Medicaid for the Elderly and People with Disabilities Handbook

M-1200, Program Overview

Revision 22-3; Effective September 1, 2022

The MBI program is a Medicaid program for people with disabilities who are working and earning more than the allowable limits for regular Medicaid. MBI allows people with disabilities who are working to earn more income without the risk of losing vital health care coverage. The income limit is up to 250% of the federal poverty level (FPL). A person may have to pay a monthly premium as a condition of eligibility. The amount of the premium is determined on a sliding scale, based on the recipient’s earned and unearned income.

MBI recipients receive a Your Texas Benefits Medicaid ID card. If a recipient is eligible for both Medicare and Medicaid, prescriptions are available through a Medicare Part D Prescription Drug Plan.

All regular MEPD policies apply to this program except for the eligibility items specifically identified in this chapter. For example, citizenship and Texas residency are not addressed in this chapter. Therefore, follow regular MEPD policies for citizenship and Texas residency.

All eligibility requirements for this program must be verified. MBI is not a client-declaration program.

M-1300, MBI and Other Programs

M-1310 MBI and Home and Community-Based Services Waivers

Revision 16-2; Effective June 1, 2016

If a person is currently eligible for Medicaid Buy-In (MBI) and requests waiver services, the Long-Term Services and Supports (LTSS) programs (such as STAR+PLUS Waiver) do not require a change in Medicaid type program for payment of services. Do not do a program transfer for ME-Waivers.

Do not calculate a copay for individuals who are MBI-eligible and receive waivers services. A person is not subject to a financial copay unless financial eligibility is determined using the 300% of Supplemental Security Income, Special Income Group limit, e.g., ME-Waivers.

M-1320 MBI and Medicare Savings Programs

Revision 11-4; Effective December 1, 2011

An MBI-eligible applicant/recipient can also have:

  • Qualified Medicare Beneficiary (QMB)
  • Specified Low-Income Medicare Beneficiary (SLMB)

An MBI-eligible applicant/recipient cannot have:

  • Qualifying Individuals-1 (QI-1). The applicant/recipient must choose between MBI and QI-1.
  • Qualified Disabled Working Individuals

Note: Deeming of income and resources and support and maintenance applies to the Medicare Savings Program.

M-2000, Automation

Revision 11-4; Effective December 1, 2011

MBI is worked only in the Texas Integrated Eligibility Redesign System (TIERS) and is type of assistance TP 87. The program name displays as ME-Medicaid Buy-In.

M-3000, Non-Financial

Revision 19-4; Effective December 1, 2019

All regular non-financial MEPD policies apply to MBI, except those specifically identified in this chapter.

Non-financial requirements apply only to an MBI applicant/recipient, even if there are other household members.

 

M-3100, Age

Revision 11-4; Effective December 1, 2011

MBI has no age limit.

M-3200, Disability

Revision 19-4; Effective December 1, 2019

All persons applying for the Medicaid Buy-In (MBI) program must meet the Supplemental Security Income definition of disability. If the person does not have an established Social Security Administration disability determination, request the determination from HHSC's Disability Determination Unit. Follow normal MEPD policy for disability determinations. For MBI, the disability requirement also applies to persons age 65 or older.

The MBI program allows an exception to the requirement that the person be unable to engage in any substantial gainful activity (SGA). For purposes of MBI, a person who is able to engage in SGA still might meet disability requirements because SGA is disregarded in deciding whether the person meets the definition of disabled for MBI.

Related Policy

Disability, D-1400
Requesting a Decision from the Disability Determination Unit (DDU), D-2300

M-3300, Household of One

Revision 15-4; Effective December 1, 2015

Being a household of one means an applicant/recipient is not penalized for assets owned by the spouse. For example, if one member of a couple applies for the MBI program, only the assets of the applicant are considered when determining eligibility for the program. If both an applicant/recipient and spouse own the asset, only half of the asset is considered owned by each spouse. If the person applying for the MBI program is a minor and lives with his or her parents, the assets of the parents are not considered the minor's assets. Consider an MBI recipient/applicant a household of one, regardless of the living arrangement or age. Do not deem income or resources. Do not consider support and maintenance. If an applicant lives with a spouse who is eligible for Medicaid, the applicant and spouse are each considered a household of one.

M-4000, Resources

Revision 11-4; Effective December 1, 2011

All regular MEPD policies for resources apply to this program, except those specifically identified in Chapter M.

ResourceDetail
Resource LimitCountable resources must be equal to or less than $2,000.
ExclusionsWhen determining resource exclusions, use current MEPD eligibility criteria, including the special $3,000 MBI Resource Exclusion.

Count any non-excluded separate resources of the applicant.
SpouseDo not count any separate resources of the spouse.

If the person and the ineligible spouse have a jointly owned resource with unrestricted access, consider that each owns an equal share. Divide the countable value of the resource, counting half as available to the applicant.
Jointly OwnedIf a non-excluded resource is jointly owned with other persons (not the spouse), use current MEPD eligibility criteria.

M-4100, Special MBI Resource Exclusions

Revision 11-4; Effective December 1, 2011

Exclude the following resources for MBI:

  • Retirement-related accounts
  • Independence accounts
  • Plan to Achieve Self Support (PASS)
  • $3000 MBI Resource Exclusion

M-4110 Retirement Accounts

Revision 11-4; Effective December 1, 2011

For the MBI program, Retirement-related accounts are not countable. These accounts include Individual Retirement Accounts, 401(K)s, Tax Sheltered Annuities, and Keoghs that comply with Internal Revenue Service regulations, and Keogh or HR-10 plans which are qualified employer plans set up by a self-employed individual.

M-4120 Independence Accounts

Revision 11-4; Effective December 1, 2011

An Independence Account is a separate designated account for health care and/or work-related expenses. For the MBI program, exclude an Independence Account if all:

  • funds from the account are used for health care or work-related expenses, and
  • deposits into the Independence Account are:
    • from the person's earned income, and
    • equal to or less than 50% of the person's gross earnings for the SSA qualifying quarter.

For the MBI program, count an Independence Account if any:

  • funds from the account are used for non-health care or non-work related expenses, and/or
  • deposits into the Independence Account:
    • exceed 50% of the person's earnings for the SSA qualifying quarter,
    • are from sources other than the person's earnings or interest earned on the Independence Account, and
    • include income from another person.

Evaluate the account at each complete redetermination. If the person takes action requiring the Independence Account to be counted, the exclusion for the Independence Account is lost. Consider the account as a countable resource for 12 calendar months beginning with the first month after the SSA qualifying quarter during which the exclusion was lost. The person may again request designation of an Independence Account after the 12-month countable period.

Example: John Smith deposited a $900 gift from his grandmother into the Independence Account in May. The exclusion of the Independence Account was lost. The balance of the Independence Account is a countable resource effective July 1 through June 30 of next year. Effective July of next year, Mr. Smith may request designation of an Independence Account.

If counting the resource results in denial, follow current denial process.

M-4130 Plan for Achieving Self-Support (PASS)

Revision 11-4; Effective December 1, 2011

See Section F-4400, Plan for Achieving Self-Support (PASS).

Do not count the resources and income that are essential for accomplishing the objectives of an SSA or HHSC approved PASS as long as the PASS is in effect. Any money set aside for a PASS must be identifiable from other funds – usually a separate bank account.

PASS resources are considered "set aside" when they are one or more of the following:

  • Owned by the individual
  • Used to pay for expenses, including expenses already incurred
  • Used directly in the job
  • Saved for future expenses

Information concerning a PASS and forms for exemption consideration are located on the SSA website at www.ssa.gov/online/ssa-545.pdf.

Send any PASS that needs HHSC approval to OFS Policy, State Office, Mail Code 2090.

For the MBI program, exclude any PASS resources if:

  • Resources are part of the PASS
  • PASS is approved and in effect
  • Money is in a separate PASS account

For the MBI program, end the PASS if the person has neither:

  • Met milestones as scheduled in the PASS
  • Set funds aside as agreed in the PASS
  • Spent funds as agreed in the PASS

Evaluate the person's ongoing compliance with the PASS at:

  • Each complete redetermination
  • The report of a change
  • Reapplication

If the PASS ends, count the PASS resources the month after the PASS end date. If counting the resources results in the person exceeding the resource limit, follow current denial process.

M-4140 $3,000 MBI Resource Exclusion

Revision 11-4; Effective December 1, 2011

Before comparing the countable resources to the $2,000 resource limit and after allowing all exemptions, exclusions and Special MBI Resource Exclusions (Retirement Accounts, Independence Accounts, PASS), deduct an additional $3,000 MBI resource exclusion.

M-5000, Income

Revision 21-2; Effective June 1, 2021

All regular MEPD policies for income apply to this program, except those specifically identified in Chapter M.

There is no support and maintenance considered for MBI. Do not develop support and maintenance.

There is no deeming of income for this program.

 

M-5100, Income Verification

Revision 13-3; Effective September 1, 2013

To be eligible, a person must be working and earning income. The person must provide proof of employment. Consider any of the following as proof of employment:

  • Tax payment verification under the Federal Insurance Contribution Act (FICA); or
  • Tax payment verification under the Self-Employment Contribution Act (SECA); or
  • A written explanation that substantiates the person is in an employed status.

Treatment of income will be different for the MBI income eligibility budget and the post eligibility premium budget.

Income limits are subject to change annually. See Appendix XXXI, Budget Reference Chart, for current limits.

M-5200, Medicaid Buy-In Income Limits

Revision 24-2; Effective June 1, 2024

To be eligible for MBI, a person must have countable income less than 250 percent of the federal poverty level (FPL).

Monthly Income Limits for the MBI Program

Date Range250% FPL
March 1, 2024 to Present$3,138
March 1, 2023 to Feb. 29, 2024$3,038
March 1, 2022 to Feb. 28, 2023$2,832
March 1, 2021 to Feb. 28, 2022$2,684
March 1, 2020 to Feb. 28, 2021$2,659
March 1, 2019 to Feb. 29, 2020$2,603
March 1, 2018 to Feb. 28, 2019$2,530
March 1, 2017 to Feb. 28, 2018$2,513
March 1, 2016 to Feb. 28, 2017$2,475
March 1, 2015 to Feb.  29, 2016$2,453
March 1, 2014 to Feb. 28, 2015$2,432
March 1, 2013 to Feb. 28, 2014$2,394
March 1, 2012 to Feb. 28, 2013$2,328
March 1, 2011 to Feb. 29, 2012$2,269
March 1, 2010 to Feb. 28, 2011$2,257

M-6000, Budgeting

Revision 22-3; Effective September 1, 2022

Budgeting for the MBI program is different than budgeting for other Medicaid programs.

  • There are two income-related budget tests for the MBI program, the MBI Income Eligibility Budget and the MBI Post Eligibility Premium Budget.
    • Income Limit — 250% federal poverty level (FPL)
    • Income Verification — Verify that a person is currently employed. Use established verification of earnings.
    • Eligibility Budget — Based on all gross earned income, after all allowable exclusions and tested against 250% FPL. Unearned income is not considered.
    • Post Eligibility Budget – Premium Budget — Unearned income and earned income is used to determine the MBI monthly premium amount.
  • Income that is exempt for other programs is considered in the MBI Income Eligibility Budget. For example, irregular and infrequent income of $30 or less per quarter is excluded in other programs. For the MBI Income Eligibility Budget, all irregular and infrequent earned income is counted.
  • MBI Income Eligibility Budget – The person’s gross earned income minus all allowable exclusions is compared to 250% FPL. Do not consider the person’s gross unearned income in the income eligibility budget.
  • MBI Post Eligibility – Premium Budget -The person’s gross monthly unearned and monthly net earned income is used to determine the MBI monthly premium amount.

Related Policy

Income Eligibility Budget, M-6100
Post Eligibility Premium Budgets, M-7100
Budget Reference Chart, Appendix XXXI
Screening Tool and Worksheets, Appendix XXXIX

M-6100, Income Eligibility Budget

Revision 11-4; Effective December 1, 2011

Do not consider unearned income in the income eligibility budget for MBI. The income eligibility test for the MBI program is based on all gross earned income from wages and self-employment based on a monthly amount.

Exclusions to the monthly gross earned amount are allowed in the MBI program. The exclusions are subtracted in a mandatory order. The 10 potential exclusions in the mandatory order are:

  1. Earned income tax credit payments
  2. Child tax credit
  3. Infrequent or irregular income equal to or less than $30 per month
  4. Earned income of blind or disabled student
  5. $20 general income
  6. $65 earned income
  7. Impairment-related work-related expenses
  8. One half of remaining earned income
  9. Blind work-related expenses
  10. PASS-related earned income

Note: If the person fails to provide verification for the exclusion, do not allow the exclusion in the income eligibility budget. Do not deny the case for "failure to provide" verification.

M-6110 Earned Income Tax Credit Payments Exclusion

Revision 11-4; Effective December 1, 2011

See Section E-2210, Income Tax Credits. An earned income tax credit (EITC) is a special tax credit that reduces the federal tax liability of certain low-income working taxpayers. This tax credit may or may not result in a payment to the taxpayer. EITC payments are allowed as an advance from an employer or as a refund from the Internal Revenue Service (IRS) and are excluded from income, regardless of the tax year involved. Normally this is exempt income – never considered as income and never deducted. For the MBI program, deduct the EITC in the month received from the employer or divide the annual EITC refund from the IRS by 12 to get the monthly EITC exclusion.

 

M-6120 Child Tax Credit Exclusion

Revision 11-4; Effective December 1, 2011

The child tax credit is the annual amount. Divide the annual child tax credit by 12 to get the monthly child tax credit exclusion. Child tax credit exclusions apply only to the MBI program. Use the federal tax return or other IRS documentation for sources of verification.

M-6130 Infrequent or Irregular Income Exclusion

Revision 11-4; Effective December 1, 2011

The first $30 of infrequent or irregular earned income is excluded in the Income Eligibility Budget. See Section E-9000, Infrequent or Irregular Income.

M-6140 Earned Income - Blind or Students with Disabilities Exclusion

Revision 11-4; Effective December 1, 2011

See Section E-2220, Student Earnings. For the MBI program, consider all gross monthly earned income and allow the income exemption when the MBI person is:

  • blind or disabled,
  • a student,
  • younger than age 22.

See Special Income Exemption for Student in Appendix XXXI, Budget Reference Chart, for the monthly and yearly amount limits for the exemption.

M-6150 $20 General Income Exclusion

Revision 11-4; Effective December 1, 2011

Since unearned income is not considered in the MBI Income Eligibility Budget, subtract the $20 general income exclusion from the remaining earned income after subtracting the first four exclusions.

See Section M-6100, Income Eligibility Budget, for mandatory order of allowable exclusions.

 

M-6160 $65 Earned Income Exclusion

Revision 11-4; Effective December 1, 2011

Subtract the $65 earned income exclusion from the remaining earned income after subtracting the first five exclusions. Do not subtract the normal "one half of the remaining earnings" as part of the $65 earned income exclusion until Step 8 in the mandatory order of allowable exclusions.

M-6170 Impairment-Related Work-Related Expense (IRWE) Exclusion

Revision 11-4; Effective December 1, 2011

This exclusion is based on the SSI work incentive for persons who are determined to be disabled. The cost of certain items and services that a person with impairment needs in order to work can be deducted from earnings, even though such items and services also are needed for normal daily activities. The IRWE exclusion is subtracted if the MBI person is under age 65 and the items are used to pay expenses directly related to the impairment and needed in order to work.

In the following table, possible IRWE exclusion items are listed. There are also items that are not allowed as IRWE items. Allow only the possible IRWE exclusion item if the person's earnings are used to pay the cost of the item.

Possible IRWE Exclusion Items Prohibited IRWE Exclusion Items
  • Attendant care services
  • Drugs to control disabling condition
  • Expendable medical supplies
  • Medical devices and equipment
  • Medical services to control disabling condition
  • Non-medical equipment/services
  • Other work-related equipment/services
  • Physical therapy
  • Prostheses
  • Service animal expenses
  • Structural home modifications
  • Training to use impairment-related item
  • Transportation
  • Vehicle Modification
  • Expenses that will be reimbursed
  • Health and life insurance premiums
  • Routine annual physical examinations
  • Routine optician services (unrelated to a disabling visual impairment)
  • Routine dental examinations

M-6180 Blind Work-Related Expense (BWE) Exclusion

Revision 11-4; Effective December 1, 2011

This exclusion is based on the SSI work incentive for persons who are determined to be legally blind. From the earnings of the legally blind MBI person, an exclusion for most work-related expenses, whether or not they relate to blindness, is allowed. The MBI person must be:

  • legally blind,
  • under age 65,
  • if age 65 or older, must have received SSI payment due to blindness for the month before attaining age 65.

In the following table, possible BWE exclusion items are listed. There are also items that are not allowed as BWE items. Allow only the possible BWE exclusion item if the person's earnings are used to pay the cost of the item.

Possible BWE Exclusion Items Prohibited BWE Exclusion Items
  • Attendant care services
  • Child care
  • Drugs to control disabling condition
  • Expendable medical supplies
  • Federal, state and local income taxes
  • Fees, licenses and dues
  • Mandatory pension contributions and savings plans
  • Meals consumed during work or school hours
  • Medical devices and equipment
  • Medical services to control disabling condition
  • Non-medical equipment/services
  • Other work-related equipment/services
  • Physical therapy
  • Prostheses
  • Service animal expenses
  • Structural home modifications
  • Training to use impairment-related item
  • Transportation
  • Vehicle modification
  • Expenses that will be reimbursed
  • Expenses claimed on a self-employment tax return
  • General educational development
  • In-kind payments
  • Health and life insurance premiums
  • Meals consumed outside of work hours
  • Self care items
  • Voluntary pension contributions and savings plans
  • Work-related items furnished by others

 

M-6190 PASS-Related Earned Income Exclusion

Revision 11-4; Effective December 1, 2011

See Section F-4400, Plan for Achieving Self-Support (PASS), and Section M-4130, Plan for Achieving Self-Support (PASS). This exclusion is based on the SSI work incentive for persons who are determined to be blind or disabled. Any earned income used to fulfill an SSA or HHSC-approved PASS is excluded from the person's earnings as long as the PASS is in effect.

The following are allowable PASS expenses only if the person intends to pay the expense and the expense is necessary to meet an occupational goal. If the expense is reimbursable, it is not allowable.

Possible PASS Exclusion Items
  • Attendant care services
  • Basic living skills training
  • Business-related expenses
  • Child care
  • Drugs to control disabling condition
  • Expendable medical supplies
  • Federal, state and local income taxes
  • Fees, licenses and dues
  • Finance and services charges
  • Job coaching/counseling services
  • Job search or relocation expenses
  • Mandatory pension contributions and savings plans
  • Meals consumed during work or school hours
  • Medical devices and equipment
  • Medical services to control disabling condition
  • Non-medical equipment/services
  • Other work-related equipment/services
  • PASS preparation fees
  • Physical therapy
  • Prostheses
  • Service animal expenses
  • Shelter and food due to temporary absence from permanent residence
  • Specialized clothing and appropriate attire
  • Structural home modifications
  • Subscription costs for publications for academic or professional purposes
  • Training to use impairment-related item
  • Transportation
  • Vehicle modification

A person may have more than one PASS during the person's lifetime; however, a person is limited to only one PASS at a time.

The SSI work incentives – IRWE, BWE, PASS – allow for earned income exclusions to occur for a person. A person may have an IRWE, a BWE, and a PASS at the same time. Expenses allowed, as an income exclusion from one of the SSI work incentives, must be mutually exclusive unless the expense is for a different reason. For example, child care is allowable under a BWE or a PASS. If the child care is for work and attending night school, allow the expense as an exclusion under one or both of the SSI work incentives depending on what is available to the person. Another example would be transportation. Transportation is allowable under IRWE and BWE. If the gas expense is for work and attending training, allow the expense as an exclusion under one or both of the SSI work incentives depending on what is available to the individual.

M-7000, Premiums

Revision 21-2; Effective June 1, 2021

A person may have to pay a monthly premium as a condition of eligibility. The premium amounts are based on a sliding scale, dependent upon the person's income. The MBI monthly premium amount is determined based on the person's unearned and earned income.

M-7100 Post Eligibility — Premium Budgets

Revision 24-2; Effective June 1, 2024

Premium Budgeting Steps

There are three steps to calculate the premium amount.

Note: While unearned income is excluded in the income eligibility budget, it is used in the calculation of the premium amount.

Step 1

Unearned Income

The unearned income premium amount is based on unearned income after allowable exemptions and exclusions.

Note: Support and maintenance does not apply to the MBI program.

Find the unearned income premium amount by subtracting the SSI federal benefit rate amount for one person from the person's countable unearned income.

Step 2

Earned Income

Find the earned income premium amount by adding:

  • gross earned income minus mandatory payroll deductions; and
  • any countable earned self-employment income.

This calculation results in the net earnings. If the net earnings are equal to or less than 150 percent of the federal poverty level (FPL), the monthly premium is $0. If the net earnings exceed 150 percent of the FPL, the person must pay a monthly premium based on the earned income amount. Compare the net earnings amount to the FPL ranges to find the earned income premium amount.

The 2024 FPL ranges for the earned income premium amounts are listed in the chart below. Income limits are subject to change annually.

2024 FPL RangeEarned Income Premium Amount
Earnings at or below 150% FPL
(less than or equal to $1,883)
$0
Earnings above 150% FPL up to and including 185% FPL
(greater than $1,883 up to and including $2,322)
$20
Earnings above 185% FPL up to and including 200% FPL
(greater than $2,322 up to and including $2,510)
$25
Earnings above 200% FPL up to and including 250% FPL
(greater than $2,510 up to and including $3,138)
$30
Earnings above 250% FPL
(greater than $3,138)
$40

Step 3

Add the unearned income premium amount to the earned income premium amount to get the total monthly MBI premium amount.

Total Monthly Premium Limit

The total monthly premium may not exceed $500. If the unearned income premium amount plus the earned income premium amount is greater than or equal to $500, then the total monthly premium is $500.

Examples

Below are three examples for calculating the MBI premium.

Example 1

A person has $974 in unearned monthly income. After applying all deductions, the remaining earned income is $1,250.

Step 1: Subtract the SSI federal benefit rate amount for one person from the person's countable unearned income.

DescriptionAmount
Unearned income$974
SSI federal benefit rate– $943
Unearned income premium amount$31

Step 2: Compare the net earned income to the chart showing the FPL ranges to find the earned income premium amount.

DescriptionAmount
Net monthly earnings$1,250
Earned income premium amount$0

Step 3: Add the unearned income premium amount to the earned income premium amount to get the total monthly MBI premium amount.

DescriptionAmount
Unearned income premium amount$31
Earned income premium amount+ $0
Total monthly premium$31

Example 2

A person has $974 in monthly unearned income and $1,915 in monthly earned income after applying all deductions.

Step 1: Subtract the SSI federal benefit rate amount from the person's countable unearned income.

DescriptionAmount
Unearned income$974
SSI federal benefit rate– $943
Unearned income premium amount$31

Step 2: Compare the net earned income to the chart showing the FPL ranges to find the earned income premium amount.

DescriptionAmount
Net monthly earnings$1,915
Earned income premium amount$20

Step 3: Add the unearned income premium amount to the earned income premium amount to get the total monthly MBI premium amount.

DescriptionAmount
Unearned income premium amount$31
Earned income premium amount+$20
Total monthly premium$51

Example 3

A person has $1,500 in monthly unearned income and $1,889 in monthly earned income after applying all deductions.

Step 1: Subtract the SSI federal benefit rate amount from the person's countable unearned income.

DescriptionAmount
Unearned income$1,500
SSI federal benefit rate– $943
Unearned income premium amount$557

Step 2: Compare the net earned income to the chart showing the FPL ranges to find the earned income premium amount.

DescriptionAmount
Net monthly earnings$1,889
Earned income premium amount$20

Step 3: Add the unearned income premium amount to the earned income premium amount to get the total monthly MBI premium amount.

DescriptionAmount
Unearned income premium amount$557
Earned income premium amount+$20
Total monthly premium$577*

* The total of the unearned income premium amount plus the earned income premium amount is $577. However, the total monthly premium cannot exceed $500.

Related Policy

Budget Reference Chart, Appendix XXXI

M-8000, Medical Effective Date, Prior Months' Eligibility and Case Actions

M-8100, Medical Effective Dates

Revision 11-4; Effective December 1, 2011

The eligibility begin date for MBI is the first day of the first month in which a person meets all eligibility criteria and pays the required premium, if any is required. Eligibility is established in TIERS, but eligibility is not granted until the first premium is paid. Eligibility is in a suspended status until an MBI person pays the premium. Once the premium is paid, actual eligibility is granted

M-8200, Prior Month's Eligibility

Revision 11-4; Effective December 1, 2011

Eligibility for three prior months to the application month is available with this program.

The coverage date is determined by the application file date and the first premium amount the person chooses to pay. Since potential eligibility is determined up to three months prior to the application file month, the person has the option of choosing the months of coverage. Payments are applied to months in reverse chronological order, beginning with the current or the following month, backwards, up to three months prior.

Payment must be for a full month. Partial month payments will be refunded to the individual. Form H0052, Medicaid Buy-In Refund Notice, will be sent to the individual stating that partial payments are not accepted. The notice also will state that it can take up to 60 days for the refund.

M-8300, Case Actions

M-8310 Disposition

Revision 11-4; Effective December 1, 2011

Since MBI eligibility is determined in TIERS, an initial eligibility determination group (EDG) is created with a "Suspended" status. This will be used when the MBI EDG is approved for potential eligibility. The EDG status will be updated based on vendor communication. The EDG status will be updated to "Approved" when vendor communication confirms that at least one month's premium has been received. The EDG status will be updated to "Denied" when vendor communication confirms that the payment was not received by the due date. If the payment is received during the adverse action time period then the EDG is reopened.

M-8320 Eligibility Summary

Revision 16-4; Effective December 1, 2016

When the Medicaid Buy-In (MBI) potential eligibility EDG is disposed, Form TF0001, Notice of Case Action, is automatically sent to batch but must not be sent to the individual. Instead, the eligibility worker sends a manual Form H0053, Medicaid Buy-In Potential Eligibility Notice, containing the premium amount(s) and the premium due date. If the eligibility worker sends Form H0053 before cut-off, the premium payment is due at the end of the same month and is applied to the following month. If the individual does not make the first payment by the due date, deny the case.

On the first day of every month, TIERS automatically generates Form H0051, Medicaid Buy-In Premium Payment Notice, which is mailed directly to the individual. The notice has a coupon attached and a postage-paid envelope enclosed. The individual submits the premium payment, along with the coupon, by the due date. Failure to make the premium payment by the due date will cause the individual to be denied. Adverse action requirements pertain to MBI.

If an individual whose MBI eligibility was denied for failure to submit premium payments reapplies for MBI, the individual must pay all past due premium payments and current monthly payments to be reinstated into the program. All past due premiums and current premiums must be paid by the due date on Form H0053 sent to the individual for the reapplication.

Note: Premium payments must be received in the form of a check or a money order payable to MBI.

The premium payment address is:
Medicaid Buy-In
P.O. Box 650868
Dallas, TX 75265-9843

Once MBI receives the premium payment and the EDG is disposed, Form TF0001, Notice of Case Action, is automatically sent to batch but must not be sent to the individual. Instead, the eligibility worker sends a manual Form H0054, Medicaid Buy-In Eligibility Notice, containing the month(s) of eligibility and the corresponding premium amount(s) received.

M-8400, Initial Premium Due Dates

Revision 13-3; Effective September 1, 2013

The first premium payment is due based on the date of disposition.

  • If disposed before the current month's cutoff, the payment is due by the end of the disposition month.
  • If disposed after the current month's cutoff, the payment is due by the end of the following disposition month.

Example 1: Month of application: May. Prior months: April, March and February. If cutoff is May 15, and the MEPD Specialist disposes the case on May 11, the due date of all premiums for ongoing and all prior months (if the individual wants coverage for all) would be May 31,20XX. So payment is due for:

  • June – ongoing month and mandatory, must be paid first;
  • May – month of application and optional;
  • April – prior month one and optional;
  • March – prior month two and optional; and
  • February – prior month three and optional.

Note: If the individual wants those optional months, he or she must pay in reverse chronological order. This means the ongoing month must be paid first, then the previous month, then the month before that and so forth. Like the order in the example above.

Example 2: Month of application: May. Prior months: April, March and February. If cutoff is May 15, and the MEPD Specialist disposes the case on May 19, the due date of all premiums for ongoing and all prior months (if the individual wants coverage for all) would be June 30, 20XX. So payment is due for:

  • July – ongoing month and mandatory, must be paid first;
  • June – month after month of application and optional;
  • May – month of application and optional;
  • April – prior month one and optional;
  • March – prior month two and optional; and
  • February – prior month three and optional.

Note: If the individual wants those optional months, he or she must pay in reverse chronological order. This means the ongoing month must be paid first, then the previous month, then the month before that and so forth. Like the order in the example above.

M-8410 Ongoing Premium Due Dates

Revision 13-3; Effective September 1, 2013

Monthly premiums are due the end of each month. If payment is not received by the end of the month, the coverage will be terminated at the end of the following month.

  • If the remaining amount due is received two days prior to cutoff, then there is no interruption in coverage.
  • If the remaining amount due is received after the deadline for payment (two days before cutoff), the individual is denied and the payment will be applied to any unpaid months the individual received benefits.
  • Funds are to be applied to satisfy the ongoing month and any months premiums were not paid.
  • After 12 months from the denial for non-payment the individual can reapply without having to pay any unpaid premium.

Example 1: Payment Received Timely: The due date for the May premium is April 30, 20XX, and cutoff is May 15. If no payment is received by April 30, 20XX, the MEPD Specialist will send a manual denial notice to the individual on that date, but will NOT run eligibility (EDBC) and deny the case at that time. If payment IS received between the due date (end of previous month) and two days prior to cutoff (in this example, May 13, 20XX) there will be no disruption in coverage.

Example 2: Payment Not Received Timely: The due date for the May premium is April 30,20XX, and cutoff is May 15. If no payment is received by April 30, 20XX, the MEPD Specialist will send a manual denial notice to the individual on that date, but will NOT run eligibility (EDBC) and deny the case at that time. If payment IS NOT received by two days prior to cutoff (in this example, May 13, 20XX) the MEPD Specialist will run eligibility (EDBC) and deny the case on May 14, 20XX, and document it in case comments. No denial notice needs to be sent at this time because one was previously sent.

M-8411 Non-Sufficient Funds for Ongoing Cases

Revision 13-3; Effective September 1, 2013

Ongoing cases for MBI are certified or approved cases. Individuals are currently on the program as they have made premium payments. Their EDG is in approved status.

The vendor will notify the individual through written notice of non-sufficient funds (NSF) when they occur. The vendor notifies the MEPD Specialist if non-sufficient funds occur.

  • If payment is not rectified and received within the adverse action period (two days before next month's cutoff), it will be treated as a non-payment and the case denied.
  • If the individual makes a replacement payment within the adverse action period (two days before cutoff), there will be no disruption in benefits.
  • If the individual makes a replacement payment after the adverse action period (two days before cutoff) the case will be denied and the payment will be applied to any unpaid months where benefits were received. If there is any remaining payment, it will be refunded to the individual.

M-8412 Non-Sufficient Funds for Suspended Eligible Cases

Revision 13-3; Effective September 1, 2013

Suspended-eligible cases are cases where benefits have not been approved due to pending premium payments. The EDG stays in suspended status until payment is made, eligibility is determined and the case is disposed.

If the premium is not paid because of non-sufficient funds (NSF), the vendor will notify the individual through written notice of non-sufficient funds. The vendor notifies the MEPD Specialist if NSF occurs.

  • If no replacement payment is made, benefits will not be granted and the case will be denied.
    • Example – Cutoff is June 20, 20XX. The MES disposes the case on June 10, 20XX. The premium payment is due June 30, 20XX. If no premium payment is received by June 30, 20XX, the case is denied.
  • If the individual makes a replacement payment prior to the due date (end of the month) benefits will be granted.
    • Example A – Cutoff is June 20, 20XX. The MES disposes the case on June 10, 20XX. The Premium payment is due June 30, 20XX. The Premium payment received June 15, 20XX. On June 22, 20XX, vendor notifies MEPD the payment was NSF. The individual replaces/rectifies the premium on June 25, 20XX. MES approves the case and benefits granted.
    • Example B – Cutoff is June 20, 20XX. MES disposes the case on June 22, 20XX (after cutoff). The Premium payment is due July 31, 20XX. The Premium payment is received July 1, 20XX. On July 10, 20XX, the vendor notifies MEPD the payment was NSF. The individual replaces/rectifies the premium on July 15, 20XX. MES approves the case and benefits granted.
    • Note: The individual has to pay the ongoing month first, then any optional month, such as prior months, if this was an application.
  • If the individual makes a replacement payment after the due date (end of the month) benefits will be denied and payment will be refunded.
    • Example — Cutoff is June 20, 20XX. The MES disposes the case on June 10, 20XX. The Premium payment is due June 30, 20XX. The Premium payment is received June 15, 20XX. On June 20, 20XX, the vendor notifies the MEPD the payment was NSF. The individual sends a replacement premium on June 25, 20XX, but it is not received until July 5, 20XX. MES denies the case and benefits on June 30, 20XX. The monies are refunded to the individual.

Note: If the NSF notification is received after the due date (end of the month), ongoing rules will apply.

Example – Cutoff is June 20, 20XX. The MES disposes the case on June 10, 20XX. The individual received notice to pay the premium on June 20, 20XX. The premium is received on June 30, 20XX; the vendor notifies MEPD and MES approves the case. On July 4, 20XX, the vendor notifies MEPD the payment is NSF. Because the NSF notification was received after the due date – end of the month – MES must use the ONGOING policy. See M-8411,Non-Sufficient Funds for Ongoing Cases.

M-8420 Premium Payment Notices

Revision 15-3; Effective September 1, 2015

On the first day of every month, TIERS automatically generates Form H0051, Medicaid Buy-In Premium Payment Notice, which is mailed directly to the person. The notice has a coupon attached and a postage-paid envelope enclosed. The person submits the premium payment, along with the coupon, by the due date. Failure to make the premium payment by the due date will cause the person to be denied. Adverse action requirements pertain to MBI. A person whose MBI eligibility is denied for failure to submit premium payments must pay all past due premium payments and current monthly payments to be reinstated into the program.

Note: Premium payments must be received in the form of a check or a money order payable to MBI.

The premium payment address is:
MBI
P.O. Box 650868
Dallas, TX 75265-0868

Once MBI receives the premium payment and the EDG is disposed, Form TF0001, Notice of Case Action, is automatically sent to batch but must not be sent to the person. The eligibility worker sends a manual Form H0054, Medicaid Buy-In Eligibility Notice, containing the month(s) of eligibility and the corresponding premium amount(s) received.

M-8430 Presidential-Declared Emergency (PDE)

Revision 12-1; Effective March 1, 2012

A PDE hardship exemption will automatically be granted to recipients living in the declared area and premiums waived for three months. Recipients do not have to request a hardship for PDE. TIERS will send an "emergency special notice" to inform recipients at the start of the PDE period that the premiums have been waived. There is no limit to how many PDEs for which a recipient may have premiums waived; however, a recipient may only have up to three months of premiums waived once per emergency.

For MBI recipients, the waiver of premiums for a PDE begins in the month in which the emergency is declared and continues forward for a total of three consecutive months. Premiums for retroactive months will not be waived. Any premiums received and applied to a month in which a PDE is in effect will be refunded.

Example 1: A PDE is declared for March through May. Premiums may be waived for March, April and/or May. Premiums may be waived for one, two or three months, depending on the date the person is approved for MBI.

Example 2: The PDE period is declared for March through May.

March is the month in which the MBI application is received by HHSC. On April 18, the individual residing in a PDE area is approved for MBI. The individual is eligible to have monthly premiums waived for April and May.

Example 3: The PDE period may be longer than three months (e.g., declared in March, extended through July – five months).

Regardless of the length of the PDE, the recipient may only have premiums waived for three consecutive months (e.g., March, April and May), regardless of the PDE time period. In the third month for which premiums have been waived, Form H0051, Medicaid Buy-in Premium Payment Notice, which has a payment coupon attached, should be mailed no later than the 20th requesting payment for the month of June, even though the emergency period has not ended.

M-8500, Denial Reasons

Revision 21-1; Effective March 1, 2021

In addition to the MEPD denial codes for all programs, there are eleven denial reasons specific to the MBI program. The correct reason for denial must be manually entered in the case comments section of Form TF0001, Notice of Case Action, before the system generates and sends out the notice. Use the following denial reasons for MBI as appropriate.

  1. You failed to pay your MBI premium by the due date.
  2. Your Independence Account is a countable resource from <mmddyy> through <mmddyy> for one or more of the following reasons:
    • Money was used for non-health care or non-work related expenses.
    • Deposits exceed 50% of your earnings for the Social Security Administration qualifying quarter.
    • Deposits are from sources other than earnings or interest earned on this account.
    • Deposits include income from another individual.
  3. Your countable income increased because you did not pay a designated impairment-related work expense (IRWE) with your income.
  4. Your countable income increased because you did not pay a designated blind work-related expense (BWE) with your income.
  5. The resources excluded as part of your Plan to Achieve Self-Support (PASS) are now countable because you have not met the goal dates in your PASS.
  6. The resources excluded as part of your PASS are now countable because funds have not been set aside as agreed.
  7. The resources excluded as part of your PASS are now countable because funds have not been spent as agreed.
  8. The income excluded as part of your PASS is now countable because you have not met the goal dates in your PASS.
  9. The income excluded as part of your PASS is now countable because funds have not been set aside as agreed.
  10. The income excluded as part of your PASS is now countable because funds have not been spent as agreed.
  11. You did not meet the requirements of completing a Social Security Administration Qualifying Quarter.

M-8510 Redeterminations

Revision 11-4; Effective December 1, 2011

Redeterminations for MBI follow regular MEPD policy for redeterminations.

Streamlining methods and passive reviews are not allowed for an MBI redetermination.

M-8520 Appeals

Revision 13-1; Effective March 1, 2013

HHSC is responsible for all appeals including those concerning premiums.

If an individual is dissatisfied with HHSC's decision concerning his eligibility for medical assistance, he 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.

M-9000, Notices and Forms

Revision 21-4; Effective December 1, 2021

Application

Form H1200-MBI, Application for Benefits – Medicaid Buy-In. 

Application form for the Medicaid Buy-In (MBI) program. MBI applicants may also submit Form H1200, Application for Assistance — Your Texas Benefits, and write in “MBI” on the top of the form.

Missing Information

Form H1020, Request for Information or Action

Use to request missing information or verification.

Certification

Use Form H0053, Medicaid Buy-In Potential Eligibility Notice, to notify an applicant of potential eligibility for the MBI program. 

Use Form H0054, Medicaid Buy-In Eligibility Notice, to notify an applicant of eligibility for the MBI program. 

Complete the form by entering the benefit month(s), the certified person, the monthly premium amount(s), the premium due date and all other required information. 

Note: After the MBI potential eligibility EDG is disposed, Form TF0001, Notice of Case Action, is automatically generated. Do not send the TF0001 to the applicant as the system-generated notice has incorrect information.  Suppress the TF0001 and send a manual Form H0053. The Form H0053 provides instructions on how MBI recipients send in their first premium payment.
 

Denials

Form TF0001 is automatically generated and sent to batch when an MBI EDG is denied. Staff must confirm the Form TF0001 includes the correct MBI denial reason. If the incorrect reason is listed, manually add the correct reason for denial in the comments section before generating the Form TF0001. 

Case in Ongoing Mode (Approved or Denied)

Form H0054, is used to notify a recipient of receipt of their premium payment, months of coverage and premium amount received.  
 

Related Policy

Missing Information Due Dates, B-6420
Denials, B-6500
Denial Reasons, M-8500
MBI Screening Tool and Worksheet, Appendix XXXIX

M-9100, Replacement Medicaid Card

Revision 22-3; Effective September 1, 2022

A recipient will only receive one Your Texas Benefits Medicaid card, which is intended to be the recipient’s permanent card. A recipient’s Your Texas Benefits Medicaid card will only be replaced if the card is damaged, lost or stolen. 

Related Policy

Your Texas Benefits Medicaid Card, R-2300