Revision 10-2; Effective June 1, 2010

Federal law requires that anyone who wishes to apply for Medicaid be allowed to file an application, regardless of the person's ultimate eligibility for services. See Chapter B, Applications and Redeterminations, for more information.

In addition to meeting other requirements, a person must file an application to become eligible to receive benefits. An authorized representative may accompany, assist and represent an applicant or recipient in the application or eligibility redetermination process.

Someone who is Supplemental Security Income (SSI) eligible automatically receives Medicaid and does not have to file a separate application unless coverage for unpaid or reimbursable bills during prior months to the SSI application is requested. See Section A-4300, Retroactive Coverage.

To apply for an MEPD program, an application for assistance must be received that is:

• HHSC approved for MEPD Medicaid,
• completed according to HHSC instructions, and
• signed and dated under penalty of perjury by the applicant and/or authorized representative or someone acting responsibly for the applicant (if the applicant is incompetent or incapacitated).

An applicant or authorized representative must also provide all requested information according to HHSC instructions. See Section C-8000, Responsibility to Provide Information and Report Changes.

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.

Filing an application will:

• permit HHSC to make a formal determination whether or not a person is eligible to receive Medicaid; and
• give a person the right to appeal if there is a disagreement with the determination.

Revision 09-4; Effective December 1, 2009

Applicants/recipients have a right to correct any information that HHSC has about the applicant/recipient and any other individual on the applicant's/recipient's case.

A request for correction must be in writing and must:

• identify the individual asking for the correction;
• identify the disputed information about the individual;
• state why the information is wrong;
• include any proof that shows the information is wrong;
• state what correction is requested; and
• include a return address, telephone number or email address at which HHSC can contact the individual.

If HHSC agrees to change individually identifiable health information, the corrected information is added to the case record, but the incorrect information remains in the file with a note that the information was amended per the applicant's/recipient's request.

Notify the applicant/recipient in writing within 60 days (using current HHSC letterhead) that the information is corrected or will not be corrected and the reason. Inform the applicant/recipient if HHSC needs to extend the 60-day period by an additional 30 days to complete the correction process or obtain additional information.

If HHSC makes a correction to individually identifiable health information, ask the applicant/recipient for permission before sharing with third parties. HHSC will make a reasonable effort to share the correct information with persons who received the incorrect information from HHSC if they may have relied or could rely on it to the disadvantage of the applicant/recipient. Follow regional procedures to contact HHSC's privacy officer for a record of disclosures.

Note: Do not follow procedures above if the accuracy of information provided by a applicant/recipient is determined by another review process, such as:

• a fair hearing;
• a civil rights hearing; or
• another appeal process.

The decision in that review process is the decision on the request to correct information.

Revision 09-4; Effective December 1, 2009

Keep all information HHSC has about an applicant/recipient or any individual on the applicant's/recipient's case confidential. Confidential information includes, but is not limited to, individually identifiable health information.

Before discussing or releasing information about an applicant/recipient or any individual on the applicant's/recipient's case, take steps to be reasonably sure the individual receiving the confidential information is either the applicant/recipient or an individual the applicant/recipient authorized to receive confidential information (for example, an attorney or personal representative).

 

C-2210 Telephone Contact

Revision 11-4; Effective December 1, 2011

Establish the identity of an individual who identifies himself/herself as an applicant/recipient using his/her knowledge of the applicant's/recipient's:

• Social Security number;
• date of birth;
• other identifying information; or
• call back to the individual.

Establish the identity of a personal representative by using the individual's knowledge of the applicant's/recipient's:

• Social Security number;
• date of birth;
• other identifying information;
• call back to the individual; or
• the knowledge of the same information about the applicant's/recipient's representative.

Establish the identity of attorneys or legal representatives by asking the individual to provide Form H1003, Appointment of an Authorized Representative, completed and signed by the applicant/recipient.

Establish the identity of legislators or their staff by following regional procedures.

 

C-2220 In-Person Contact

Revision 12-3; Effective September 1, 2012

Establish the identity of the individual who presents himself/herself as an applicant/recipient or applicant's/recipient's representative at an HHSC office by:

• driver's license;
• date of birth;
• Social Security number; or
• other identifying information.

Establish the identity of other HHSC staff, federal agency staff, researchers or contractors by:

• employee badge; or
• government-issued identification card with a photograph.

Identify the need for other HHSC staff, federal staff, research staff or contractors to access confidential information through:

• official correspondence or telephone call from state office or regional offices, or
• contact with regional attorney.

Contact appropriate regional or state office staff when federal agency staff, contractors, researchers or other HHSC staff, etc., come to the office without prior notification or adequate identification and request permission to access HHSC records.

Note: Contractors cannot have access to IRS Federal Tax Information (FTI).

 

C-2230 Verification and Documentation

Revision 12-3; Effective September 1, 2012

If disclosing individually identifiable health information, document how you verified the identity of the person if contact is outside the interview.

Verify the identity of the person who contacts you with a request to disclose individually identifiable health information using sources such as:

• valid driver's license or Department of Public Safety ID card;
• birth certificate;
• hospital or birth record;
• adoption papers or records;
• work or school ID card;
• voter registration card;
• wage stubs; and
• U.S. passport.

As a condition for receiving federal taxpayer returns and return information from the IRS, HHSC is required pursuant to IRC 6103(p)(4) to establish and maintain, to the satisfaction of the IRS, safeguards designed to prevent unauthorized access, disclosure, and use of all returns and return information and to maintain the confidentiality of that information. The IRS security requirements for safeguarding IRS FTI are outlined in Publication 1075, Tax Information Security Guidelines for Federal, State and Local Agencies, Safeguards for Protecting Federal Tax Returns and Return Information.

MEPD Income Eligibility and Verification System (IEVS) specialists must independently verify the income and resource information from any of the data matches to ensure continuous financial eligibility for the MEPD programs.

For all case actions regarding the clearance of the IEVS match of IRS FTI, MEPD staff must not enter any IRS FTI into TIERS (including comments). Documentation on the TIERS income/resource screen is limited to the approved language indicated in the centralized process available on the Social Services Intranet on the Medicaid Eligibility for the Elderly and People with Disabilities home page at hhs.texas.gov/laws-regulations/handbooks/medicaid-elderly-people-disabilities-handbook.

 

C-2240 Alternate Means of Communication

Revision 09-4; Effective December 1, 2009

HHSC must accommodate an applicant's/recipient's reasonable request to receive communications by alternative means or at alternate locations.

The applicant/recipient must specify in writing the alternate mailing address or means of contact and include a statement that using the home mailing address or normal means of contact could endanger the applicant/recipient.

Revision 21-3; Effective September 1, 2021

Records must be safeguarded. Use reasonable diligence to protect and preserve records and to prevent disclosure of the information they contain except as provided by HHS regulations.

"Reasonable diligence" for employees responsible for records includes keeping records:

• in a locked office when the building is closed;
• properly filed during office hours;
• always in the office except when authorized to remove or transfer them; and
• electronic file information as referenced in HHS Computer Usage and Information Security training.

Reporting Unauthorized Inspection or Disclosure of Internal Revenue Service (IRS) Federal Tax Information (FTI)

Upon discovery of an actual or possible compromise of an unauthorized inspection or disclosure of IRS FTI including breaches and security incidents, the person making the observation or receiving the information must contact the HHS IRS Coordinator immediately at 512-706-7158. They must also email the HHS Privacy Office Mailbox. If you are unable to personally reach the HHS IRS Coordinator by phone, send a secure email to the HHS IRS Coordinator Mailbox.

The HHS IRS Coordinator will report the incident by contacting the office of the appropriate Special Agent-in-Charge, Treasury Inspector General for Tax Administration (TIGTA) and the IRS Office of Safeguards as directed in Section 10.2 of Publication 1075.

Reporting Unauthorized Inspection or Disclosure of Social Security Administration (SSA) Provided Information

Staff who become aware of an incident of unauthorized access to, or disclosure of, restricted verified SSA information or confidential information must contact the HHS Privacy Office Mailbox immediately.

The HHS Privacy Office will report the incident by contacting the Chief Information Security Office (CISO).

If a person is responsible for a security breach or an employee's employment is terminated, the user's access to all information resources is removed. Supervisors must follow agency procedures for removing access for employees, contractors, vendors or trainees.

Revision 21-3; Effective September 1, 2021

Revision 21-3; Effective September 1, 2021

To dispose of documents with an applicant or recipient's information, follow procedures for destruction of confidential data according to Texas Health and Human Services records management policies.

The approved method of destruction of IRS FTI is shredding. The IRS requires the following safeguards:

• HHS staff must perform the destruction of IRS FTI at an HHS facility.
• Destruction of IRS FTI must be documented on Form H1861, Federal Tax Information Record Keeping and Destruction Log.
• IRS FTI documents should be inserted into the shredder so the lines of print are perpendicular to the cutting line to render the document undisclosable.
• IRS FTI documents should be shredded to 1 mm x 5 mm (0.04 in. x 0.2 in.) in size (or smaller).

Revision 12-3; Effective September 1, 2012

1. If information about an applicant/recipient is requested but cannot be released, inform the inquiring person or agency that federal and state laws and HHSC regulations require that the information being requested remain confidential. Refer the questioner to Title 42 of the United States Code, Section 1396a(a)(7); 42 CFR Sections 431.300-431.307; and Texas Human Resource Code, Sections 12.003 and 21.012. For individually identified health information, refer the requestor to 45 CFR sections 164.102-164.534. For tax information obtained through IEVS, also refer the requestor to the Internal Revenue Service (IRS) Code, Sections 7213, 7213A and 7431. Title 26 US Code Section 6103 is the confidentiality statue that prohibits disclosure of FTI. For human services agencies, it is IRC 6103(1)(7).
   
   Reference: See Appendix XVIII, IRS Tax Code, Sections 7213, 7213A and 7431.

2. If subpoenaed to appear in court with an applicant's/recipient's record, notify the supervisor immediately. Give the supervisor all the facts about the case and the date and time of the court hearing. The supervisor should contact the lawyer who is requesting the record and determine whether the requested information is confidential. If a problem exists, the supervisor should inform the regional attorney about all relevant facts. Usually, the subpoenaed employee must take the record and appear in court as directed by the summons. When requested to disclose information from the record, ask the judge to be excused from disclosing the information because of the statutory prohibitions stated previously in this section. Abide by the ruling of the judge.

3. If subpoenaed to appear in court, and no time is allowed to follow the steps specified in this section, take the record and appear in court as directed by the summons. When requested to disclose the information from the record, follow the procedure described in Step 2.

For individually identifiable health information, refer the requestor to 45 CFR Sections 164.102-164.534.

Revision 21-4; Effective December 1, 2021
 
HIPAA requires HHSC to provide a notice of privacy practices that explains:

• the person’s privacy rights;
• the duties of HHSC to protect the person’s health information; and
• how HHSC may use or disclose the person’s health information without an authorization. For example, HHSC may share health information with the person’s providers to:
  • arrange for services; or 
  • with other government entities to report suspected abuse or neglect.

Provide Form 0401, Notice of Privacy Practices (English), or Form 0401S, Aviso de Normas Sobre la Privacidad (Spanish), as appropriate, to each household with a person enrolled in a medical program.

Provide Form 0401 or Form 0401S with Form TF0001, Notice of Case Action, to each household enrolled in a medical program:

• at initial certification; or
• at recertification after a break in services of more than 180 days.

Form 0403, Explanation to Health Information Privacy Rights, provides a reminder of privacy practices and where to locate Form 0401.

Provide Form 0403 with Form TF0001 to each head of household:

• at each recertification;
• after a break in services of at least 30 days but not more than 180 days; or
• when a new person is added to a case.

Revision 11-4; Effective December 1, 2011

The applicant/recipient may authorize the release of his or her health information from HHSC records by using a valid authorization form. Form H1003, Appointment of an Authorized Representative, includes all the authorization elements required by HIPAA privacy regulations. See Section C-3000, When and What Information May Be Disclosed, for the elements necessary for a valid authorization.

Revision 09-4; Effective December 1, 2009

Reasonable efforts must be made to limit the use, request or disclosure of individually identifiable health information to the minimum necessary to determine eligibility and operate the program. The disclosure of individual medical information from HHSC records must be limited to the minimum necessary to accomplish the requested disclosure. For example, if an applicant/recipient authorizes release of income verification, including disability income, do not release related case medical information unless specifically authorized by the applicant/recipient.

Revision 09-4; Effective December 1, 2009

If the applicant/recipient is an adult or emancipated minor, including married minors, the applicant/recipient's personal representative is a person who has the authority to make health care decisions about the applicant/recipient and includes a:

• person the applicant/recipient has appointed under a medical power of attorney, a durable power of attorney with the authority to make health care decisions, or a power of attorney with the authority to make health care decisions;
• court-appointed guardian for the applicant/recipient; or
• person designated by law to make health care decisions when the applicant/recipient is in a hospital or nursing home and is incapacitated or mentally or physically incapable of communication. Follow regional procedures to contact the regional attorney for approval.

Revision 09-4; Effective December 1, 2009

A parent is the personal representative for a minor child except when:

• the minor child can consent to medical treatment by himself or herself. Under these circumstances, do not disclose to a parent information about the medical treatment to which the minor child can consent. A minor child can consent to medical treatment by himself or herself when the:
  • minor is on active duty with the U.S. military;
  • minor is age 16 or older, lives separately from the parents and manages his own financial affairs;
  • consent involves diagnosis and treatment of a disease that must be reported to a local health officer or the Texas Department of State Health Services (DSHS);
  • minor is unmarried and pregnant and the treatment (other than abortion) relates to the pregnancy;
  • minor is age 16 years or older and the consent involves examination and treatment for drug or chemical addiction, dependency or use at a treatment facility licensed by DSHS;
  • consent involves examination and treatment for drug or chemical addiction, dependency or use by a physician or counselor at a location other than a treatment facility licensed by DSHS;
  • minor is unmarried, is the parent of a child, has actual custody of the child and consents to treatment for the child; or
  • consent involves suicide prevention or sexual, physical or emotional abuse; and
• a court is making health care decisions for the minor child or has given the authority to make health care decisions for the minor child to an adult other than a parent or to the minor child. Under these circumstances, do not disclose to a parent information about the health care decisions not made by the parent.

Revision 09-4; Effective December 1, 2009

The personal representative for a deceased applicant/recipient is an executor, administrator or other person with authority to act on behalf of the applicant/recipient or the applicant's/recipient's estate. These individuals include:

• an executor, including an independent executor;
• an administrator, including a temporary administrator;
• a surviving spouse;
• a child;
• a parent; and
• an heir.

Consult the regional attorney if you have questions about whether a particular person is the personal representative of an applicant or recipient.

Revision 13-2; Effective June 1, 2013

If an individual is dissatisfied with HHSC's decision concerning his eligibility for any MEPD program, including Medicaid Savings Programs, the individual has the right to appeal through the appeal process established by HHSC. In certain circumstances, the individual is entitled to receive continued benefits or services until a hearing decision is issued. Whether an individual is entitled to continued assistance is based on requirements set forth in appropriate state or federal law or regulation of the affected program. See the Fair and Fraud Hearings Handbook.

Individuals whose medical assistance is denied because of an SSA decision should file an appeal with the appropriate SSA office.

Note: If an individual submits an application during the time the continued benefits are being processed, the application must be processed as normal. See Chapters B-2300, Eligibility Determination, B-3200, Application Process, and B-6400, Processing Deadlines.

 

C-6110 Program Representation at Fair Hearings

Revision 18-4; Effective December 1, 2018  

If an applicant or recipient requests a fair hearing, the burden of proof to uphold HHSC's decision rests with HHSC. The hearing officer is a neutral party and is restricted by law from presenting HHSC's case.

Form H4800, Fair Hearing Request Summary, provides a space for the names of HHSC's representative and supervisor. The supervisor is responsible for ensuring that either the HHSC representative participates in the hearing or that a back-up person is assigned. Additionally, the supervisor should ensure that the designated representative is sufficiently prepared and knowledgeable of the case to represent HHSC during the fair hearing process.

The hearing officer has the responsibility of setting the date and time of the hearing. In those program areas where Form H4800 may be completed by someone other than agency staff (contracted case management, HHSC representatives, etc.), it is important that the hearing officer be given the name(s) of those people who are to be notified of the date and time of the hearing. If there is not sufficient space on Form H4800 to provide this information, list the name(s) on Form H4800-A, Fair Hearing Request Summary (Addendum), Item 3, "Additional Information."

In those program areas where Form H4800 is completed by HHSC staff but someone other than, or in addition to, HHSC staff will appear (Attorney General's Office staff, Workforce Commission staff, home health nurses, nursing facility staff, etc.), the person completing Form H4800 is responsible for providing the hearing officer with the name(s) of those people who are to be notified of the date and time of the hearing. If there is not sufficient space on Form H4800 to provide this information, list the name(s) on Form H4800-A, Item 3, " Additional Information."

Revision 11-4; Effective December 1, 2011

Applicants/recipients receiving MEPD programs are perceived by HHSC as essentially honest and entitled to the same protection under the law as all other individuals. When potential fraud is indicated, the allegations must be investigated.

HHSC also endorses the concept that people who provide services are essentially honest and are entitled to the same protection under the law as all other individuals. However, if there is an indication of potential fraud, the allegations must be investigated.

The Office of Inspector General (OIG) investigates waste, abuse and fraud in all health and human services programs in Texas. Any state employee or private citizen may report waste, abuse and fraud to the OIG.

HHSC staff, concerned citizens, providers (for example, doctors, dentists, counselors, etc.), Medicaid applicants/recipients and others can help prevent cases of waste, abuse and fraud by notifying OIG.

If applicant/recipient or provider waste, abuse or fraud is suspected in the Medicaid system, complete the OIG's online complaint form, which is available at: https://oig.hhsc.state.tx.us/wafrep/.

If access to the Internet is not available, contact the fraud hotline at 800-436-6184 or mail the complaint to:

Texas Health and Human Services Commission
Office of Inspector General
Mail Code 1361
P.O. Box 85200
Austin, TX 78708-5200

Revision 13-3; Effective September 1, 2013

All Programs

HHSC is required to provide interpreter services and written translated materials to applicants and recipients who are Limited English Proficient (LEP). HHSC also is required to provide an effective method to communicate with applicants and recipients who indicate they are deaf or hearing impaired. Applicants and recipients indicate on Form H1200, Application for Assistance – Your Texas Benefits, or during an interview that they need interpreter services. For more information on procedures, refer to the Eligibility Operations Procedures Manual.

Revision 19-3; Effective September 1, 2019

All Programs

Staff must inform applicants and recipients about the availability of written or verbal translation services for written materials HHSC sends to them at application and redetermination.

When staff verbally communicate with Limited English Proficient (LEP) applicants or recipients at the time of application, redetermination and change actions, staff must ensure that applicants or recipients understand the eligibility action (Form H1020, Request for Information or Action, and Form TF0001, Notice of Case Action) being taken and the requirements for the application process (including the request for any missing information).

Note: This requirement is not applicable when staff process the case action without talking with the applicants or recipients.

The Vietnamese Translation Interpreter Form is automatically attached to applicable eligibility notices when Vietnamese is selected as the primary household language.