Reasons Other Than Failure to Provide Information

If an application or renewal is denied for a reason other than failure to provide information and the person requests to reapply:

  • Obtain a written, dated and signed statement of request to reapply from the person or authorized representative to establish the file date.
  • The previously completed application for assistance is valid for 90 days from the date of denial.
  • The previously completed renewal form is valid for 90 days from the last day of the last benefit month.
  • Verification must be updated if circumstances have changed.

Application or Renewals Denied in Error

  • If an application is denied in error, the original file date of the application must be used regardless of the age of the application.
  • If a renewal is denied in error, the receipt date of the renewal packet must be used regardless of the age.
  • If the application or renewal denial is determined to be agency error, do not require a new application or statement to reapply from the person or authorized representative to reopen the application if supervisory approval is obtained.

Applications Received from Other HHSC Areas

Applications for assistance may be received by other areas within HHSC, including Community Care Service Eligibility (CCSE) staff or waiver staff. Regardless of the signature date, the applications must be forwarded to Medicaid eligibility staff for an eligibility determination. Staff must contact the applicant or authorized representative to obtain current information.

Example: CCSE staff refer a person receiving Family Care to MEPD for a financial eligibility determination for Community Attendant Services (CAS). The application was signed and dated two months prior. MEPD staff must contact the person to obtain current income and resource information.

Related Policy

Date of Application, B-4000
Processing Deadlines, B-6400

B-6000, Eligibility Determination

B-6100, Face-to-Face and Telephone Interviews

Revision 10-3; Effective September 1, 2010

As a result of the initiative to integrate application and eligibility determination processes, a face-to-face interview or a telephone interview is not required in determining eligibility for Medicaid programs within this handbook.

At the request of the person or the person's authorized representative, conduct a face-to-face interview or an interview by telephone based on the request. Form H1246, Medicaid Eligibility Interview Guide, is optional for staff to use to record information during the interview.

Information to consider for the case documentation:

  • Whether a face-to-face or telephone interview was conducted.
  • Date of the interview and name of the person interviewed (applicant or authorized representative).
  • Relationship of the authorized representative to the applicant.
  • Reason, if an interview was requested but not conducted.

Interviews are not required for Medicaid applicants or recipients. If an appointment is scheduled and the person does not keep the appointment, do not deny based on the missed appointment.

B-6200, Financial Management

Revision 10-3; Effective September 1, 2010

If a person does not report a bank account, trust fund or similar account on Form H1200, Application for Assistance – Your Texas Benefits, or other application for assistance, ask the person or the authorized representative to explain how the person's financial affairs are handled. This includes determining who:

  • cashes the checks and where;
  • pays the bills and how; and
  • keeps the money and how the funds are kept.

If the person reveals previously unreported liquid resources, request verification to determine the value, ownership and accessibility according to the requirements for the resource involved.

Sources for verifying financial management are as follows:

  • Statements from the applicant and the person who handles the applicant's funds.
  • Statement from a knowledgeable third party (for example, an administrator or bookkeeper in the facility usually knows who receives the applicant's benefit payments and pays the bills).

Use Appendix XVI, Documentation and Verification Guide, for sources of needed verifications.

Include the following information in the case record documentation:

  • Where checks are cashed and how bills are paid.
  • Who handles the person's checks, pays the person's bills and maintains the person's money.
  • How much money, if any, the person or anyone else keeps.
  • How much has accumulated.
  • Source of information.

Note: If the person's bank account is dormant, financial management must be verified and documented. For applications, explore financial management if there has been no activity in a reported account during the month of application and the month before.

B-6300, Institutional Living Arrangement

Revision 19-2; Effective June 1, 2019

Determine the first day a person’s eligibility can be established under the special income limit. Form 3618, Resident Transaction Notice (PDF); Form 3619, Medicare/SNF Patient Transaction Notice (PDF); and Form H0090-I, Notice of Admission, Departure (PDF), Readmission or Death of an Applicant/Recipient of Supplemental Security Income and/or Assistance Only in a State Institution, provide adequate verification of dates of admission to a Medicaid facility. In absence of the above-listed forms, eligibility staff may contact the administrator, bookkeeper or office manager for the date of admission.

Eligibility under the special income limit cannot be processed or disposed until the applicant has resided in an institutional setting for at least 30 consecutive days.

The 30-day requirement begins with confinement to one or more Medicaid-certified facilities (Medicare-SNF, NF or ICF/IID) for at least 30 consecutive days. The date of admittance to an institution is day zero.

Example 1: Mr. Smith entered the nursing facility on March 27. He stayed there for 30 consecutive days – not going home, to the hospital or to another nursing facility. The earliest staff can certify the case is the 31st day, which is April 27.

Example 2: Mr. Lopez entered the hospital on Feb. 10 and entered the nursing facility on Feb. 19. He stayed there for 30 consecutive days – not going home, to the hospital or to another nursing facility. The start of the 30 consecutive days started on Feb. 19, not Feb. 10. The earliest staff can certify the case is the 31st day, which is March 22.

Example 3: Mr. Johnson entered the nursing facility on March 1. He went to the hospital on March 5. He returned to the nursing facility on March 10. The 30 consecutive days started on March 1 and was not interrupted by the hospital stay. The earliest staff can certify the case is the 31st day, which is April 1.

Example 4: Mr. Brown entered the nursing facility on May 10. The 31st day is June 10. He went home on June 1. He did not stay the required 30 consecutive days. Staff cannot certify the case.

Example 5: Mr. Leo entered the nursing facility on April 20. The 31st day is May 21. He died on May 10. He did not stay the required 30 consecutive days, however, staff can certify the case if the person meets all other eligibility requirements.

Example 6: Mr. Smith entered the hospital on Feb. 15 and then went directly to the nursing home on March 10. His wife continues to live in their home in the community. The 30 consecutive days starts on March 10, not Feb. 15. The earliest staff can certify the case is the 31st day, which is April 10th.

Note: The hospital stay in February is the start date for the continuous period in an institution for the spousal resource assessment – which is different than the 30-consecutive day’s requirement.

See Chapter J, Spousal Impoverishment, regarding the resource assessment and spousal protected resource amount (SPRA). When determining the 30 consecutive day requirement, consider both the days in a medical facility and the days in the Home and Community-Based Services waiver setting.

Use the special income limit for the month of entry to a Medicaid-certified long-term care facility (Medicare-SNF, NF or ICF/IID) if it is anticipated that the person will remain in a Medicaid-certified facility for at least 30 consecutive days. When eligibility is based on the special income limit, finalization of the person’s eligibility cannot be processed or disposed until the 30 consecutive days in an institutional setting have been met.  See MEPD Due Date Chart job aid on The LOOP, to determine the 31st day.

It may be necessary to verify the living arrangement for prior months by contacting the  applicant or authorized representative to ensure the appropriate income limit is used for determining eligibility for prior months. It may also be necessary to contact the facility, the Home and Community-Based Services waiver provider or the hospital, if  an applicant has been discharged to a hospital, to ensure that the 30 consecutive day requirement is met.

The case record must include the following verification and documentation  :

  • Date the applicant entered the Medicaid facility.
  • Date the applicant met the 30 consecutive day requirement (or date of death).
  • Source of verification.

See Appendix XXX, Medical Effective Dates (MEDs). Use the information under the Institutional Based area to determine the appropriate income limit for the month of application and the prior months.

The 30 consecutive day requirement does not apply to a regular Medicaid recipient who:

  • is eligible for SSI; or
  • was eligible for SSI and continues regular Medicaid eligibility through one of the cost of living adjustment (COLA) disregard programs.

The COLA disregard programs are:

  • ME-Pickle
  • ME-Disabled Adult Child
  • ME-Disabled Widow(er)
  • ME-Early Aged Widow(er)

Related Policy

Medical Effective Dates (MEDs), Appendix XXX
Medicaid Certified Person Enters Nursing Facility or Home and Community-Based Services Waiver Program, B-7450
Institutional Eligibility Budget Types, G-6000
Prior Coverage, G-7000

B-6400, Processing Deadlines

Revision 10-3; Effective September 1, 2010

Make and document an eligibility decision on an application as soon as all required verification is received.

Time frame for eligibility determination:

  • Make an eligibility decision within 45 days on applications from applicants 65 years or older.
  • Make a decision within 45 days on applications from applicants under age 65 who have had disability established based on the Social Security Administration criteria for RSDI Title II or SSI Title XVI disability.
  • Make a decision within 90 days on applications from applicants who must have disability established by the HHSC Disability Determination Unit.

References:

  • See section B-4000, Date of Application, for clarification of date of application and complete application.
  • See section R-3100, Establish Processing Deadlines, for automation procedures to follow when applications cannot be completed within the normal 45/90-day limit and for requirements to request a delay in certification.
  • See section D-2100, When a Medical Determination Is Not Required, and section D-2200, When a Medical Determination Is Required, for further information regarding a medical determination for applicants under age 65.

B-6410 Application Due Dates

Revision 20-2; Effective June 1, 2020

Applications must be processed in a timely manner. For timeliness and processing purposes:

  • The timeliness count begins the date the completed and signed application for assistance is received by HHSC.
  • The file date of an application is day zero for application processing.

If a person applies for multiple programs and all requested information is provided for one program and not the other(s), make an eligibility determination for the program in which all the information has been received. Continue to allow for the opportunity to provide the remaining missing information for the other program(s) until the final due date.

Reminders:

  • The date of application is established when HHSC receives the completed and signed application form.
  • For applications submitted after the close of business for the day, or on days when HHSC is closed (including weekends and holidays), the date of application is the following business day.
  • If an application is denied in error, the original date of application must be protected no matter how old the original date on the application for assistance. A new application processing date must be established.

Related Policy

Date of Application, B-4000
Previously Completed Application, B-5000

B-6420 Missing Information Due Dates

Revision 14-1; Effective March 1, 2014

Applications

Use Form H1020, Request for Information or Action (PDF), to request missing information or verifications. The final due date for missing information for applications on Form H1020 is the:

  • 39th day from the date of application, or
  • 84th day from the date of application for a person who needs a disability determination.

Do not send a second request for missing information. Take appropriate case action based on the original request for missing information.

Delay in Certification

When there is an approved delay in certification, the 39th and 84th days are extended 90 days.

Always send notification to the applicant/authorized representative and nursing facility, using Form H1020 and Form H1247, Notice of Delay in Certification (PDF).

Use Form H1020 to indicate the needed information and the re-established due dates during the delay in certification. See section B-6510, Failure to Furnish Missing Information.

Re-established due dates are based on the reason for the delay in certification and reasonable MEPD specialist judgment. For example, if the delay is due to the 30-day consecutive requirement not being met, the re-established due date would not automatically need to be the full 90-day extension. However, if the delay is due to the facility pending certification, the full 90-day extension may be necessary. When unsure of the re-established due dates based on the reason for the delay in certification, consult the supervisor to determine the re-established pending period. Do not send a second request for missing information during the re-established due dates based on the delay in certification. Take appropriate case action based on the Form H1247 and Form H1020 used to notify the applicant of the delay in certification and the needed verification.

Redeterminations

Use Form H1020 to request missing information or verifications. The due date for missing information or verifications for redeterminations should be 10 days from the date on Form H1020.

B-6500, Denials

Revision 11-4; Effective December 1, 2011

Before a person is denied for any reason during application, eligibility for QMB/SLMB must also be tested.

Examples:

  • An applicant for nursing facility coverage also must be tested for QMB coverage. If the applicant is ineligible for nursing facility coverage but eligible for QMB, certify the applicant for QMB. Indicate on the notice that the applicant is ineligible for nursing facility coverage but eligible for QMB coverage.
  • When an MQMB recipient dually eligible for nursing facility coverage leaves the nursing facility to live at home, test for continuing QMB coverage in the new living arrangement.
  • When a Community Attendant Services (CAS) recipient who is also QMB-eligible no longer has physician's orders and is ineligible for CAS, do not deny the QMB coverage unless a change in the recipient’s circumstances also results in ineligibility for QMB.

B-6510 Failure to Provide Missing Information

Revision 20-4; Effective December 1, 2020

Applications

For applications, initiate the written request for verification within 30 calendar days from the date the application is received by the Texas Health and Human Services Commission (HHSC).

If more information or verification is required to complete an application, the applicant or the applicant’s authorized representative (AR) is allowed at least 10 days to provide the information or verification. The final due date must be a workday.

Send Form H1020, Request for Information or Action (PDF), to request the needed verification. The Form H1020 provides:

  • the information or verification needed;
  • the date the information or verification is due; and
  • the final decision date.

Note: The final decision date is the date the application may be denied if the required information or verification is not received.

The day Form H1020 is sent is considered day zero of the pending period.

Deny the application if the requested information is not received by close of business on the final decision date provided on the H1020.

If the required information is requested more than 30 days after the file date, allow at least 10 days to provide the required verification. Do not deny the application for the missing information before close of business on the 10th day.

Do not send a second request for missing information for applications.

Delay in Certification

Delay in certification procedures may be necessary if the applicant or the AR is attempting to obtain the information but cannot meet the deadline.

Note: If Asset Verification System (AVS) information impacts eligibility, pend the case and send Form H1020. Allow at least 10 days to provide verification of the new information. Delay in certification procedures may be necessary if the missing information due date is after the application due date.

Redeterminations

All information and verification needed to make an eligibility redetermination decision must be provided.

Send Form H1020, Request for Information or Action, to request the needed verification. The Form H1020 provides:

  • what is required;
  • the date the verification is due; and
  • the date the renewal could be denied if the verification is not received.

The day Form H1020 is sent is considered day zero of the pending period.

Allow at least 10 days to provide the requested verification. The system-generated due date is 10 days from the date of the H1020.

Do not send a second request for previously requested information for redeterminations.

If all previously requested information is returned and new information that impacts eligibility is discovered before disposition, send a new Form H1020 and allow at least 10 days to provide verification of the new information.

Deny the redetermination if the information or verification is not provided by the close of business on the final decision date indicated on the H1020.

Do not deny the redetermination for missing information before close of business on the 10th day.

Related Policy

Date of Application, B-4000
Missing Information Due Dates, B-6420
Establish Processing Deadlines, R-3100
Consideration of AVS Information, R-3744

B-7000, Special Application Procedures

B-7100, SSI Applications

Revision 11-1; Effective March 1, 2011  

The Social Security Administration (SSA) determines Medicaid eligibility for all persons who apply for SSI cash benefits. When SSA makes a determination on an application for SSI cash benefits (either approved or denied), HHSC is notified by means of the SSA/State Data Exchange System (SDX).

SSA is responsible for redetermination of SSI Medicaid eligibility. See section H-6000, Co-Payment for SSI Cases, for other special handling of SSI eligible individuals.

B-7110 Continuous Medicaid Coverage After SSI Denial for Income

Revision 20-3; Effective September 1, 2020 

Certain SSI recipients are eligible for temporary Medicaid following the loss of SSI due to excess income. Medicaid eligibility is automatically extended for a short time for the following SSI recipients:

  • children under 18 years old who receive waiver services; and
  • people who receive an increase in Social Security Disabled Adult Children (DAC) benefits or Early Aged or Disabled Widow(er)’s benefits, who have no other income.

Recipients must return the Form H1200 and be determined eligible to continue to receive Medicaid after the short-term extended period ends.  

Recipients who do not return a Form H1200 will be denied Medicaid at the end of the extended period.  If SSA reinstates the recipient’s SSI benefits, SSI Medicaid will be reinstated.  Medicaid coverage will not be extended again at subsequent SSI denials or suspensions for the following 12 months.

Correspondence

Send the following correspondence when Medicaid is extended after the loss of SSI:

If Form H1200 is received, determine ongoing eligibility for the appropriate type of Medicaid. Expedite processing applications received before the extended Medicaid coverage ends.  Expedited applications must be processed within 10 workdays from the date of application.

Children Receiving Waiver Services

Children who receive services through one of the following waiver programs are eligible to receive temporary ME-Waiver Medicaid for one month following the loss of SSI due to excess income:

  • Medically Dependent Children Program (MDCP);
  • Community Living Assistance and Support Services (CLASS);
  • Home and Community-based Services (HCS);
  • Youth Empowerment Services (YES); or
  • Deaf Blind with Multiple Disabilities (DBMD).

Ongoing Eligibility

If Form H1200 is received, determine ongoing eligibility for ME-Waiver Medicaid.  If eligible, ME-Waiver Medicaid will remain active through the end of the month of the child’s 18th birthday.  If the child is determined not eligible under any other Medicaid type of assistance, Medicaid is denied at the end of the one-month extended period.

  • Applications submitted by the child or their parent or authorized representative do not require an associated Form H1746-A, MEPD Referral Cover Sheet.  
  • Applications submitted by program providers, including Managed Care Organizations (MCOs), Local Intellectual & Developmental Disability Authorities (LIDDAs) and Local Authorities (LAs), on behalf of a child receiving extended ME-Waiver Medicaid must include an associated Form H1746-A.

SSI Eligibility

If SSI benefits are reinstated while the child is active ME-Waiver Medicaid, SSI Medicaid will be suppressed, and ME-Waiver Medicaid will remain active. This is to avoid future gaps in coverage.

If SSI benefits are active when the child turns 18, ME-Waiver Medicaid will terminate and SSI Medicaid will be reinstated.

If SSI benefits are not active when the child turns 18, ME-Waiver Medicaid will remain active and will follow the regular renewal process.

Recipients of DAC or Widow/Widower Benefits

SSI recipients denied due to an increase in or receipt of RSDI disabled adult children’s benefits or widow/widower’s benefits, who do not receive income other than RSDI, are eligible to receive temporary Medicaid for two months following the loss of SSI.

  • People receiving Social Security DAC benefits are eligible for ME-DAC Medicaid. (Note: People receiving SSI and QMB will receive ME-DAC and MC-QMB.)
  • People receiving Social Security Early Aged or Disabled Widow/Widower’s benefits are eligible for ME-Disabled Widow(er) or ME-Early Aged Widow(er) Medicaid.

If Form H1200 is received, determine ongoing eligibility for the appropriate type of Medicaid, ME-DAC, ME-Disabled Widow(er) or ME-Early Aged Widow(er).  If the recipient is determined not eligible, Medicaid will be denied at the end of the two-month extended period.

Related Policy

Supplemental Security Income (SSI), A-2100
Disabled Adult Children (DAC), A-2310
Pickle, A-2330
Widow(er)s, A-2340
SSI Applications, B-7100
When Deeming Procedures Are Not Used, E-7200

B-7200, SSI Cash Benefits Denied Due to Entry into a Medicaid Facility

Revision 12-3; Effective September 1, 2012  

When an SSI recipient enters a Medicaid facility and the SSI cash benefit will be denied because the income is greater than the reduced federal benefit rate, and:

  • If contacted by the recipient/authorized representative (AR), inform the recipient/AR to notify SSA of the entry to the Medicaid facility. Send Form H1200, Application for Assistance – Your Texas Benefits (PDF), to the recipient/AR to complete and return to HHSC.
  • If contacted by the Medicaid facility, inform the facility to notify SSA of the entry to the Medicaid facility. Obtain the AR's information, including mailing address, and send Form H1200 to the AR to complete and return to HHSC.

TIERS is notified by the State Data Exchange (SDX) system when SSI cash benefits have been denied because of income that is greater than the reduced SSI federal benefit rate. Once the SDX denial notice is received by TIERS, the SSI Medicaid will be denied by the system.

There is no overlay option in TIERS. Certification for MEPD benefits cannot occur until the SSI is denied. This may require delay in certification, closing and re-opening applications until the SSI is denied.

When SSI has been denied and an MEPD application has not been filed, and:

  • If contacted by the recipient/AR, send Form H1200 to the recipient/AR to complete and return to HHSC.
  • If contacted by the Medicaid facility, obtain the AR's information, including mailing address. Send Form H1200 to the AR to complete and return to HHSC.

Reference: See section B-7210, Ensuring Continuous Medicaid Coverage.

After receipt of Form H1200, determine the recipient's financial eligibility for MEPD using the special income limit beginning with the first month after SSI denial. Also determine whether the recipient has an approved medical necessity or level of care and meets all other eligibility requirements. If the recipient has been denied a medical necessity or level of care but remains in the Medicaid facility (Medicare-SNF, NF or ICF/IID), or if the recipient does not remain in a Medicaid facility (Medicare-SNF, NF or ICF/IID) for 30 consecutive days, deny the MEPD application and refer the recipient back to SSI for reinstatement of full SSI benefits. If the recipient will not be reinstated for full SSI benefits, test eligibility for other Medicaid-funded programs, such as QMB, ME-Pickle, etc.

Notes:

  • If the MEPD application is not returned, the eligibility specialist contacts the recipient/authorized representative to attempt to obtain information to determine continued Medicaid eligibility. The eligibility specialist uses Form H1200 as a recording document, if necessary.
  • Follow the procedures for SSI to MEPD transfer, unless continued SSI eligibility occurs under temporary provisions. If that situation occurs, do not process an institutional Medicaid application unless the SSI benefits are denied and the recipient is still in the facility.

Reference: See Chapter H, Co-Payment, for exceptions to reduced SSI payment standard.

B-7210 Ensuring Continuous Medicaid Coverage

Revision 13-4; Effective December 1, 2013

When a recipient is eligible for institutional Medicaid coverage, the medical effective date (MED) is the day after the date of SSI denial, when the SSI denial is due to entry into an institution. This ensures continuous Medicaid coverage.

Note: To ensure continuous Medicaid coverage for SSI recipients who enter institutions, the coverage may be more than three months from the application file date. For example, SSI was denied March 31, 2013. The individual applied for ME-Nursing Facility on Sept. 10, 2013. The MED can go back to April 1, 2013, which is more than three months prior.

B-7300, MEPD Eligibility Pending a Decision of SSI Application

Revision 19-4; Effective December 1, 2019

Persons who have applied for SSI, whose SSI application has been delayed longer than 90 days, may be certified under the appropriate MEPD program pending the SSI eligibility decision.  

Person(s) must meet all non-financial and financial MEPD criteria to be eligible including:

  • establishing disability, if applicable;
  • pursuing all other benefits; and
  • meeting the 30 consecutive days of institutionalization, if applicable.

Consider the age of the person to determine if a disability determination is needed.

The state office Disability Determination Unit (DDU) needs a disability determination if the person is younger than 65. DDU cannot make a disability determination decision unless 90 days have passed since the SSI date of application and SSA's disability decision is still pending. If SSA finds the person is not disabled after DDU has established a disability, DDU is required to follow SSA’s decision and eligibility must be denied. Staff must set a special review for the fifth month to monitor the final SSA decision on disability.

Once an MEPD eligibility recipient becomes eligible for SSI, SSA will report the SSI eligibility to HHSC via the SDX system. Once the SDX information is received, TIERS will automatically deny MEPD coverage and activate the SSI coverage. This is not an adverse action because the person does not lose benefits.

The above should be used only in situations where the processing of a SSI application has been delayed. Staff must verify and document that an SSI application has been filed.

Note: If the person is age 65 or older, no disability determination is needed. Verify that the person has filed an application for SSI.

Related Policy

SSI Applications, B-7100
Special Reviews, B-8430
Supplemental Security Income (SSI) Applicants and Retroactive Coverage, D-2500
Application for Other Benefits Requirement, D-6300
Other Benefits Subject to Application Requirement, D-6310
Other Benefits Exempt from Application Requirement, D-6320
Supplemental Security Income (SSI), D-6340

B-7400, Application for Institutional Care

Revision 12-3; Effective September 1, 2012

HHSC is responsible for processing Medicaid applications for certain residents of Medicaid facilities (Medicare SNF, NF, ICF/IID and institutions for mental diseases (IMD)). To qualify for medical assistance for institutional care, a person must:

  • meet the 30-consecutive-day stay requirement (for verification and documentation requirements, see Appendix XVI, Documentation and Verification Guide);
  • meet financial criteria; and
  • have an approved level of care or medical necessity determination.

Reference: Section B-6300, Institutional Living Arrangement.

HHSC processes:

  • initial applications from persons whose income is equal to or in excess of the reduced SSI federal benefit rate; and
  • reapplications for Medicaid from persons who will be or have been denied SSI on the basis of excess income because the SSI federal benefit rate has been reduced after entry into a Medicaid facility.

B-7410 Persons Under Age 22

Revision 09-4; Effective December 1, 2009

State law (Chapter 242, Health and Safety Code) requires that community resource coordination groups (CRCG) be notified when a recipient under age 22 with a developmental disability enters an institutional setting. HHSC must notify the CRCG in the county of residence of the recipient's parent or guardian within three days of the recipient's admission.

The name and telephone number of the appropriate CRCG can be obtained by calling the CRCG state office at 1-866-772-2724. A CRCG list is available on the Internet at: /services/service-coordination/community-resources-...

Documentation of the notification to the CRCG should be filed in the case record.

B-7420 Level of Care/Medical Necessity

Revision 20-4; Effective December 1, 2020

To be eligible for Medicaid in an institutional setting, a person must have an approved level of care (LOC) for an intermediate care facility for persons with intellectual disabilities (ICF/IID) or an approved medical necessity (MN) with a nursing facility LOC. Texas Medicaid & Healthcare Partnership (TMHP), the state Medicaid claims administrator, is responsible for determining MN for recipients in Medicaid certified facilities.

Do not approve a person for medical assistance for institutional care unless the person has been in a Medicaid facility for at least 30 days and has an approved LOC or MN determination.

For applicants residing in a Medicare skilled nursing facility, the Medicare determination of need for care is acceptable as verification of a valid MN determination. Form 3071, Recipient Election/Cancellation/Discharge Notice (PDF), substitutes for the MN determination when hospice is elected as referenced in A-5200, Hospice in a Long-Term Care Facility.

Use the previous LOC or MN determination if:

  • a person is being reinstated for assistance (a case that was denied in error or a request for a program transfer from SSI to MEPD institutional care); and
  • vendor payments were made to the Medicaid facility up to the date of denial based on the previous LOC or MN determination.

Program Support Unit (PSU) staff are responsible for providing verification of an approved LOC or MN determination for a person applying for a Home and Community Based Services (HCBS) waiver program.

An approved MN determination for HCBS waiver eligibility is valid to complete a program transfer from an HCBS waiver Medicaid program to the appropriate institutional care program.

A permanent MN determination remains valid at reapplication if a denied Medicaid recipient is discharged from a Medicaid facility for not more than 30 days.

If the LOC or MN determination is still pending prior to certification and the person meets all other eligibility criteria, place the application on delay pending the approved LOC or MN. If verification of the LOC or MN is not received before the end of the delay period, deny the application for no LOC or MN. If the LOC or MN determination is denied, deny the application.

Reopen the application if verification of an approved LOC or MN is received within 90 days of the date of denial following policy in B-5000, Previously Completed Application.

Related Policy

Previously Completed Application, B-5000
Establish Processing Deadlines, R-3100
Documentation and Verification Guide, Appendix XVI

B-7430 Reserved for Future Use

Revision 20-4; Effective December 1, 2020

B-7431 Denial of Level of Care/Medical Necessity Determination

Revision 13-4; Effective December 1, 2013

If a level of care/medical necessity determination is denied for an MEPD recipient, initiate denial procedures immediately.

A recipient may continue to be Medicaid-eligible as long as the recipient meets all eligibility criteria and:

  • has a diagnosis of mental illness, intellectual disabilities or a related condition;
  • no longer meets the medical necessity criteria; and
  • has lived in a nursing facility for 30 months before the date medical necessity is denied and chooses to remain in the facility.

If the recipient has not been in the facility for 30 months, regular Medicaid denial procedures apply.

If an MEPD recipient in a private Medicaid facility is denied solely because of no level of care/medical necessity determination, refer the person to SSA if available income is less than the SSI full federal benefit rate. Refer SSI recipients who are denied a level of care/medical necessity determination to SSA for rebudgeting to the full federal benefit rate.

B-7440 Alternate Care Services

Revision 21-3; Effective September 1, 2021

Information about all available long-term services and supports must be provided to long term care recipients, their authorized representatives (ARs) and at least one family member of the recipient, if possible. This allows them to make an informed decision about service options.

Form H1204, Long Term Care Options (PDF), provides information on available long-term services and supports. It is included with the TF0001, Notice of Case Action, for all MEPD certifications, except for recipients residing in state supported living centers, state hospitals and state centers.

If an applicant, recipient, AR or family member(s) has questions about available long-term care services, refer them to 2-1-1 for current information.

Form H1746-A, MEPD Referral Cover Sheet (PDF), includes an "LTSS Information Shared" checkbox. Referring agencies will select the box to indicate that Form H1204 has been shared with the person.

B-7450 Medicaid Certified Person Enters Nursing Facility or Home and Community-Based Services Waiver Program

Revision 22-2; Effective June 1, 2022

Eligibility Systems and Payment Systems

Service Authorization System Online (SASO) identifies the recipient as Service Group 1 and allows vendor payment when:

  • an active recipient with coverage Code R (either Long Term Care or Texas Works) enters a nursing facility; and
  • has a valid medical necessity and facility admission.

The system also automatically assigns a Code 60 (authorization for unlimited medications). This allows all medications to be paid through the vendor drug benefit.

If the nursing facility stay is temporary and the recipient returns home before being transferred to institutional Medicaid, no action is required. Retroactive coverage code changes are not needed.

Texas Works Medicaid to MEPD

If an active Texas Works Medicaid recipient enters a facility for a long-term stay, TIERS receives the nursing facility admission information from the DADS webservice interface. TIERS automatically denies the Texas Works Eligibility Determination Group (EDG) and creates a pending ME-Nursing Facility EDG. An H1200 Application for Assistance - Your Texas Benefits must be received before testing for ME-Nursing Facility Medicaid. Disposition of both EDGs must be coordinated. There is no need for retroactive coverage code changes. Vendor payment and medications are authorized through SASO.

If a facility notifies HHSC that an active Texas Work Medicaid recipient has entered the facility, staff should advise the facility that an application is required. Once the application is received, process as any other application and coordinate with Texas Works.

Community to Nursing Facility or Home and Community-Based Services Waiver Eligibility Considerations

If an active MEPD Medicaid or Medicare Savings Program recipient enters a facility for a long-term stay or requests waiver services, before completing a program transfer, staff must address all factors that may impact eligibility or co-payment. Staff must explore transfer of assets and substantial home equity and provide required information about annuities, estate recovery and long-term care options. 

Related Policy

Medicaid Estate Recovery Program Notification Requirements, B-2600
Alternative Care Services, B-7440
Notice Requirements for Application and Redeterminations, F-7250
Medicaid Coverage Issues Related to Nursing Facility Costs, H-7300
Medicare Skilled Nursing Facilities, R-1210
Notices, R-1300

B-8000, Redeterminations

B-8100, Certificates of Insurance Coverage

Revision 09-4; Effective December 1, 2009

The certificate of insurance coverage is proof of a Medicaid recipient's most recent period of Medicaid coverage. The Department of State Health Services sends the certificate, a requirement of the Health Insurance Portability and Accountability Act (HIPAA) of 1996, to denied recipients. HIPAA mandates that prior health insurance coverage must be counted toward reducing or eliminating any applicable pre-existing condition exclusion period when a person enrolls in a new health insurance plan. Former Medicaid recipients may request a certificate within 24 months after their Medicaid is denied by calling 1-800-723-4789.

B-8200, Redetermination Cycles

Revision 15-4; Effective December 1, 2015

A recipient’s eligibility is redetermined:

  • when necessary because of previously obtained information indicating an anticipated change;
  • within 10 workdays after receipt of a report indicating changes that may affect eligibility or co-payment, including program transfers;
  • within 30 workdays after receipt of a report indicating changes that affect neither eligibility nor co-payment;
  • at periodic intervals not to exceed 12 months; and
  • at least every six months, if income is averaged or an incurred medical expense is budgeted. The person's income is verified and documented and past co-payment is reconciled.

For more information on redeterminations, see Section B-8430, Special Reviews, and Section B-8440, Streamlined Redetermination (Passive Redetermination).

Note: For couple cases, including cases with spouses who may be certified under different type programs, redeterminations should be synchronized to minimize the redetermination process for the recipients and the workload for the eligibility specialist. A complete redetermination of each person's eligibility must be completed at least once every 12 months.

It is a recommended practice to review community-based cases at least every three months if the recipient's countable resources are within $100 of the resources limit.

Monitor eligibility at least every three months if the person's:

  • countable resources are within $100 of the resources limit, or
  • total countable income is within $10 of the income limit.

The following information must be included in the case record documentation:

  • Whether a special review is needed
  • Date special review will be conducted
  • Method of monitoring for special review

Clearly document:

  • specific information regarding the reason a special review is set,
  • which person is affected, and
  • the eligibility area(s) subject to the review.

Example: If someone has a private pension and the pension amount is anticipated to increase in the future, a special review must be set for the anticipated change. The eligibility area will be income. Documentation must specify pension information that will need to be verified at the special review, including:

  • date on which the anticipated change is to occur,
  • type of pension,
  • source of pension, and
  • frequency of payment of pension that will need to be verified at the special review.

Use Form H1020, Request for Information or Action, and Form H1020-A, Sources of Proof, to request information from the person or authorized representative. When requesting missing information on a redetermination, allow 10 calendar days from the date the notice is mailed for the individual to provide the information. Do not deny the case for failure to furnish information before the due date listed on Form H1020.

Note: Monitor special reviews for resource or income elements through entry of the special review due date in the applicable TIERS screen.

Data Broker is not required on redeterminations, including the streamlined versions.

B-8300, Who May Sign a Redetermination Form

Revision 12-4; Effective December 1, 2012

Note: A person who may complete or sign a redetermination form for a recipient may possibly not be on the list of people to whom HHSC can release the recipient’s individually identifiable health information. See C-5000, Personal Representatives, for persons who may receive or authorize the release of a recipient’s individually identifiable health information under HIPAA privacy regulations.

See B-3220, Who May Sign an Application for Assistance, to determine who may sign a redetermination form. The requirements for signing a redetermination form are the same as the requirements for signing an application.

Note: A signature is not needed when the redetermination is passive or simplified. See B-8440, Streamlined Redetermination (Passive Redetermination).

B-8400, Procedures for Redetermining Eligibility

Revision 23-4; Effective Dec. 1, 2023

Administrative Renewal Process

All MEPD types of assistance (TOAs) go through an annual administrative renewal process. The system starts  the administrative renewal without staff action. 

The automated administrative renewal process uses information from the existing case record and electronic data sources to determine if the person remains eligible for Medicaid benefits. The electronic data is requested the weekend before cutoff in the ninth month of the recipient’s certification period.

During the administrative renewal process, the system also checks for the required verification by program.  

The administrative renewal process uses electronic data to automatically:

  • assess the verification required by program type;
  • determine the eligibility outcome; and
  • send the renewal correspondence to the recipient, the authorized representative (AR) or both.

Note: This automated process does not change the verification requirements for renewals.

If there is enough information to verify continued eligibility, the person’s eligibility is renewed without any staff action.

If more verification is required, the system automatically generates and mails a renewal form to the recipient, AR or both. The renewal form and all required verification must be returned within 30 days to complete the redetermination.

The system generates the applicable correspondence from the list below per  the eligibility outcome of the automated renewal process and the action needed by the person:

  • Form H1211, It Is Time to Renew Your Health Care Benefits Cover Letter;
  • Form H1233, Redetermination Cover Letter;
  • Form H1233-MBIC, Redetermination Cover Letter (Medicaid Buy-In for Children);
  • Form H1200, Application for Assistance – Your Texas Benefits;
  • Form H1200-A, Medical Assistance Only (MAO) Recertification;
  • Form H1200-EZ, Application for Assistance;
  • Form H1200-MBIC-R, Application for Benefits – Medicaid Buy-In for Children;
  • Form H1200-PFS, Medical Application for Assistance (for Residents of State Facilities);
  • Form H1200-SR, MEPD Streamlined Redetermination;
  • Form H1206ME, Health-Care Benefits Renewal;

The cover letter informs the recipient that it is time to renew benefits, provides instructions on how to complete and return the renewal form along with any required verification documents, and informs the recipient that the information must be returned within 30 days. If the recipient does not return the renewal form and required verification, eligibility is automatically terminated at cutoff in the 12th month for failure to provide the requested information.

Notes: Form H1211 and Form H1206ME are generated when the automated renewal process results in Eligibility Approved. Form H1211 informs the recipient to only return Form H1206ME  if the information is incorrect or if there has been a change to their case.

Recipients are not required to return Form H1200-SR. The renewal cover letter informs the recipient that they do not need to return the renewal form if the information on Form H1200-SR is correct and has not changed.

For applicable MEPD programs, Asset Verification System (AVS) must be requested at every renewal.

If the renewal form indicates that the recipient wants to register to vote, complete the "Voter Registration Information" section of the "Citizen" tab in the Individual Demographics logical unit of work (LUW). Select “YES” in the "Send Voter Registration Application?" dropdown to send Form H0025, HHSC Application for Voter Registration, to the mailing address on file. If the recipient contacts the office declining to complete Form H0025, mail Form H1350, Opportunity to Register to Vote, to the recipient. Form H1350 records the recipient's decision about registering to vote.
 

Related Policy

Who May Complete an Application for Assistance, B-3210
Who May Sign an Application for Assistance, B-3220
Redetermination Cycles, B-8200
Streamlined Redetermination (Passive Redetermination), B-8440
Voter Registration, C-7000
Asset Verification System (AVS), R-3740

B-8410 Financial Management

Revision 09-4; Effective December 1, 2009

For redeterminations, explore financial management if there has been no activity in the person’s bank account, other than interest credited, since the last redetermination.

If a person does not report a bank account, trust fund or similar account on the application for assistance, ask the person or the authorized representative to explain how the person’s financial affairs are handled. This includes determining who cashes his checks and where, who pays his bills and how, and who keeps his money and how the funds are kept.

If the person reveals previously unreported liquid resources, determine the value, ownership and accessibility according to the requirements for the resource involved.

Sources for verifying financial management are as follows:

  • Statements from the recipient and the person who handles the recipient’s funds.
  • Statement from a knowledgeable third party (for example, an administrator or bookkeeper in facility usually knows who receives the recipient’s benefit payments and pays the bills).

Include the following information in the case record documentation:

  • Where checks are cashed and how bills are paid.
  • Who handles the person’s checks, pays the person’s bills and maintains the person’s money.
  • How much money, if any, the person or anyone else keeps.
  • How much has accumulated.
  • Source of information.

B-8420 Notification of Changes as a Result of Redetermination

Revision 11-4; Effective December 1, 2011

On receipt of the completed, signed and dated H1200 series form, redetermine eligibility for MEPD. A review may result in no changes being made or one of the following situations:

  • Decrease of co-payment

    If a review results in a decrease in a recipient's co-payment, dispose of the case action and send Form TF0001, Notice of Case Action, to notify the recipient, and Form TF0001P, Provider Notice, to notify the facility. To correct co-payment for a previous period of time, complete Form H1259, Correction of Applied Income.
  • Increase of co-payment

    If a review results in an increase in the recipient's co-payment, dispose the case action and send Form TF0001 to the recipient and Form TF0001P to the facility. If the recipient does not indicate a desire to appeal by the end of the 12-day notification period, the increased co-payment remains.
  • Denial of benefits

    If a review results in a denial of benefits, send Form TF0001 to advise the recipient and Form TF0001P to notify the facility (if applicable). If the recipient does not indicate a desire to appeal by the end of the 12-day notification period, the benefits remain denied.

Note: Complete Form H1259 manually for notification if co-payment involves averaged income (raised or lowered) or incurred medical expenses. If all amounts are lower in the reconciliation shown on Form H1259, then adverse action is not required. In the above situations, ensure that if Form TF0001 and/or Form TF0001P is not sent automatically, a manual Form TF0001 and/or Form TF0001P is sent.

If there is no change in eligibility or co-payment, there is no mandate to send a notification to the recipient.

B-8430 Special Reviews

Revision 10-1; Effective March 1, 2010

A special review occurs between the annual review cycles to evaluate one or more eligibility elements without completing the annual review. The annual review (redetermination) packet is not required for a special review.

The need for a special review is based on policy, a reported change or the eligibility specialist's judgment.

Examples of when special reviews are needed for follow-up:

  • On the person's action for applying for potential benefits. An initial 30-calendar day special review is required to evaluate if the person made application after the person has been notified to do so. This may occur before the application is completed. Another special review will be needed to follow up to see if the recipient continues to be eligible.
  • When variable income and/or incurred medical expenses are averaged and projected. Special reviews are required at least every six months unless documentation substantiates an exception.
  • Within a 90-day time frame when the total countable income is within $10 of the income limit.
  • Within a 90-day time frame when the total countable resources are within $100 of the resource limit.
  • When any change is anticipated to occur.

For special reviews, document clearly the detailed reason(s) for the special review. Documentation must include:

  • specific information regarding the reason a special review is set;
  • the name of the individual who is affected; and
  • the eligibility area(s) subject to the review.

Include this information on correspondence sent to the person to request information concerning the special review. No redetermination packet is required.

For example, if someone has a private pension and the pension amount is anticipated to increase in the future, set a special review for the anticipated change. The eligibility area will be income. Documentation must specify pension information that will need to be verified at the special review. Include the:

  • date on which the anticipated change is to occur;
  • type of pension;
  • source of pension; and
  • frequency of payment of pension that will need to be verified at the special review.

Form H1020, Request for Information or Action, and Form H1020-A, Sources of Proof, are used to request information from the person or authorized representative. Include the due date on Form H1020 or H1020-A. If the recipient calls with questions, follow Appendix XVI, Documentation and Verification Guide, for acceptable verification sources.

Example:

George Black called this morning saying he received a letter requesting verification that he had applied for Veterans Affairs (VA) benefits. He stated that he had applied and was told that it would take at least six months to hear anything.

Document what Mr. Black said. Recipient declaration is acceptable verification that he has applied for additional benefits. Be sure to tell Mr. Black to call and report if he hears anything about his eligibility from the VA.

B-8440 Streamlined Redetermination (Passive Redetermination)

Revision 19-2; Effective June 1, 2019

For certain stable community-based cases, a redetermination may be completed without requiring a renewal form. The passive redetermination is completed based on information available in the case record or other information available through electronic data sources.

Community-based cases are considered stable and eligible for a passive redetermination if they have no more than:

  • one bank account; 
  • excluded burial funds;
  • excluded resources;
  • income requiring no more than annual verification; and
  • variable income not more than $4.99.

For community-based cases that meet the criteria for a passive redetermination, the Form H1200-SR, Streamlined Redetermination for Medicaid for the Elderly and People with Disabilities, is sent.  If there are no changes in income or resources to report, a completed renewal form is not required and eligibility is automatically renewed based on existing case information.

If the recipient returns the Form H1200-SR, process the redetermination following regular redetermination policy and procedures.

At least one annual redetermination must be completed using a regular application or redetermination form (Form H1200, Form H1200-A or Form H1200-EZ) before a case may be considered for the passive renewal process.

The streamlined redetermination process only applies to the following Types of Assistances (TOA’s):

  • TP-14-ME-CAS - Community Attendant Services
  • TP-23-MC-SLMB - Specified Low-Income Medicare Beneficiaries
  • TP-24-MC-QMB - Qualified Medicare Beneficiaries
  • TP-25-MC-QDWI - Qualified Disabled and Working Individuals
  • TP-26-MC-QI-1 - Qualifying Individuals.

AVS applicable TOAs are not eligible for a passive redetermination.

Related Policy

Procedures for Redetermining Eligibility, B-8400
Asset Verification System (AVS), R-3740

B-8450 Special Reviews when Facility Contract Closure or Cancellation Occurs

Revision 21-3; Effective September 1, 2021

When a facility’s Medicaid contract is terminated, the facility notifies the recipient and provides them with the option to move to a Medicaid covered facility.

If the Medicaid recipient continues to live in an uncontracted facility, deny Medicaid eligibility and send Form TF0001, Notice of Case Action, to the recipient and or authorized representative (AR) and TF0001P, Provider Notice of Case Action, to the facility. The person will then be responsible for the full vendor payment for that facility.

If the recipient relocates to a Medicaid contracted facility, process a change of address, verify the person continues to meet all Medicaid eligibility criteria and send out a new TF0001 to the recipient and or AR and TF0001P to the new facility.

Related Policy

Institutional Living Arrangements, B-6300
Redetermination Cycles, B-8200
Notices, R-1300

B-8460 Changes and Program Transfers

Revision 21-4; Effective December 1, 2021

Changes

Changes are situations that may affect a person’s eligibility, continued eligibility or co-payment amount.

An applicant, recipient or authorized representative must report changes within ten days of the event, including the following:

  • Change of address;
  • Change in living arrangements;
  • Change in income;
  • Change in resources; and
  • Change in marital status.

To ensure the most accurate information is on file, staff must act on reported changes:

  • Within ten workdays for changes that may affect eligibility or co-payment; or
  • Within 30 workdays for changes that do not affect eligibility or co-payment.

Program Transfers

A program transfer occurs when a Medicaid or MSP recipient is determined eligible for another type of Medicaid due to a change in circumstances.

Example: A CAS recipient enters a nursing facility or requests waiver services.

A request for a program transfer to a new program or a request to add another type of Medicaid is considered a change. Process the change within ten workdays of receiving the request.

Redetermine eligibility and verify all required eligibility criteria for the new program, including the 30-day consecutive stay, transfer of assets, substantial home equity and spousal impoverishment, if applicable. Request AVS prior to disposing eligibility. If more information is needed, send Form H1020, Request for Information or Action. The due date for missing information or verifications should be 10 days from the date on Form H1020.

If an active recipient reports a spouse, process the change within 10 workdays. Request verification for the new person and redetermine eligibility as appropriate for a couple or companion case.

Related Policy

Medicaid Certified Person Enters Nursing Facility or Home and Community-Based Services Waiver Program, B-7450
Redetermination Cycles, B-8200
Responsibility to Provide Information and Report Changes, C-8000

B-9000, Denials

B-9200, Medical Necessity/Level of Care Determination at Redetermination

Revision 09-4; Effective December 1, 2009  

When reviewing an MEPD case, verify medical necessity/level of care determination if:

  • the recipient's medical necessity or level of care determination has been denied, or
  • the recipient has relocated to a different facility and no medical necessity/level of care determination has been received.

If the medical necessity/level of care determination has been denied, do not sustain the review.

Reference: See Section B-7431, Denial of Level of Care/Medical Necessity Determination, for procedures when medical necessity/level of care is denied.

B-9300, Date of Death Denials and Verification Sources

Revision 19-3; Effective September 1, 2019

Date of Death Matches

HHSC matches recipients on active TIERS Eligibility Determination Groups (EDGs) with records from the Social Security Administration (SSA), Texas Bureau of Vital Statistics (BVS), the Centers for Medicaid and Medicare Services (CMS), and DADS Webservices to identify deceased persons and automatically remove them from active EDGs. If unable to process the death data automatically, TIERS creates tasks for staff to perform more research to determine the validity of the computer match. TIERS will attempt to update the Date of Death (DOD) information for all active and inactive person(s).

Death Verification Sources

Take action to clear any discrepancies when DOD data is received on an active or inactive person within TIERS and the system is unable to automatically dispose the case. When the system cannot dispose the case, a series of alerts are created for staff to explore and request additional verification of the death data.

Primary source of verification of death is the Bureau of Vital Statistics (BVS).

If BVS is not available, verify the date of death using two of the following sources:

  • Social Security Administration (SSA);
  • statement from guardian or other authorized representative;
  • copy of death certificate;
  • statement from a doctor;
  • newspaper death notice (obituary);
  • statement from a relative or household member;
  • statement from funeral director; or
  • records from hospital or other institution where the person died.

Note: If BVS is received but the date of death does not match previously reported information, accept BVS as verification and dispose the case. No additional verification is needed because BVS is considered the primary verification source.

Example: DOD data received from an SSA interface shows a DOD of 01/15/2019 but, the same person had a DOD of 01/13/2019 listed in TIERS. Alert 812, Verify Discrepancy in Date of Death for Individual is created for additional action. Staff verify the DOD by contacting the nursing home where the person was residing prior to death and also locate the person's obituary online. Staff enter the DOD based on the additional information and clear the alert

For detailed processing instructions, staff may review the Eligibility Services State Processes document and the Change and Alert Guide.

Related Policy

Social Security Administration Deceased Individual Report, R-4110