Chapter N, Medicaid Buy-In for Children

N-1000, Medicaid Buy-In for Children

Revision 18-1; Effective March 1, 2018

 

N-1100 Texas Administrative Code Rules

Revision 11-2; Effective June 1, 2011

 

§361.101. Overview and Purpose.

(a) This chapter governs the eligibility requirements for Medicaid Buy-In for Children (MBIC), which is authorized under §531.02444 of the Texas Government Code. MBIC provides Medicaid benefits under the option explained in §1902(cc) of the Social Security Act (42 U.S.C. §1396a(cc)).

(b) MBIC is a Medicaid buy-in program for children with disabilities administered by the Texas Health and Human Services Commission (HHSC). It provides Medicaid benefits to eligible children with disabilities who are not eligible for Supplemental Security Income (SSI) for reasons other than disability. A child does not have to have applied for SSI in order to meet eligibility requirements for MBIC.

(c) Nothing in these rules shall be construed to violate the maintenance of eligibility requirements of section 5001 of the American Recovery and Reinvestment Act of 2009 (Public Law 111-5) and make eligibility standards, methodologies, or procedures under the Texas State Plan for Medical Assistance (or any waiver under section 1115 of the Social Security Act (42 U.S.C. §1315)) more restrictive than the eligibility standards, methodologies, or procedures, respectively, under such plan (or waiver) that were in effect on July 1, 2008.

 

§361.103. Definitions.

The following words and terms, when used in this chapter, have the following meanings, unless the context clearly indicates otherwise:

(1) Applicant — A person seeking Medicaid benefits under MBIC who is not currently receiving Medicaid services.

(2) Authorized representative — An individual:

(A) who assists and represents a person in the application or eligibility redetermination process, and who is familiar with that person and that person's financial affairs; or

(B) who is a representative payee for an applicant or recipient for another federal benefit.

(3) CFR — Code of Federal Regulations.

(4) Child — An unmarried person under 19 years of age.

(5) Child with disabilities — A child who meets the Supplemental Security Income (SSI) program's definition of disability for children, as explained in 20 CFR §416.906.

(6) Eligibility certification month — Month in which MBIC eligibility is established.

(7) Family — A unit consisting of an applicant or recipient and the applicant's or recipient's parents and siblings who live in the same household as the applicant or recipient.

(8) Federal Poverty Level (FPIL) — The household income guidelines issued annually and published in the Federal Register by the U.S. Department of Health and Human Services. Percentages of these guidelines are used to determine income eligibility for MBIC and certain other public assistance programs. In other programs, the FPIL may be referred to as the Federal Poverty Income Level or the Federal Poverty Guidelines.

(9) HHSC — The Texas Health and Human Services Commission.

(10) Income — Funds a person receives that can be used to meet his or her need for food or shelter.

(11) In-kind support and maintenance — The value of food or shelter furnished to an applicant's or recipient's family.

(12) Intermediate care facility for persons with mental retardation (ICF/MR) — A Medicaid-certified facility that provides care in a 24-hour specialized residential setting for persons with mental retardation or a related condition. An ICF/MR includes a state supported living center and a state center.

(13) MBIC — Medicaid Buy-In for Children. A Medicaid buy-in program that provides Medicaid benefits to children with disabilities who are not eligible for SSI for reasons other than disability.

(14) Medicaid — A state and federal cooperative program, authorized under Title XIX of the Social Security Act and the Texas Human Resources Code, that pays for certain medical and health care costs for people who qualify. Also known as the medical assistance program.

(15) Parent — A child's natural or adoptive parent or the spouse of the natural or adoptive parent.

(16) Premium — A monthly payment to be made by a family to HHSC or its designee to buy MBIC coverage.

(17) Recipient — A person receiving Medicaid benefits under MBIC, including a person whose Medicaid eligibility is being redetermined.

(18) Sibling — A child's unmarried brother or sister (natural, adoptive, or step).

(19) U.S.C. — United States Code.

 

§361.105. Applying and Providing Information.

(a) A person or the person's authorized representative applies for MBIC by completing an application prescribed by HHSC and submitting it to HHSC in accordance with HHSC instructions. The date of receipt of the completed signed application by HHSC is the application filing date, which establishes the application month explained in §361.119 of this chapter (relating to Medical Effective Date).

(b) An applicant or authorized representative must provide HHSC with all requested documentation and information that HHSC determines is necessary to make an eligibility determination or calculate a monthly premium. If the applicant or authorized representative fails or refuses to provide requested information by the date specified in a written request from HHSC, HHSC may deny the application for failure to furnish information. When this occurs but the person later provides the requested information, the date that the requested information is provided to HHSC becomes the application filing date explained in subsection (a) of this section.

(c) HHSC notifies a recipient in writing when it is time to redetermine the recipient's eligibility. This usually occurs once per year, although HHSC may require a person to send in documentation and information more often if HHSC determines that a special review of the person's eligibility is appropriate. A recipient must provide requested documentation and information when HHSC sends written notice of the requirement to the recipient's case address of record. The written notice explains the deadline to provide the information. If a recipient fails to provide the information by the deadline stated in the written notice, HHSC may terminate the recipient's MBIC eligibility.

(d) An applicant or recipient must report to HHSC within 10 calendar days any information that may impact the person's eligibility or monthly premium amount, in accordance with 42 U.S.C. §1383(e)(1)(A).

 

§361.107. Nonfinancial Requirements.

(a) Citizenship, immigration status, and residency. To be eligible for MBIC, a child must meet the citizenship, immigration status, and residency requirements in Chapter 358, Subchapter B of this title (relating to Nonfinancial Requirements).

(b) Disability. To be eligible for MBIC, a child must meet the Supplemental Security Income program's definition of disability for children, as explained in 20 CFR §416.906.

(c) Age. A child is eligible for MBIC through the month of his or her 19th birthday, if the child meets all other eligibility criteria.

(d) Marital status. To be eligible for MBIC, a child must not be married.

(e) Living arrangement.

(1) An applicant or recipient must not reside in a public institution, including a jail, prison, reformatory, or other correctional or holding facility, as defined in 42 CFR §435.1009 and §435.1010.

(2) If a recipient enters a nursing facility or intermediate care facility for persons with mental retardation, HHSC does not process the denial of MBIC Medicaid until eligibility for the appropriate institutional Medicaid program is determined.

(f) Social security number. In accordance with 42 CFR §435.910, a child or the child's authorized representative must give the child's social security number to HHSC as a condition of eligibility for MBIC.

(g) Application for other benefits. To be eligible for MBIC, a child or the child's authorized representative must apply for and obtain, if eligible, all other benefits to which the child may be entitled, in accordance with 42 U.S.C. §1382(e)(2).

 

§361.109. Third-party Resources.

Medicaid is considered the payor of last resort for a person's medical expenses. As a condition of eligibility, in accordance with 42 CFR §§433.138 - 433.148, an applicant or recipient must:

(1) assign to HHSC the applicant's or recipient's right to recover any third-party resources available for payment of medical expenses covered under the Texas State Plan for Medical Assistance; and

(2) report to HHSC any third-party resource within 60 days after learning about the third-party resource.

 

§361.111. Income.

(a) To be eligible for MBIC, a child's family must have monthly countable income less than or equal to 150% of the Federal Poverty Level (FPIL).

(b) Countable income means:

(1) earned income for purposes of the Supplemental Security Income (SSI) program minus all applicable exclusions and exemptions, as explained in 20 CFR §§416.1110 - 416.1112; and

(2) unearned income for purposes of the SSI program minus all applicable exclusions and exemptions, as explained in 20 CFR §§416.1120 - 416.1124, except HHSC does not count in-kind support and maintenance as income.

(c) To determine the family's monthly countable income, HHSC counts the income of the child applying for or receiving MBIC, the income of the child's parents living in the same household as the child, and the income of the child's ineligible siblings living in the same household as the child.

(1) For a stepparent's income to count, the stepparent must be the current husband or wife of a natural or adoptive parent living in the same household as the child and the natural or adoptive parent.

(2) A sibling's income counts through the month of the sibling's:

(A) 18th birthday; or

(B) 22nd birthday, if the sibling is, as determined by HHSC, regularly attending school, college, or job training.

(3) HHSC calculates the family's monthly countable income as follows:

(A) Total the following:

(i) Monthly countable income of the child applying for or receiving MBIC.

(ii) Combined monthly countable income of the child's parents.

(iii) Countable monthly income of each of the child's ineligible siblings that is in excess of 150% of the FPIL for a household of one, multiplied by 2, plus $85.

(B) Subtract $85 from the total arrived at in subparagraph (A) of this paragraph.

(C) Divide the total arrived at in subparagraph (B) of this paragraph by 2.

 

§361.113. Employer-sponsored Health Insurance.

As a condition of a child's eligibility for MBIC, a parent of an applicant or recipient living in the same household as the applicant or recipient must apply for, enroll in, and pay any required premiums for an employer-sponsored health insurance plan, if the parent's employer:

(1) offers family coverage under a group health plan that covers the applicant or recipient; and

(2) contributes at least 50 percent of the total cost of annual premiums.

 

§361.115. Cost Sharing.

(a) Monthly premium requirements for the months after the eligibility certification month. After HHSC establishes MBIC eligibility, HHSC or its designee sends the recipient written notice of the monthly premium amount and the due date for the monthly premium payment. HHSC provides a grace period of 60 days from the date on which the monthly premium is past due for the recipient to pay the monthly premium, in accordance with 42 U.S.C. §1396o(i)(3). If HHSC does not receive a monthly premium payment within the grace period, then HHSC terminates MBIC eligibility, effective the first day of the month after the grace period ends.

(b) Monthly premium requirements for the three months prior to the application month. As described in §361.119 of this chapter (relating to Medical Effective Date), an applicant may receive MBIC coverage for up to three months prior to the application month if the applicant meets the MBIC eligibility requirements. A month prior to the application month is a retroactive month. Prior to certifying MBIC eligibility for a retroactive month, HHSC or its designee sends the applicant written notice of the monthly premium amount for each eligible retroactive month and the due date for the monthly premium payment. HHSC provides the applicant at least 60 days to submit the premium payment for eligible retroactive months, in accordance with 42 U.S.C. §1396o(i)(3). HHSC or its designee must receive, by the due date, a full premium payment for at least one of the eligible retroactive months to certify MBIC eligibility for a retroactive month. If HHSC or its designee receives a premium payment that is less than the total amount due for all of the eligible retroactive months, then HHSC or its designee applies the amount to the eligible retroactive months in reverse chronological order.

(c) Monthly premium amounts. HHSC determines the monthly premium amounts on a sliding scale based on total monthly income as described in §361.111(c)(3)(A) of this chapter (relating to Income).

(1) For a recipient who is not enrolled in employer-sponsored health insurance, HHSC establishes full monthly premium amounts, up to the maximum amounts allowed by federal law.

(2) For a recipient who is enrolled in employer-sponsored health insurance and who receives premium assistance from HHSC under §1906 of the Social Security Act (42 U.S.C. §1396e), HHSC establishes reduced monthly premium amounts.

(d) Monthly premium amounts for a family with more than one MBIC recipient. If there is more than one MBIC recipient in a family, the family pays only one monthly premium amount.

(e) Undue hardship waivers. HHSC may, in its discretion, waive monthly premiums for undue hardship. HHSC determines eligibility for the undue hardship waivers described in paragraphs (1), (2), and (3) of this subsection based on information provided at application or information provided as described in §361.105 of this chapter (relating to Applying and Providing Information). A recipient must apply for the undue hardship waiver described in paragraph (4) of this subsection. HHSC does not waive monthly premiums for any months prior to the application month.

(1) A recipient who is an American Indian or Alaska Native as defined in 25 U.S.C. §§1603(c), 1603(f), 1679(b) or who has been determined eligible, as an Indian, pursuant to 42 CFR §136.12 or Title V of the Indian Health Care Improvement Act, to receive health care services is exempt from monthly premiums for the duration of enrollment in MBIC.

(2) A recipient who is enrolled in employer-sponsored health insurance, as determined by HHSC, and who does not receive premium assistance from HHSC under §1906 of the Social Security Act (42 U.S.C. §1396e) is exempt from monthly premiums for MBIC as long as the recipient remains enrolled in employer-sponsored health insurance and is not receiving premium assistance.

(3) A recipient residing in a federally declared disaster area is exempt from monthly premiums for three months beginning with the month in which the disaster is declared. A recipient may only receive one undue hardship waiver per disaster.

(4) A recipient or authorized representative may apply for an undue hardship waiver for loss of income.

(A) HHSC may grant an undue hardship waiver for loss of income if the loss of income is due to:

(i) termination of employment because of a layoff or business closing;

(ii) an involuntary reduction in work hours;

(iii) a parent leaving the household because of divorce or separation; or

(iv) a parent's death.

(B) A recipient who is determined by HHSC to be eligible for an undue hardship waiver for loss of income may be exempt from monthly premiums for three months.

(C) A recipient may only receive one undue hardship waiver for loss of income per 12 months.

(D) An undue hardship waiver for loss of income begins the first month for which HHSC or its designee did not receive a premium payment for the recipient.

(f) Cost-share limits. A recipient is exempt from monthly premiums for the remainder of the coverage period when the cost-share expenditures for the recipient reach the cost-share limit. HHSC determines the cost-share limit for a recipient, up to the maximum allowed by 42 U.S.C. §1396o(i)(2)(A).

(g) Tracking cost-share expenditures. For a recipient without employer-sponsored health insurance, HHSC or its designee determines when MBIC premium payments reach the cost-share limit. A recipient with employer-sponsored health insurance must track cost-share expenditures on the form provided by HHSC or its designee and report to HHSC or its designee when the annual cost-share limit is reached. Eligible cost-share expenditures include the monthly premiums for MBIC and cost sharing for employer-sponsored health insurance. HHSC or its designee:

(1) computes the cost-share limit for each recipient and informs the recipient of the cost-share limit at enrollment;

(2) provides the recipient with a form for keeping track of monthly premiums for MBIC and cost sharing for employer-sponsored health insurance; and

(3) provides a refund if HHSC receives a monthly premium payment that causes the recipient to exceed the cost-share limit.

The provisions of this §361.115 adopted to be effective January 1, 2011, 35 TexReg 11572

 

§361.117. Notice of Eligibility Determination and Right to Appeal.

(a) After making an eligibility determination on an initial application, HHSC sends the applicant:

(1) a written notice of eligibility, including notice of any monthly premium requirements and the medical effective date described in §361.119 of this chapter (relating to Medical Effective Date); or

(2) a written notice of ineligibility and the reason for the decision.

(b) After making an eligibility determination or redetermination, HHSC sends the recipient a written notice of any change in eligibility or monthly premium requirement.

(c) The written notice informs the applicant or recipient of the right to request a hearing to appeal HHSC's decision. The hearing is held in accordance with 42 CFR Part 431, Subpart E and HHSC's fair hearing rules in Chapter 357 of this title (relating to Hearings).

 

§361.119. Medical Effective Date.

(a) Beginning with the three months before the application month, except as described in subsection (b) of this section, the medical effective date for MBIC coverage is the first day of the first month in which a person meets all eligibility criteria.

(b) The medical effective date for MBIC cannot predate January 1, 2011.

 

N-1200 Program Overview

Revision 16-1; Effective March 1, 2016

 

The Medicaid Buy-In for Children (MBIC) program is a Medicaid program for children with disabilities up to the age of 19 with family income up to 300 percent of the federal poverty level (FPIL). A family may have to pay a monthly premium as a condition of eligibility. The amount of the premium is based on the family’s income and whether an applicant/recipient is covered under a parent's employer-sponsored health insurance plan. For a definition of terms used for MBIC, see the Glossary.

MBIC recipients receive regular Medicaid benefits, a Medicaid ID card and an MBIC member handbook. The handbook is a guide that has basic information about MBIC. It explains what to do if an applicant/recipient has questions or needs help while in the program.

All regular Medicaid for the Elderly and People with Disabilities (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 specifically for MBIC; therefore, follow regular MEPD policies for citizenship and Texas residency.

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

 

N-1300 Medicaid Buy-In for Children (MBIC) and Other Programs

Revision 11-3; Effective September 1, 2011

 

 

N-1310 MBIC and Nursing Facilities

Revision 11-3; Effective September 1, 2011

 

Medicaid Buy-In for Children (MBIC) is a community-based program. If an MBIC recipient enters a nursing facility or intermediate care facility for persons with mental retardation, contact the authorized representative to determine if the facility stay will be less than 90 days. MBIC will remain active in the Texas Integrated Eligibility Redesign System (TIERS) and will pay for nursing facility stays of less than 90 days. TIERS will track the 90 days and notify MEPD specialists via a task before the 90th day.

If the facility stay is going to be more than 90 days, obtain a new Form H1200, Application for Assistance – Your Texas Benefits, gather any additional eligibility verifications needed and complete the program transfer.

 

N-1320 MBIC and Home and Community-Based Services Waivers

Revision 18-1; Effective March 1, 2018

 

Home and Community-Based Services waiver services (for example, Community Living Assistance and Support Services) are not paid under the MBIC systems eligibility codes. Therefore, if a referral for waiver services is received, obtain a new Form H1200, gather any additional verification needed to determine eligibility for ME-Waivers and complete a program transfer if all eligibility criteria are met.

 

N-1330 MBIC and Medicare Savings Programs

Revision 11-3; Effective September 1, 2011

 

An MBIC-eligible applicant/recipient can also have:

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

An MBIC-eligible applicant/recipient cannot have:

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

Reminder: Resource information is required for Medicare Savings Programs (MSP). Parental deeming of income and resources and support and maintenance applies to MSP.

 

N-1340 Medicaid Estate Recovery Program (MERP)

Revision 11-3; Effective September 1, 2011

 

Due to the age of these recipients, the Medicaid Estate Recovery Program (MERP) does not apply to MBIC.

 

N-2000, Automation

Revision 11-3; Effective September 1, 2011

 

Medicaid Buy-In for Children (MBIC) is worked only in the Texas Integrated Eligibility Redesign System (TIERS) and is type of assistance "TA-88." The program name displays as "ME-MBIC."

The TIERS system will do the eligibility budgeting and premium calculations for this program. However, staff need to understand the policy.

 

N-3000, Non-Financial

Revision 13-2; Effective June 1, 2013

 

All regular, non-financial Medicaid for the Elderly and People with Disabilities (MEPD) policies apply to Medicaid Buy-In for Children (MBIC), except those specifically identified in this chapter.

Non-financial requirements apply only to an MBIC applicant/recipient.

Note: In the eligibility system, list the parent/guardian of the MBIC child as the head of household. The parent/guardian also needs to be listed as the alternate payee as well as the EDG name. This is primarily for any premium reimbursements and managed care purposes.

 

N-3100 Date of Birth

Revision 11-3; Effective September 1, 2011

 

Although MEPD policy does not require a date of birth for an applicant/recipient's family members, the Texas Integrated Eligibility Redesign System (TIERS) requires an entry in the date of birth (DOB) field for all members of the family unit for file clearance purposes. If a non-MBIC family unit member does not provide a DOB, use a default DOB of 02-29-1988. The date will automatically make any siblings' age over 22 so they will not be included in either the family unit or budget group. Do not request the DOB for a non-MBIC family member if it is not provided.

 

N-3200 Age

Revision 11-3; Effective September 1, 2011

 

Eligibility is available through the end of the month of the child's 19th birthday. If an application is received in the month of the 19th birthday, process the MBIC application and determine eligibility for that month and the three months prior to that application.

Example: Application is received on April 5. Applicant turns 19 on April 17. Determine eligibility for the application month of April and three prior months of January, February and March.

 

N-3300 Disability

Revision 11-3; Effective September 1, 2011

 

An applicant/recipient must meet the Supplemental Security Income (SSI) definition of disability. If an applicant/recipient has not had a disability determination made by the Social Security Administration, use HHSC's Disability Determination Unit for disability determinations. Follow regular MEPD policy for disability determinations.

 

N-3400 Marital Status

Revision 11-3; Effective September 1, 2011

 

An applicant/recipient must not be married.

 

N-3500 School or Job Training Attendance

Revision 11-3; Effective September 1, 2011

 

Verification of school or job training attendance for siblings age 18 through age 22 is required.

 

N-4000, Resources and Income

Revision 11-3; Effective September 1, 2011

 

All regular Medicaid for the Elderly and People with Disabilities (MEPD) policies for income apply to this program, except those specifically identified in this chapter.

 

N-4100 Resources

Revision 11-3; Effective September 1, 2011

 

There is no resource test for this program.

There is no parental deeming of resources for this program.

 

N-4200 Income

Revision 11-3; Effective September 1, 2011

 

Even though there is no resource test for this program, the income from income-producing resources is considered. Determine if the income from income-producing resources is countable using regular MEPD policy.

There is no support and maintenance considered for Medicaid Buy-In for Children. Do not develop support and maintenance.

There is no parental deeming of income for this program.

 

N-5000, Employer-Sponsored Health Insurance (ESI)

Revision 11-3; Effective September 1, 2011

 

As a condition of an applicant's/recipient's eligibility for Medicaid Buy-In for Children (MBIC), a parent living in the same household as the applicant/recipient must apply for, enroll in and pay any required premiums for employer-sponsored health insurance (ESI) if:

  • the parent is actively employed, and
  • the parent's employer offers ESI that meets the following criteria:
    • the ESI is a group health plan that covers the applicant/recipient, and
    • the employer contributes at least 50 percent of the total cost of annual premiums.

 

N-5100 ESI Chart

Revision 11-3; Effective September 1, 2011

 

The following chart outlines the eligibility treatment for various situations involving ESI:

 

If Then
A parent living in the same household as the applicant/recipient has a job that offers ESI that meets the criteria but (1) the parent is not enrolled in the ESI and (2) there is a future open enrollment period during which the parent can enroll. Certify an applicant for MBIC if all other eligibility criteria are met. On the ESI Details screen, use "Is there an open enrollment period?" and "open enrollment start date" fields to monitor.
A parent living in the same household as the applicant/recipient has a job that offers ESI that meets the criteria but (1) the parent is not enrolled in the ESI and (2) enrollment is available to the parent at the time of application. Do not certify the applicant for MBIC until the parent's enrollment in ESI is verified.
A parent living in the same household as the applicant/recipient has only unearned income (such as retirement or pension) or self-employment income. ESI is not an eligibility requirement.
A parent not living in the same household as the applicant/recipient has health insurance that covers the applicant or recipient. Example: A father living outside the household that is legally required to carry insurance on the applicant/recipient. Consider that parent's insurance as a third-party resource (TPR). Follow regular Medicaid for the Elderly and People with Disabilities (MEPD) policy for TPR.
A parent living in the same household as the applicant/recipient has ESI that meets the criteria and a parent not living in the same household as the applicant/recipient has health insurance that covers the applicant or recipient. The parent living in the same household as the applicant/recipient still must apply for, enroll in and pay any required premiums for the ESI. Follow regular MEPD policy for TPR for the other parent's insurance.
An applicant or recipient works and has employer-sponsored health insurance. Consider the applicant's/recipient's health insurance as TPR. Follow regular MEPD policy for TPR.
A parent living in the same household as the applicant/recipient has begun the enrollment process for ESI, but the employer needs more time to complete the enrollment. Verify the approximate date of the enrollment decision and certify the applicant for MBIC if all other eligibility criteria are met. On the ESI Details screen, use the "Decision enrollment pending" and "potential insurance follow up date" fields to monitor.
A parent living in the same household as the applicant/recipient voluntarily withdraws from ESI after enrollment. Deny or terminate the applicant/recipient following regular MEPD policy. Client statement is acceptable verification for voluntary withdrawal from ESI

 

N-6000, Budgeting

Revision 21-2; Effective June 1, 2021

 

N-6100 Budgeting Concepts

Revision 11-3; Effective September 1, 2011

 

Medicaid Buy-In for Children (MBIC) has two budgeting concepts: family unit and budget group.

Family unit is used to determine the appropriate federal poverty level (FPIL) to use as an income limit. Budget group is used to determine the countable income of the family unit to compare to the FPIL for eligibility. Budget group is further defined in Section N-6340, Determining the Budget Group.

The total number of members in the family unit is used in eligibility income budgeting to determine the income limit for the family.

 

N-6200 Determining the Family Unit

Revision 15-4; Effective December 1, 2015

 

To determine a family unit, count the:

  • MBIC applicant or recipient, and
  • applicant's or recipient's parents living in the same household (see definition of parent in the Glossary), and
  • applicant's or recipient's siblings (eligible or ineligible) living in the same household (see definition of sibling in the Glossary).

For a stepparent to be included in the family unit and the stepparent’s income to be considered in the budget group, a stepparent must:

  • be the current spouse of a natural or adoptive parent, and
  • live in the same household as the MBIC applicant or recipient and the natural or adoptive parent.

If neither a stepparent nor the stepparent's income is considered because these criteria are not met, do not consider a stepsibling or their income.

 

N-6210 School or Job Training

Revision 11-3; Effective September 1, 2011

 

School or job training attendance must be verified before including an ineligible sibling between the ages of 18 and 22 in the family unit. If the family unit does not provide verification of school or job training attendance, don't count the ineligible sibling in either the family unit or budget group.

 

N-6220 Absences Due to Active Duty Military Assignments

Revision 11-3; Effective September 1, 2011

 

Consider absences due to active duty military assignments as temporary and consider that individual as part of the family unit and budget group.

 

N-6300 Eligibility Income Budgeting

Revision 13-4; Effective December 1, 2013

 

Eligibility income budgeting for Medicaid Buy-In for Children (MBIC) is different from other MEPD programs. As stated in the beginning of Chapter N, Medicaid Buy-In for Children, the family gross income must not exceed 300 percent of the FPIL. However, due to substantial income exclusions, the income limit used for eligibility is equal to or less than 150 percent FPIL for the family unit size. Each case may have a different income limit. See Appendix XXXI, Budget Reference Chart, for 150 percent FPIL and 300 percent FPIL amounts.

 

N-6310 Income Treatment

Revision 11-3; Effective September 1, 2011

 

Treat earned and unearned income the same in MBIC budgeting. Do not deduct:

  • the $20-general exclusion, or
  • the earned income exclusion of $65 plus one-half of the remaining income.

 

N-6320 MBIC Income Exclusion

Revision 11-3; Effective September 1, 2011

 

The MBIC income exclusion is $85 plus one-half of the remaining income and is deducted at the end of the budget calculation.

 

N-6330 Ineligible Sibling Exclusion

Revision 21-2; Effective June 1, 2021

 

Allow an exclusion from an ineligible sibling's income before counting the ineligible sibling's income in the eligibility budget. Allow this exclusion for each ineligible sibling in the family unit. Follow these steps to find the ineligible sibling exclusion:

  • Use 150 percent FPL for a family of one.
  • Multiply that figure by 2.
  • Add $85.

The total amount from these steps is the ineligible sibling's exclusion amount. Effective March 2021, this amount is $3,305. Deduct this amount from the ineligible sibling's total income. Count in the budget the ineligible sibling's excess income after the exclusion. If the ineligible sibling's income is less than the total exclusion, disregard all the ineligible sibling's income in the budget.

 

N-6340 Determining the Budget Group

Revision 15-4; Effective December 1, 2015

 

The budget group is determined by identifying the members of the family unit whose income is countable in the eligibility budget. The number of people in the family unit and in the budget group may be different.

Do not count any of the income of a family unit member that:

  • has needs-based income, such as veteran's pension or Supplemental Security Income (SSI); or
  • is a Medicaid-eligible person, such as another MBIC applicant/recipient in the household.

For a stepparent's income to count, the stepparent must:

  • be the current spouse of a natural or adoptive parent, and
  • live in the same household as the MBIC applicant or recipient and the natural or adoptive parent.

If a stepparent's income is not considered because these criteria are not met, do not consider a stepsibling's income either.

Reminders:

  • If school or job training attendance has not been verified for an ineligible sibling between ages 18 and 22, that sibling is not part of the family unit and, therefore, is not included in the budget group.
  • Consider absences due to active military assignments as temporary and include that individual in the budget group.

 

N-6350 Budgeting Steps

Revision 11-3; Effective September 1, 2011

 

Note: The Integrated Eligibility Redesign System (TIERS) will do the eligibility budgeting; however, Medicaid for the Elderly and People with Disabilities (MEPD) specialists must understand the policy.

Begin budgeting with these steps:

  1. Determine the family unit members.
  2. Use Appendix XXXI, Budget Reference Chart, to find the amount that is 150 percent of the FPIL for the family size that corresponds to the total number of family unit members. This is the income limit for this family. Example: There are five family unit members. The income limit is 150 percent of the FPIL for a family of five.
  3. Determine the budget group members.
  4. Determine the monthly gross countable income, if any, of the MBIC applicant or recipient.
  5. Determine the combined monthly gross countable income of the applicant/recipient's parents.
  6. For each ineligible sibling, determine any monthly gross countable income that exceeds the ineligible sibling's exclusion amount. If the exclusion amount is greater than the ineligible sibling's income, disregard all of that ineligible sibling's income.
  7. Total the income amounts determined in steps 4-6.
  8. Subtract $85 from the total in step 7.
  9. Divide the amount in step 8 by two.
  10. The remainder is countable income. Compare this to the income limit determined in step 2.

 

N-6351 Examples of Budgeting Steps

Revision 21-2; Effective June 1, 2021

 

The figures used in these charts are for example only and may not reflect the current FPL limits or the deduction amounts that are based on FPL.

Example 1

Determining Family Unit Members and FPL Limit to Use
Household Composition Applicant — no income
Applicant's parent — gross earnings $1,400 monthly
Applicant's stepparent — gross earnings $3,000 monthly
Applicant's ineligible 16-year-old sibling — no income
Applicant's ineligible 19-year-old sibling, non-student — gross earnings $800 monthly
Applicant's ineligible 14-year-old stepsibling — no income
Children Employed None
Family Unit Members Applicant
Applicant's parent
Applicant's stepparent
Applicant's ineligible 16-year-old sibling
Applicant's ineligible 14-year-old stepsibling
Income Limit 150% FPL for family of five

Note: Since the 19-year-old ineligible sibling is over 18 and not a student, do not consider the sibling or the sibling's income.

 

Budget Group and Eligibility
Steps Amount
Applicant's monthly gross countable income $0
Add parents' monthly gross countable income $4,400
Add each ineligible sibling's gross countable income that exceeds $3,275 $0
Balance of budget group income $4,400
MBIC exclusion ($85 + one-half of remainder) $2,242.50
Total countable income $2,157.50
150% FPL for family of five ≤ $3,880
Eligibility result Eligible

 

Example 2

Determining Family Unit Members and FPL Limit to Use
Household Composition Applicant — Retirement, Survivors, and Disability Insurance (RSDI) $167
Applicant's parent — gross earnings $4,500 monthly
Stepparent, died one year ago
Applicant's ineligible 16-year-old sibling — gross earnings $100 monthly
Applicant's 20-year-old ineligible sibling, student — gross earnings $400 monthly
Applicant's 10-year-old stepsibling — no income
Children Employed 2
Family Unit Members Applicant
Applicant's parent
Applicant's ineligible 16-year-old sibling
Applicant's ineligible 20-year-old sibling (student)
Income Limit 150% FPL for family of four

Note: Since the stepparent is deceased, do not consider the ineligible stepsibling or the ineligible stepsibling's income.

 

Budget Group and Eligibility
Steps Amount
Applicant's monthly gross countable income $167
Add parent's monthly gross countable income $4,500
Add each ineligible sibling's monthly gross countable income that exceeds $3,305 $0
Balance of budget group income $4,667
MBIC exclusion ($85 + one-half of remainder) $2,376
Total countable income $2,291
150% FPL for family of four ≤ $3,313
Eligibility result Eligible

 

Example 3

Determining Family Unit Members and FPL Limit to Use
Household Composition Applicant — RSDI $88
Applicant's stepparent — gross earnings $5,925 monthly
Applicant's parent, died two years ago
Applicant's ineligible two-year-old sibling — no income
Applicant's ineligible 19-year-old sibling, non-student — gross earnings $800 monthly
Applicant's ineligible seven-year-old stepsibling — no income
Children Employed None
Family Unit Members Applicant
Applicant's ineligible two-year-old sibling
Income Limit 150% FPL for family of two

Note: Since the natural parent died and the stepparent is no longer a current spouse of the natural parent, do not consider the stepparent and the ineligible stepsibling or their income. Since the 19-year-old ineligible sibling is over 18 and not a student, do not consider the sibling or the sibling's income.

 

Budget Group and Eligibility
Steps Amount
Applicant's monthly gross countable income $88
Add parent's monthly gross countable income $0
Add each ineligible sibling's monthly gross countable income that exceeds $3,305 $0
Balance of budget group income $88
MBIC exclusion ($85 + one-half of remainder) $86.50
Total countable income $1.50
150% FPL for family of two ≤ $2,178
Eligibility result Eligible

 

Example 4

Determining Family Unit Members and FPL Limit to Use
Household Composition Applicant — RSDI $88
Sibling, seven-year-old, also an applicant — RSDI $88
Applicant's parent — gross earnings $7,800 monthly
Applicant's other parent, died two years ago
Applicant's ineligible two-year-old sibling — no income
Children Employed None
Family Unit Members Applicant
Applicant's seven-year-old sibling, who is also an MBIC applicant
Applicant's parent
Applicant's ineligible two-year-old sibling
Income Limit 150% FPL for family of four

Note: If a sibling is also applying for MBIC, count this sibling in the family unit size, but calculate separate budgets since one "eligible" sibling's income is not counted in the other "eligible" sibling's budget group.

 

Budget Group and Eligibility
Steps Applicant 1 Applicant 2
First applicant's monthly gross countable income $88 $88
Second applicant's monthly gross countable income N/A N/A
Add parent's monthly gross countable income $7,800 $7,800
Add each ineligible sibling's monthly gross countable income that exceeds $3,305 $0 $0
Balance of budget group income $7,888 $7,888
MBIC exclusion ($85 + one-half of remainder) $3,986.50 $3,986.50
Total countable income $3,901.50 $3,901.50
150% FPL for family of four > $3,313 > $3,313
Eligibility result Not eligible Not eligible

Note: Use separate budgets when more than one child with disabilities in the same family unit is applying for MBIC.

 

Example 5

Determining Family Unit Members and FPL Limit to Use
Household Composition Applicant — RSDI $88
Applicant's parent — RSDI $699
Applicant's ineligible two-year-old sibling — RSDI $88
Applicant's ineligible five-year-old sibling — RSDI $88
Children Employed None
Family Unit Members Applicant
Applicant's parent
Applicant's ineligible two-year-old sibling
Applicant's ineligible five-year-old sibling
Income Limit 150% FPL for family of four

 

Budget Group and Eligibility
Steps Amount
Applicant's monthly gross countable income $88
Add parent's monthly gross countable income $699
Add each ineligible sibling's monthly gross countable income that exceeds $3,305 $0
Balance of budget group income $787
MBIC exclusion ($85 + one-half of remainder) $436
Total countable income $351
150% FPL for family of four ≤ $3,313
Eligibility result Eligible

 

Example 6

Determining Family Unit Members and FPL Limit to Use
Household Composition Applicant — no income
Applicant's parent — gross earnings $4,500 monthly
Applicant's other parent — $850 Veterans Affairs (VA) benefits with aid and attendance monthly; gross earnings of $300 monthly
Children Employed None
Family Unit Members Applicant
Applicant's parents
Income Limit 150% FPL for family of three

 

Budget Group and Eligibility
Steps Amount Documentation
Applicant's monthly gross countable income $0  
Add parents' monthly gross countable income $4,500 VA income is needs-based, so none of the other parent's income is included in the budget.
Add each ineligible sibling's monthly gross countable income that exceeds $3,305 N/A  
Balance of budget group income $4,500  
MBIC exclusion ($85 + one-half of remainder) $2,292.50  
Total countable income $2,207.50  
150% FPL for family of three ≤ $2,745  
Eligibility result Eligible  

N-7000, Premiums

Revision 16-4; Effective December 1, 2016

 

Medicaid Buy-In for Children (MBIC) correspondence refers to a premium as a monthly payment.

A family may have to pay a monthly premium as a condition of eligibility. The premium amounts are based on a sliding scale, dependent upon family income and whether the applicant/recipient is covered under a parent's employer-sponsored health insurance (ESI) plan. If a parent's insurance qualifies, the Health Insurance Premium Payment Program (HIPP) can reimburse the family for the ESI premium (see D-7700, Health Insurance Premium Payment Reimbursement Program). HIPP eligibility is also a determining factor in the MBIC premium amount.

Note: The 50% rule for ESI only applies to eligibility and not to premium calculations.

Premium amounts are calculated using the gross countable family income. In the budgeting examples in Section N-6351, Examples of Budgeting Steps, the amount of gross family income used for premium calculation is the "balance of budget group income." Since the premium amount is calculated before the substantial MBIC exclusion of $85 + one-half of the remainder, 300 percent of the federal poverty level is used for the premium calculations.

Note: In TIERS, list the parent/guardian of the MBIC child as the head of household. The parent/guardian also needs to be listed as the alternate payee as well as the EDG name. This is primarily for any premium reimbursements and managed care purposes.

 

N-7100 Premiums for Alaskan Native or American Indian

Revision 11-3; Effective September 1, 2011

 

Premiums are waived if an applicant/recipient is an Alaskan Native or American Indian.

 

N-7200 Premiums in Multiple MBIC-eligible Families

Revision 11-3; Effective September 1, 2011

 

If there is more than one MBIC-eligible recipient in the family unit, there will be only one premium per family unit. Each eligibility determination group (EDG) will have a premium amount calculated; however, the lowest premium amount of all EDGs will be the premium charged.

 

N-7300 Premium Due Dates

Revision 11-3; Effective September 1, 2011

 

Premiums are due on the fifth of each month.

Premiums are not required for application month, disposition month or any month in between.

Example: Application is received in January 2011. Case is disposed in March 2011 with a medical effective date (MED) of Jan. 1, 2011. No premiums are required for January, February or March. First premium is due April 5. Premiums are required for the month following the disposition month regardless of the MED.

If premiums are required, payment of MBIC premiums is a condition of continued eligibility.

 

N-7310 Grace Period for Premiums

Revision 11-3; Effective September 1, 2011

 

An applicant/recipient is given a 60-day grace period to make a premium payment before denial occurs. If a recipient has missed making a premium payment for two consecutive months, the Texas Integrated Eligibility Redesign System (TIERS) will send Form H0062-MBIC, Late Payment Notice, and Form H0065-MBIC, Hardship Form. If a payment is not received by two days before TIERS cutoff, two months after the first missed payment, and a valid hardship is not claimed by the due date on the Form H0065-MBIC, TIERS will auto terminate the MBIC EDG(s) effective the end of that month.

Example: First missed payment is May 5, 2011. On June 5, 2011, the May payment is missed a second time. On June 7, 2011, Form H0062-MBIC, Late Payment Notice, and Form H0065-MBIC, Hardship Form, are sent to the client/authorized representative. Due date for premium payment is July 6, 2011. Due date for a hardship to be claimed is June 17, 2011 (10 days from the date of Form H0065-MBIC). Payment must be received by two days before cut-off in July 2011 or hardship claimed by June 17, 2011. If no payment is received or hardship claimed, denial is effective July 31, 2011. TIERS will auto terminate the MBIC EDG(s) effective the end of that month.

 

N-7320 Premiums and Reapplication for MBIC

Revision 11-3; Effective September 1, 2011

 

If a person is denied MBIC, but later reapplies and is eligible for MBIC, there is no requirement to pay the missed premiums from the last eligibility period before new eligibility can be granted.

 

N-7330 Coordination with the Children with Special Health Care Needs (CSHCN) Program

Revision 11-3; Effective September 1, 2011

 

If an MBIC applicant/recipient is also eligible for the CSHCN Program through the Department of State Health Services (DSHS), the state will pay the MBIC premium. There is no coordination or verification required by Medicaid for the Elderly and People with Disabilities (MEPD) specialists. Direct payment of the person's medical insurance premiums by anyone on the person's behalf is not considered as income. See Section E-1710, Medical Care and Services That Are Not Income.

DSHS will make referrals of CSHCN persons that may be potentially eligible for MBIC. Some of these people may already be eligible for the Children's Health Insurance Program (CHIP). Based on information from DSHS, there is no requirement for a CSHCN eligible person that is also eligible for CHIP to switch to MBIC. It is the person's choice. If the person chooses to remain in CHIP, document in case comments the person's choice and deny the MBIC application as a voluntary withdrawal.

 

N-7400 Premium Amounts

Revision 11-3; Effective September 1, 2011

 

Premium amounts vary based on whether the family does or does not have ESI and whether HIPP is involved or not. Premium amounts are automatically determined by TIERS.

The charts in Section N-7410, Charts for Premium Amounts, outline the premium amounts for persons with:

  • no ESI;
  • ESI and state-paid HIPP; or
  • ESI and no state-paid HIPP.

 

N-7410 Charts for Premium Amounts

Revision 14-3; Effective September 1, 2014

 

No ESI

Note: These premium amounts are current. These amounts are subject to change when FPIL limits change.

Family Income Family of 1 or 2
Premium Amount
Family of 3 or More
Premium Amount
At or below 150% FPIL $0 $0
151–200% FPIL $90 $115
201–300% FPIL $180 $230

 

ESI with State-Paid HIPP

Note: These premium amounts are current. These amounts are subject to change when FPIL limits change.

Family Income Family of 1 or 2
Premium Amount
Family of 3 or More
Premium Amount
At or below 150% FPIL $0 $0
151–200% FPIL $25 $35
201–300% FPIL $50 $70

 

ESI and No State-Paid HIPP

No premiums are required for families with ESI who are not eligible for HIPP. These families are paying their full share of the premium for ESI and are not expected to also pay a premium for MBIC.

 

N-7500 Hardship

Revision 11-3; Effective September 1, 2011

 

A hardship exemption may be granted for loss of income if the loss of income is due to:

  • termination of employment because of layoff or business closing;
  • involuntary reduction in work hours;
  • a parent leaving the household because of divorce or separation; or
  • a parent's death (the parent had to be previously residing in the same household as the MBIC applicant/recipient).

No hardship exemption is allowed to waive prior months premium(s).

Hardship exemption is only allowed once per household every 12 calendar months (regardless of how many MBIC recipients are in the household).

A hardship must be requested within 10 days from the date on Form H0065-MBIC, Hardship Form. A hardship request must be in writing; however, a verbal request is acceptable to meet the 10-day deadline. Written follow-up is required.

Example: First missed payment is May 5, 2011. On June 5, 2011, the May payment is missed a second time. On June 7, 2011, Form H0062-MBIC, Late Payment Notice, and Form H0065-MBIC, Hardship Form, are sent to the client/authorized representative. Due date for premium payment is July 6, 2011. Due date for a hardship to be claimed is June 17, 2011 (10 days from date of Form H0065-MBIC). Payment must be received by two days before cut-off in July 2011 or hardship claimed by June 17, 2011. If no payment is received or hardship claimed, denial is effective July 31, 2011. TIERS will auto terminate the MBIC EDG(s) effective the end of that month.

 

N-7510 Hardship Approval

Revision 11-3; Effective September 1, 2011

 

Approve a hardship request if one of the valid reasons is met. Do not require verification of hardship reasons. Use client's statement and signature on Form H0065-MBIC, Hardship Form, as proof of the hardship; however, if the reason is something that would potentially impact benefits (such as loss of job), verify the change for potential eligibility changes to ongoing benefits. This does not have to be done before the hardship can be approved. Notify a client/authorized representative of the hardship approval on Form TF0001-MBIC, Hardship Waiver Approved.

If approved, the hardship exemption begins on the first of the month for which a premium payment was not received and is granted for three consecutive months.

Example: Premiums were missed in May and again in June. Hardship was claimed on Form H0065-MBIC, and hardship was approved in July. Premiums are waived for May, June and July.

 

N-7511 Hardship Approval Reasons

Revision 11-3; Effective September 1, 2011

 

Form TF0001-MBIC, Hardship Waiver Approved, will be pre-populated with one of the following reasons.

  • Someone living with you was laid off their job. – OR – The place where they work closed.
  • Someone living with you has less income because they work fewer hours.
  • A parent left the house because of a divorce or separation.
  • A parent died. (This is an approval reason but this actual verbiage will not print on the TF0001.)

 

N-7520 Hardship Denial

Revision 11-3; Effective September 1, 2011

 

Deny a hardship request if:

  • none of the valid reasons are met; or
  • Form H0065-MBIC, Hardship Form, or a verbal request was not received by the due date; or
  • a hardship has been granted within the past 12 calendar months. TIERS will track the12-month period.

Notify a client/authorized representative of the hardship denial via Form TF0001-MBIC, Hardship Waiver Denied.

 

N-7521 Hardship Denial Reasons

Revision 11-3; Effective September 1, 2011

 

Form TF0001-MBIC, Hardship Waiver Denied, will be pre-populated with one of the following reasons.

  • We didn't get your "Hardship Form" (H0065-MBIC) by the due date.
  • It hasn't been 12 months since we last stopped your payments. Your payments can be stopped for three months only once in 12 months.
  • You didn't lose money from a job (income) for reasons that allow us to stop your payments.

 

N-7600 Presidential-Declared Emergency

Revision 11-3; Effective September 1, 2011

 

A presidential-declared emergency hardship exemption will automatically be granted to recipients living in the declared area and premiums will be waived for three months. Recipients do not have to request a hardship for a presidential-declared emergency. TIERS will send an "emergency special notice" to inform recipients at the start of the presidential-declared emergency period that the premiums have been waived.

For MBIC recipients, the waiver of premiums for a presidential-declared emergency is for the month of declaration and forward for a total of three months.

Hardship exemption and presidential-declared emergency periods can overlap. They do not run consecutively.

Example: A recipient has hardship exemption for January, February and March. A presidential-declared emergency is declared for March. The presidential-declared emergency hardship would normally be allowed for March, April and May. Total number of months the recipient is not required to pay premiums is five, which are January, February, March, April and May.

A presidential-declared emergency has priority over a hardship exemption if the two situations fall during the same time period. If a hardship exemption has been approved but a presidential-declared emergency is granted for the same time period, the client cannot have another hardship exemption for 12 months.

There is no limit to how many times a recipient may receive a presidential-declared emergency hardship; however, a recipient may only receive one presidential-declared emergency per disaster.

 

N-7700 Prior Months' Premiums

Revision 11-3; Effective September 1, 2011

 

MBIC correspondence refers to these as "payments for past months."

Prior months' eligibility is not granted until premiums for prior months are paid. If all prior months have a $0 premium, eligibility will be granted upon disposition. If any of the prior months have a premium, the premium is due two months after the initial premium due date.

Example: Application is filed in March, disposed on April 1.The prior months are January and February. The premiums for January and February are due on July 5 (two months after May 5, the initial premium due date).

When premiums are paid, eligibility is granted beginning with the last month of the prior month period. Months cannot be skipped, even if a month with a $0 premium falls between two months that require a premium. In the following examples, January, February and March are prior months.

Examples:

  • January is $90, February is $90 and March is $90. As premiums are paid, eligibility is granted first for March, then February, and then January.
  • January is $90, February is $0 and March is $90. March has to be paid before February is granted.

Reminder: No hardship is allowed to waive prior months' premium(s).

 

N-7800 Health Insurance Premium Payment (HIPP)

 

Revision 11-3; Effective September 1, 2011

 

If a parent gets health insurance at work, that information will be sent to the HIPP program for review. If certain standards are met, HIPP will pay the entire health insurance premium as a reimbursement to the individual.

Parents/persons who want to learn more can call 1-800-440-0493 or visit www.gethipptexas.org.

When ESI information is entered into TIERS, this information is automatically sent to HIPP. HIPP eligibility is not an MEPD specialist's responsibility; however, HIPP eligibility does impact the MBIC premium amount.

 

N-7900 Cost-Sharing

 

Revision 11-3; Effective September 1, 2011

 

Cost-sharing is the amount a person pays out of their own pocket for health care. Cost-sharing includes MBIC premiums. Recipients will receive information from the premium processing vendor regarding what expenses are included in cost-sharing.

 

N-7910 Cost-Share Limit

 

Revision 11-3; Effective September 1, 2011

 

Each recipient has a cost-share limit. TIERS will calculate a cost-share limit for each recipient and populate the cost-share limit on Form TF0001-MBIC, Initial Certification.

There is no cost-share limit for the prior months.

Cost-share limit is set at the eligibility determination group level. If there is more than one MBIC-eligible recipient in the family unit, there will be only one cost-share limit per family unit. Each EDG will have a cost-share limit calculated; however, the lowest cost-share limit of all EDGs will be used at a case level.

The cost-share limit for each family is set at:

  • 5% of countable gross annual income for a family whose countable gross annual income is at or below 200 percent of the FPIL.
  • 7.5% of countable gross annual income for a family whose countable gross annual income is 201% to 300% of the FPIL.

The amount of monthly gross countable income in the month following disposition is multiplied by 12 in order to determine the gross annual income used in calculating the cost-share limit. This is the total gross countable income prior to the MBIC exclusion of $85 + one-half.

The cost-share limit can change if there is a change in income during that initial 12-month period. Example: MBIC application is received in January 2011 and certified in March 2011. The cost-share limit is based on income budgeted for April 2011 and begins April 2011. In August 2011, a change in income is reported and case action is taken in August (cut-off is taken into consideration). A new cost share limit will begin in September 2011.

 

N-7920 Cost-Share Period

 

Revision 11-3; Effective September 1, 2011

 

A cost-share period is established for each recipient. This period begins the first day of the disposition month and lasts for 12 months. This is the period during which an MBIC recipient's medical costs and MBIC premiums can be counted toward the cost-share limit.

There is no cost-share period for the prior months.

The original cost-share period is retained for MBIC eligibility determination groups when:

  • an individual is denied in error and then reactivated; and
  • a previously certified MBIC client enters a facility (transfer) and then returns to MBIC within the same cost-share period.

A new cost-share period will be set (based on the new disposition date) when a person reapplies if an MBIC EDG is denied or terminated for any reason except for:

  • denied in error, or
  • transfer between programs.

 

N-7930 Tracking Cost-Share Expenses

Revision 11-3; Effective September 1, 2011

 

A recipient is exempt from MBIC monthly premiums for the remainder of the coverage period when the cost-share expenditures for the recipient reach the cost-share limit.

For a recipient without employer-sponsored health insurance, the premium processing vendor will determine when the MBIC premium payments reach the cost-share limit.

For a recipient with employer-sponsored health insurance and the Health Insurance Premium Payment Program, the recipient must track cost-share expenses. A form will be provided by the premium processing vendor for the recipient to report when the cost-share limit is reached. This form is entitled "Medical Costs List."

The premium processing vendor will provide a refund if a monthly premium payment is received after the cost-share limit has been met. This is automatically tracked by the premium processing vendor.

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

Revision 17-2; Effective June 1, 2017

 

N-8100 Medical Effective Date

Revision 11-3; Effective September 1, 2011

 

The medical effective date (MED) for Medicaid Buy-In for Children (MBIC) cannot be before Jan. 1, 2011. This includes any prior months' eligibility for MBIC. If an application is received in which the prior months occur before January 2011, determine eligibility for other MEPD programs in those prior months. Do not automatically disregard the prior months because an MBIC application is received and the prior months occur before January 2011.

 

N-8200 Prior Months' Eligibility

Revision 17-2; Effective June 1, 2017

 

Eligibility for three prior months to the application month is available for this program. Prior months' eligibility for MBIC cannot be granted before Jan. 1, 2011.

If a premium is required, eligibility for prior months is not granted until premiums have been paid.

See Appendix XLIX, Medicaid Buy-In for Children Forms Chart. Form TF0001-MBIC, Prior Months Eligibility Notice, serves as both the eligibility notice and denial notice. If the premiums are not received by the due date, the prior months are not granted and are denied. Do not send a separate denial notice for failure to pay premium for prior months.

 

N-8300 Case Actions

Revision 11-3; Effective September 1, 2011

 

 

 

N-8310 Verification Checklist and Pending Reasons

Revision 11-3; Effective September 1, 2011

 

The following new verification checklist and pending reasons have been created for this program. These reasons will be pre-populated by TIERS on Form H1020, Request for Information or Action.

  • Send proof that you signed up for your job's health insurance.
  • Send proof that shows you get health insurance through your job.
  • Send proof that the child applying for Medicaid Buy-In for Children can't be on your job's health insurance plan.
  • Send proof that your health insurance company changed.
  • Let us know the next date you can enroll in your job's health insurance plan.
  • Send proof that your job pays at least half the premium of your health insurance.

 

N-8320 Change Action Reasons

Revision 11-3; Effective September 1, 2011

 

The following new change action reasons have been created for this program. These reasons will be pre-populated by TIERS on Form TF0001-MBIC, Change in Monthly Premium Amount or Cost-Share Limit.

  • You reached your cost-share limit for this benefit period.
  • You did not reach your cost-share limit for this benefit period.
  • Your family is making more money (income).
  • Your family is making less money (income).
  • The number of people in your family changed.
  • You have health insurance through your job
  • You don't have health insurance through your job.
  • The Health Insurance Premium Payment program (HIPP) is paying for your private health insurance.
  • The Health Insurance Premium Payment program (HIPP) isn't paying for your private health insurance.

 

N-8330 Denial Reasons

Revision 11-3; Effective September 1, 2011

 

In addition to existing MEPD denial codes, new denial reasons have been created for this program. These reasons and references will be pre-populated by TIERS on:

  • Form TF0001-MBIC, Case Action Termination;
  • Form TF0001-MBIC, Case Action Denial; and
  • Form TF0001-MBIC, Prior Months Eligibility.

Section N-8331 below outlines the reasons and references.

 

N-8331 Denial Reasons and Reference Chart

Revision 11-3; Effective September 1, 2011

 

Denial Reason Reference
It is too late to ask for benefits for these months. 1 TAC §361.115(g)
<Child's name> is married. 1 TAC §361.107
You didn't send proof that shows you get health insurance through your job. 1 TAC §361.113
You didn't send proof that shows when your job's health insurance benefits began. 1 TAC §361.113
You didn't send proof that shows your child can't be on your job's health insurance plan. 1 TAC §361.113
You didn't send proof that shows you signed up for your job's health insurance. 1 TAC §361.113
Your payment couldn't be processed. 1 TAC §361.115(a)
<Child's name> is age 19 or older. 1 TAC §361.107

 

N-8340 Redeterminations

Revision 11-3; Effective September 1, 2011

 

Redeterminations for MBIC follow regular Medicaid for the Elderly and People with Disabilities (MEPD) policy for redeterminations.

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

If a case has an MBIC eligibility determination group (EDG) and another ME EDG, the persons in the case will get both a Form H1200-MBIC and another Form H1200 for the redeterminations.

A TIERS MBIC redetermination packet will include:

  • Form H1233-MBIC, Redetermination Cover Letter;
  • Form H1200-MBIC-R, Application for Benefits – Medicaid Buy-In for Children;
  • Form H1028-MBIC, Employment Verification (Medicaid Buy-In for Children);
  • Form H0003, Agreement to Release Your Facts; and
  • Form H5017-MBIC, Items We Need from You.

 

N-8350 Appeals

Revision 13-1; Effective March 1, 2013

 

HHSC is responsible for all appeals, including those concerning premiums and cost sharing. If premium and/or cost-sharing information is needed for an appeal, refer to the MBIC business process document.

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.

N-9000, Notices and Forms

Revision 20-2; Effective June 1, 2020

 

Form H1200-MBIC and new forms have been created for this program. Most of the new forms are pre-populated by the system. These forms are also available in this handbook. If a form is completed manually from this handbook, follow the instructions for that particular form.

Even though a new application has been created for this program, also accept the Form H1200, Application for Assistance – Your Texas Benefits, as an application for the Medicaid Buy-In for Children (MBIC) program.

Use the current Form H1020, Request for Information or Action, for missing information. The H1020 instructions are updated to include MBIC program-specific information.

Appendix XLIX, Medicaid Buy-In for Children Forms Chart, outlines the:

  • form name;
  • purpose of each form;
  • naming convention of each form in TIERS; and
  • naming convention of each form in this handbook.

TIERS generates Form TF0001-MBIC for all eligibility notices. The MBIC program has seven notices that will use the TF0001 format in TIERS. Because the TF0001 is a TIERS-generated form, MBIC eligibility notices have a different number in this handbook. The form content is the same.

 

N-9100 Replacement Medicaid Card

Revision 12-1; Effective March 1, 2012

 

An individual will only receive one Your Texas Benefits (YTB) Medicaid card, which is intended to be the individual's permanent card. If the individual loses the card, they can get a replacement card by calling 1-800-827-3748.

For a temporary card replacement, use H1027-A, Medicaid Eligibility Verification, or Form H1027-B, Medicaid Eligibility Verification – MQMB. Use H1027-A to replace a lost YTB Medicaid card for MBIC only. Use Form H1027-B to replace a lost YTB Medicaid card for MBIC with QMB. A Form H1027-A or Form H1027-B is provided for the current month only.