Revision 07-1; Effective January 1, 2007

 

1. Reasons for Opening Aged, Blind, or Disabled MAO Cases

The code selected should represent the occurrence, during the six months preceding the date of approval for assistance, which had the greatest effect in producing the need for assistance.

When two or more reasons apply in a case, use the code for the reason primarily responsible for the need for assistance. If a reduction in income or resources and an increase in need are of equal importance, the code reflecting the reduction in income or resources should be used. If the increase in need is considerably greater than the reduction in income, the increased need becomes the primary reason.

Computer-printed reasons to the applicant will be initiated by use of the appropriate opening code. The statements that are to be computer-printed to the applicant are listed after each opening code for informational purposes.

The appropriate opening code should be taken from the following list and entered on the Form H1000-A.

Reasons Relating to Material Change in Income or Resources During Six Months Preceding Approval for Assistance

A change in income or resources should be regarded as material only if the amount of the reduction or loss of income is substantial in relation to the need for assistance. A loss of income that is based on need, such as assistance from a public or private agency, is not regarded as a material change in income. (Cases transferred from another assistance program will be coded 047.)

Earnings Lost or Reduced

Code 028 (TP03, 14) — Use this code if the applicant lost employment or had a reduction in earnings during the six months preceding application.

Computer-printed reason to applicant:

"Your earnings are less due to loss of or decrease in employment."

Support From Other Person

Code 038 (TP03, 14) — Use this code if the needs of the applicant have been met wholly or in part through contributions from a person and such contributions have been discontinued or reduced during the six months preceding application.

Computer-printed reason to applicant:

"Income available to you from another person is less."

Other Income

Code 041 (TP03, 14) — Use this code if the applicant suffered a loss of or reduction in income during the six months preceding application from some source other than those specified in Codes 028 or 038. Examples of such income are RSDI; an allowance, pension, or other payment connected with military service; unemployment benefits; workmen's compensation; and rental income. Do not include the loss of any income that was based on need.

Computer-printed reason to applicant:

"Income available to you is less."

Assets Depleted or Reduced

Code 044 (TP03, 14) — Use this code if the assets of the applicant have been depleted or reduced during the six months preceding application to an amount permitted under Department policy.

Computer-printed reason to applicant:

"Your financial resources have been reduced."

No Material Change in Income or Resources During Six Months Preceding Approval for Assistance

If the need for assistance is caused primarily by some change other than a loss of or reduction in income or assets of the applicant, use one of codes 045 through 055.

Such a change may result, for example, if the allowance for a standard budget item is raised; if an eligibility requirement such as residence is liberalized; or if an applicant's needs increased without a material change in income or assets.

Increased Medical Needs

Code 045 (TP 03, 14) — Use this code if the requirements of the applicant increased during the six months preceding application as a result of need for medical care without a corresponding increase in income or resources. The term medical care is used in the generic sense, that is, it embraces all items usually considered medical or remedial care, including care in a nursing facility.

Computer-printed reason to applicant:

"You have increased medical expense."

"Sins cuentas médicas han aumentado."

Miscellaneous

Code 047 (TP 03, 14) – Program Transfer — Use this code if the recipient receiving assistance is being transferred from a non-DHS assistance program to a DHS assistance program.

Computer-printed reason to applicant:

"You have changed from one type of assistance program to another."

"Su caso ha sido traspasado de inn programa de asistencia a otro."

 

Codes 048-052 (TP 03, 14) – Attained Technical Eligibility — If the applicant has been living below Department standards and the only change during the last six months is that the applicant has now fulfilled some technical eligibility requirement, enter the appropriate code for the particular requirement from the following codes (048-052). Do not use these codes if the applicant was eligible during the six months period but postponed applying. In such circumstances, code 053 should be used.

 

Code 048 — Age

Computer-printed reason to applicant:

"You now meet the age requirement."

"Ahora usted cumple con el requisito de edad."

 

Code 049 — Residence

Computer-printed reason to applicant:

"You now meet residence requirement."

"Ahora usted cumple con el requisito de residencia."

 

Code 050 — Citizenship or Legal Entry

Computer-printed reason to applicant:

"You now meet the citizenship requirement."

"Ahora usted cumple con el requisito de ciudadanía."

 

Code 051 — Blindness or Disability

Computer-printed reason to applicant:

Blind – "You now meet the agency's definition of economic blindness."

Ciego – "Ahora esta agencia considera que la condición de usted es ceguedad económica."

Disabled – "You now meet the agency's definition of disability."

Incapacitado – "Ahora esta agencia le considera a usted incapacitado(a)."

 

Code 052 — Other Technical Eligibility Requirement

Computer-printed reason to applicant:

"You now meet eligibility requirements."

"Ahora cumple usted con los requisitos de elegibilidad."

 

Code 053 (TP 03, 14) – Needy and Eligible — Use this code if the applicant has been needy and eligible over an extended period of time (more than six months prior to application) but postponed applying and during this period lived at a level below the Department standards.

Computer-printed reason to applicant:

"You meet all eligibility requirements."

"Usted cumple con todos los requisitos de elegibilidad."

 

Code 055 (TP 03, 14, 18, 19, 22, 23, 24, 51) – Denied in Error — Use this code if a case is reopened after having been closed by mistake, either as a result of an erroneous report of death or an erroneous denial, including a denial made on presumptive ineligibility. Reassign the previous case number. Make the medical effective date as the date after the denial.

Use this code to open MQMB and QMB coverage in order to prevent a gap in QMB coverage. Code 055 will allow QMB eligibility to begin prior to the application file date.

Computer-printed reason to applicant:

"Your case was closed by mistake."

"Su caso fue cerrado por error."

2. Reasons for Denial of Aged, Blind, and Disabled MAO Applications and Cases

Reasons for denying applications or closing cases are classified into four major groups: (1) death of applicant or recipient; (2) ineligible with respect to need; (3) ineligible with respect to requirements other than need; and (4) miscellaneous reasons.

Select the code reflecting the primary reason for denial. If a reason producing ineligibility with respect to need and reason producing ineligibility with respect to some requirement other than need occur at the same time, use the code for need. If several events occur simultaneously, none of which, alone, would produce ineligibility with respect to need, but collectively they do make the recipient ineligible, use the code for the reason having the greatest effect.

Although the applicant or recipient will receive a card explaining action taken on his/her case, the worker should make an adequate interpretation of the decision to the applicant or recipient.

Computer-printed reasons to the applicant or recipient will be initiated by use of the appropriate closing code and the computer will automatically print out the appropriate reason to the recipient corresponding to the code used.

The statements that are to be computer-printed to the applicant or recipient are listed after each closing code. The Spanish translations are to assist workers in completing FL-4 (MAO) and Form h1801. The Spanish translation will not be included on the Form H1029 mailed by the State Office.

The appropriate denial code should be taken from the following list and entered on the Forms H1000-A/B. These codes may be used on both Forms H1000-A and H1000-B with any type program unless otherwise specified.

Death

Code 059 – Death — Use this code if an application is denied because of death of applicant, or active case is closed because of death or the recipient.

Do not use this code for deceased applications that are simultaneously opened and closed.

Computer-printed reason to applicant or recipient:

No reason necessary — no notice will be sent to applicant or recipient.

Ineligible with Respect to Need: Material Change in Income or Resources During Last Six Months

A change in income or resources should be regarded as material only if the additional income is substantial in relation to the need for assistance. A material change in income or resources may result from the conversion of nonliquid assets into cash or other non-income producing assets into income producing assets, as well as from earnings or other direct income. A material change in income or resources does not necessarily mean a change with respect to cash income. For example, a recipient who has been keeping house may go to live with another person who provides food, clothing, and shelter.

Earnings

Code 060 – Earnings of Applicant or Recipient — Use this code if an application is denied because of applicant's earnings from employment, or active case is denied because of a material change in income as a result of recipient's employment or increased earnings. The change in earnings must have occurred during the preceding six months. Earnings may be from self-employment, seasonal employment, increased employment, or higher wages.

Computer-printed reason to applicant or recipient:

"Your employment earnings meet needs that can be recognized by this agency."

"Su salario es suficiente para cubrir las necesidades que esta agencia puede reconocer."

 

Code 061 – Earnings of Spouse — Use this code if an applicant is denied because of earnings of his or her spouse, or active case is denied because of a material change in income as a result of employment or increased earnings of spouse. The change in earnings must have occurred during the preceding six months. Earnings may be from self-employment, seasonal employment, increased employment, or higher wages.

Computer-printed reason to applicant or recipient:

"Employment earnings of your husband or wife meet needs that can be recognized by this agency."

"El salario de su esposo o esposa es suficiente para cubrir las necesidades que esta agencia puede reconocer."

Support From Other Person

Code 066 — Use this code if an application is denied because of support from another person, or active case is denied because of the receipt of or increase in support from another person. The change must have occurred during the preceding six months.

Computer-printed reason to applicant or recipient:

"Income available to you from another person meets needs that can he recognized by this agency."

"El dinero que recibe de otra persona es suficiente para cubrir las necesidades que esta agencia puede reconocer."

Benefits – Pensions

Code 067 – RSDI — Use this code for applicants or recipients denied if the material change in income resulted, or will result from the receipt of or increase in benefits under the Federal RSDI program during the preceding six months.

Computer-printed reason to applicant or recipient:

"Income available to you from Social Security Benefit meets needs that can be recognized by this agency."

"La entrada que tiene a su disposición de los Beneficios del Seguro Social es suficiente para cubrir las necesidades que esta agencia puede reconocer."

 

Code 068 – Other Federal — Use this code if an application is denied because of receipt of a Federal benefit or pension other than RSDI, or active case is denied because of receipt of or increase in a Federal benefit or pension other than RSDI, during the preceding six months. Examples of such income include Veterans' Administration, Federal Civil Service Retirement, or SSI.

Computer-printed reason to applicant or recipient:

"Income available to you from other Federal benefit or pension meets needs that can be recognized by this agency."

"La entrada que tiene a su disposición de otros beneficios o pensiones federales es suficiente para cubrir las necesidades que esta agencia puede reconocer."

 

Code 069 – State or Local — Use this code if an application is denied because of receipt of a benefit or pension administered by a state or local government, or active case is denied because of receipt of or increase in a benefit or pension administered by a state or local government during the preceding six months. Examples include workmen's compensation benefits, State employees', teachers' or policemen's retirement.

Computer-printed reason to applicant or recipient:

"Income available to you from state or local benefit or pension meets needs that can be recognized by this agency."

"La entrada que tiene a su disposición de beneficios o pensiones locales o del estado es suficiente para cubrir las necesidades que esta agencia puede reconocer."

 

Code 070 – Non-Governmental — Use this code if an application is denied because of receipt of a non-governmental pension or benefit, or active case is denied because of receipt of or increase in a non-governmental benefit or pension during the preceding six months. Examples are pensions from United Auto Workers Union and other pensions financed by private industry.

Computer-printed reason to applicant or recipient:

"Income available to you from pension or benefit meets needs that can be recognized by this agency."

"La entrada que tiene a su disposiciòn de beneficios o pensiones es suficiente para cubrir las necesidades que esta agencia puede reconocer."

 

Code 071 – Other Income — Use this code if an application is denied because of receipt of, or active case is denied because of receipt of or increase in income during the preceding six months other than that covered by codes 060-070. Examples are income from investments or real property.

Computer-printed reason to applicant or recipient:

"Income available to you meets needs that can be recognized by this agency."

"La entrada que tiene a su disposición es suficiente para cubrir las necesidades que esta agencia puede reconocer."

Excess Assets

Code 072 — Use this code if an application is denied because of excess resources, or active case is denied because of receipt of or increase in resources during the preceding six months. Examples are cash, savings bonds, inheritance of money or property, and increase in income from investments or real property.

Computer-printed reason to applicant or recipient:

"Resources available to you from other property meets needs that can be recognized by this agency."

"Los recursos de otra propiedad que tiene a su disposición son suficientes para las necesidades que esta agencia puede reconocer."

Ineligible with Respect to Need: No Material Change in Income or Resources During Last Six Months

Decreased Medical Needs

 

Code 073 — Use this code if an applicant or recipient is ineligible because the need for medical or remedial care (available under the department's program) decreased during the preceding six months.

Computer-printed reason to applicant or recipient:

"Your need for medical care expenses that can be recognized by this agency is less."

"Se ha reducido la necesidad que esta agencia puede reconocer de gastos médicos."

Ineligible With Respect to Requirement(s) Other Than Need

If two or more reasons apply, code the one occurring first. If the occurrences were simultaneous, code the reason appearing first on the list.

Refusal To

Code 076 – Furnish Information — Use this code if an application or active case is denied because of refusal to comply with department policy or to furnish information necessary to determine eligibility. This code does not apply to applicants or recipients who fail to return their client-completed form. Code 091, Failure To Furnish Information, should be used in this circumstance.

Computer-printed reason to applicant or recipient:

"You did not wish to furnish enough information for this agency to establish eligibility for assistance."

"Usted no quiso darnos suficiente información para que esta agencia pudiera establecer su calificación para asistencia."

 

Code 077 (Form H1000-B Only) – Follow Agreed Plan — Use this code for those situations in which a recipient was granted assistance with the understanding that he would take certain steps to utilize resources that were not actually available at time of application but could be made available through recipient's efforts.

Computer-printed reason to applicant or recipient:

"You did not wish to follow agreed plan so that eligibility for assistance could be continued."

"Usted no quiso cumplir con el plan convenido para continuar su calificación para asistencia."

Other Requirements

Code 080 – Blind (Not Blind) Disabled (Not Disabled) — Use this code if a blind applicant does not meet the definition of economic blindness or a blind recipient is denied because his vision has been restored. Also, enter if a disabled applicant does not meet the definition of total and permanent disability or a disabled recipient is no longer totally disabled. If recovery from the incapacity is accompanied by employment or increased earnings, use codes 060 or 061.

Computer-printed reason to applicant or recipient:

Blind – "You do not meet the agency's definition of economic blindness."

Disabled – "You do not meet the agency's definition of total and permanent disability."

Blind – "Usted no cumple con la definición de ceguedad económica de la agencia."

Disabled – "Usted no cumple con la definición de incapacidad total y permanente de la agencia."

 

Code 081 – Not Enrolled in Medicare Part A — Use this code if the applicant is not enrolled for Medicare Part A benefits and therefore cannot qualify for Qualified Medicare Beneficiary (QMB) or the Qualified Disabled Working Individuals (QDWI) programs. Use the code to deny a QMB or QDWI case if the client becomes unenrolled in Medicare Part A.

Computer-printed reason to applicant or recipient:

"You do not have Medicare Part A benefits."

"Usted no tiene los beneficios de la Parte A de Medicare."

 

Code 083 (Form H1000-A Only) – 30 Consecutive Days Requirement — Use this code if an applicant has been denied because he does not meet the 30 consecutive day requirement.

Computer-printed reason to applicant:

"You have not lived in a Medicaid-certified long-term care facility for 30 consecutive days."

"Usted no tiene 30 días consecutivos de vivir en un establecimiento certificado por Medicaid para proveer atención de largo plazo."

 

Code 086 – Admitted to Institution — Use this code if an applicant or recipient has been denied because he is an inmate of or has been admitted to an institution.

Computer-printed reason to applicant or recipient:

"You have been admitted to an institution."

"Usted fue admitido en una institución."

 

Code 087 – Age — Use this code if an application or active case is denied because evidence proves ineligibility on the basis of age. This code does not apply to disabled recipients transferred to aged assistance on becoming 65 years old. In these cases use code 122, Category Change.

Computer-printed reason to applicant or recipient:
"You do not meet the age requirement."
"Usted no cumple con el requisito de edad."

 

Code 088 – Residence — Use this code if evidence proves applicant is ineligible on the basis of residence, or if a recipient is known to have moved out of the state or remained out of the state longer than the minimum time allowed. If a recipient has moved out of the state to obtain employment, support from relatives, or for other known reason, use the code for that reason, rather than code 088. If an applicant or recipient cannot be located, use code 095.

Computer-printed reason to applicant or recipient:

"You do not meet residence requirements for assistance."

"Usted no cumple con los requisitos de residencia para asistencia."

 

Code 089 – Citizenship or Legal Entry — Use this code if an applicant or recipient is ineligible because he is not a citizen nor a noncitizen lawfully admitted for permanent residence in the United States nor residing in the United States under color of law.

Computer-printed reason to applicant or recipient:

"You do not meet legal United States entry or citizenship requirement for assistance."

"Usted no cumple con el requisito para asistencia de entrada legal en los E.U., ni de naturalización."

 

Code 090 (Form H1000-A Only) – Prior Eligibility (Used for Simultaneous Open and Close Only) — Use this code if an applicant is either deceased or currently ineligible for assistance but was eligible for Medicaid coverage during a prior period.

Computer-printed reason to applicant:

"Medical assistance was granted during a prior period, but you are not eligible now for medical or financial assistance."

"Consiguió asistencia médica durante un periodo anterior, pero ahora no califica para asistencia médica ni financiera."

 

Code 091 – Failure to Furnish Information — Use this code only when an applicant or recipient fails to execute and return the completed eligibility form.

Computer-printed reason to applicant or recipient:

"You failed to complete and return the necessary eligibility form."

"No devolvió usted debidamente completada la forma necesaria para calificar."

 

Code 092 – Other Eligibility Requirement — Use this code if an application or active case is denied because applicant or recipient does not meet an eligibility requirement other than need not covered by codes 076-089.

Computer-printed reason to applicant or recipient:

"You do not meet eligibility requirements for assistance."

"Usted no cumple con los requisitos para calificar para asistencia."

 

Code 136 – Failure to Provide Proof of U.S. Citizenship — Use this code if an application or active case is denied because applicant or recipient is a U.S citizen or national and fails to provide proof of U.S. citizenship.

Computer-printed reason to applicant or recipient:

“(Last, First) is not eligible for Medicaid because proof of U.S. citizenship was not provided. As soon as this information is provided, this person may be eligible for Medicaid.”

“(Last name, first name) no llena los requisitos de Medicaid porque no presentó prueba de ciudadanía estadounidense. Una vez que esta persona presente la información, es posible que llene los requisitos de Medicaid.”

Miscellaneous Reasons

Code 094 – Appointment Not Kept — Use this code when an applicant or recipient is denied because: (1) he/she has failed to keep an appointment, and (2) he/she has made no response within 10 days to a follow-up inquiry.

Computer-printed reason to applicant or recipient:

"You failed to keep your appointment."

"Usted no vino a la cita qine tenía."

 

Code 095 – Unable to Locate — Use this code if an applicant or recipient is denied because he/she cannot be located.

Computer-printed reason to applicant or recipient:

"You cannot be located."

"No lo podemos localizar a usted."

 

Code 096 (Form H1000-A Only) – Application Filed in Error — Use this code if an application is to be denied because of being filed or pending in error or to deny a duplicate application, that is, more than one application filed for an individual in the same category.

Computer-printed reason to applicant:

No reason necessary - no notice will be sent to applicant.

 

Code 097 – Transfer of Property — Use this code if an application or active case is denied because of transfer of property, either real or personal, for purpose of qualifying for or increasing the need for assistance.

Computer-printed reason to applicant or recipient:

"You transferred property that has an effect on your eligibility for assistance."

"Usted transfirió propiedad que afecta su calificació; para asistencia."

 

Code 098 – Voluntary Withdrawal — Use this code only if an applicant does not wish to pursue his/her application further, or if a recipient requests that his/her grant be discontinued and the underlying cause for the withdrawal request cannot be determined. If a specific reason for the withdrawal can be determined, always use the applicable code. Do not use for applicant/recipients who have moved out-of-state. Code 088 will be used for this reason.

Computer-printed reason to applicant or recipient:

"You have requested that your application for or your grant of assistance be withdrawn."

"Usted ha pedido que su aplicación para, o su concesión de asistencia sea retirada."

 

Code 099 – Other Miscellaneous — Use this code only if an application or active case is denied for a reason which cannot be related in some respect to one of the preceding codes. Include under this code cases closed because the applicant or recipient is incarcerated, or was originally ineligible.

Computer-printed reason to applicant or recipient:

"You do not presently meet eligibility requirements."

"Al presente usted no cumple con los requisitos para calificar."

 

3. Reasons for Sustaining Aged, Blind, and Disabled MAO Cases

Notices to recipients for all redeterminations are computer-printed on special forms. These notices are "triggered" by the action code entered on the Form H1000-B. Since the reason is general, an adequate interpretation should be made to the recipient for any action taken to sustain the case.

Code

110 – "You remain eligible for medical coverage."

121 – Type Program Transfer — "You have been transferred to another type of medical assistance."

122 – Category Change — "You continue to be eligible for medical assistance."

(Note: Use Code 122 if both type program and category change.)

Revision 20-3; Effective September 1, 2020

Revision 20-3; Effective September 1, 2020

Revision 20-2; Effective June 1, 2020

 

 

Revision 07-4; Effective October 1, 2007

 

Important: Current SSI recipients and individuals entitled to or enrolled in Medicare are exempt from the citizenship documentation requirement for Medicaid. This includes individuals determined disabled for Social Security benefits and in the 24-month period before receiving Medicare.

 

Primary Evidence of Citizenship and Identity
U.S. passport Certificate of naturalization Certificate of U.S. citizenship SDX for denied SSI recipients when the denial is for any reason other than citizenship (N13) SOLQ/WTPY and documentation of reason for Medicare denial

If primary evidence of citizenship is not available, the individual must provide two documents – one to establish U.S. citizenship and one to establish identity. Acceptable evidence of identity documents is outlined last at the end of this reference guide.

When primary evidence of citizenship is not available, begin with the second level of evidence of citizenship and continue through the levels to locate the best available documentation.

 

Second Level of Evidence of Citizenship (Use only when primary evidence is not available.)

A U.S. public birth certificate showing birth in one of the 50 states, the District of Columbia, Puerto Rico (if born on or after Jan. 13, 1941), Guam (on or after April 10, 1899), the Virgin Islands of the U.S. (on or after Jan. 17, 1917), American Samoa, Swain’s Island or the Northern Mariana Islands (after Nov. 4, 1986). Conduct Bureau of Vital Statistics (BVS) inquiry for an individual born in Texas. If an individual’s date of birth is earlier than 1903 or if the birth was out of state, accept a legible/non-questionable copy. For a birth out of state, individuals may obtain a birth certificate through the following: BirthCertificate.com; vitalchek.com; or usbirthcertificate.net. Individuals may also contact usbirthcertificate.net toll-free at:1-888-736-2692. Report of Birth Abroad of a U.S. Citizen (FS-240) Certification of Birth Abroad (FS 545 or DS-1350) U.S. Citizen Identification card (Form I-179 or I-197) Northern Mariana Identification card (I-873) American Indian card (I-872) issued by Department of Homeland Security with classification code “KIC” Final adoption decree showing the child’s name and U.S. place of birth Evidence of U.S. Civil Service employment before June 1, 1976 U.S. Military record showing a U.S. place of birth (Example: DD-214)

 

Third Level of Evidence of Citizenship (Use only when primary and second level evidence is not available.)

Hospital record of birth showing a U.S. place of birth Life, health or other insurance record showing a U.S. place of birth Religious record of birth recorded in the U.S. or its territories within three months of birth that indicates a U.S. place of birth showing either the date of birth or the individual’s age at the time the record was made Early school record showing a U.S. place of birth, name of the child, date of admission to the school, date of birth, and name(s) and place(s) of birth of the applicant’s/recipient’s parents

 

Fourth Level of Evidence of Citizenship (Use only when primary, second level and third level evidence is not available.)

Any listed documents used must include biographical information, including U.S. place of birth. Federal or state census record showing U.S. citizenship or a U.S. place of birth and the individual’s age (generally for individuals born 1900-1950) Seneca Indian Tribal census record showing a U.S. place of birth Bureau of Indian Affairs Tribal census records of the Navajo Indians showing a U.S. place of birth Bureau of Indian Affairs Roll of Alaska Natives U.S. State Vital Statistics official notification of birth registration showing a U.S. place of birth Statement showing a U.S. place of birth signed by the physician or midwife who was in attendance at the time of birth Institutional admission papers from a nursing facility, skilled care facility or other institution showing a U.S. place of birth Medical (clinic, doctor or hospital) record, excluding an immunization record, showing a U.S. place of birth Affidavits from two adults regardless of blood relationship to the individual; use only as a last resort when no other evidence is available

 

Evidence of Identity

Driver's license issued by a state either with a photograph or other identifying information such as name, age, sex, race, height, weight or eye color School identification card with a photograph U.S. Military card or draft record Identification card issued by the federal, state or local government with the same information included on driver’s license Department of Public Safety identification card with a photograph or other identifying information such as name, age, sex, race, height, weight or eye color Birth certificate Hospital record of birth Military dependent’s identification card Native American Tribal document U.S. Coast Guard Merchant Mariner card Certificate of Degree of Indian Blood or other U.S. American Indian/Alaskan Native and Tribal document with a photograph or other personal identifying information Data matches with other state or federal government agencies (Example: Employee Retirement System and Teacher Retirement System) Three or more corroborating documents, such as marriage license, divorce decrees, high school diplomas and employer ID cards. Use only with second and third levels of evidence of citizenship. Adoption papers or records Work identification card with photograph Signed application for Medicaid (accept signature of an authorized representative or a responsible person acting on the individual’s behalf) Health care admission statement For children under 16, school records may include nursery or day care records For children under 16, clinic, doctor or hospital records For children under 16, an affidavit signed by a parent or guardian stating the date and place of birth of the child; use as a last resort when no other evidence is available and if an affidavit is not used to establish citizenship For disabled individuals in residential care facilities, an affidavit signed by the facility director or administrator attesting the identity of the individual when the individual does not have or cannot get any document on this list. Use as a last resort when no other evidence is available and if an affidavit is not used to establish citizenship.

Revision 21-1; Effective March 1, 2021

 

BIC Code	Type of Beneficiary
A	Primary Claimant
B	Wife, 62 or older (1st claimant)
B1	Husband, 62 or older (1st claimant)
B2	Young wife with a child in her care (1st claimant)
B3	Wife, 62 or older (2nd claimant)
B4	Husband, 62 or older (2nd claimant)
B5	Young wife with a child in her care (2nd claimant)
B6	Divorced wife, 62 or older (1st claimant)
B7	Young wife with a child in her care (3rd claimant)
B8	Wife, 62 or older (3rd claimant)
B9	Divorced wife, 62 or older (2nd claimant)
BA	Wife, 62 or older (4th claimant)
BD	Wife, 62 or older (5th claimant)
BG	Husband, 62 or older (3rd claimant)
BH	Husband, 62 or older (4th claimant)
BJ	Husband, 62 or older (5th claimant)
BK	Young wife with a child in her care (4th claimant)
BL	Young wife with a child in her care (5th claimant)
BN	Divorced wife, 62 or older (3rd claimant)
BP	Divorced wife, 62 or older (4th claimant)
BQ	Divorced wife, 62 or older (5th claimant)
BR	Divorced husband, 62 or older (1st claimant)
BT	Divorced husband, 62 or older (2nd claimant)
BW	Young husband with a child in his care (2nd claimant)
BY	Young husband with a child in his care (1st claimant)
C1-C9	Child (minor, disabled or student)
CA-CK	Child (minor, disabled or student) CA = C11, CB = C12, etc. See Note 1.
D	Widow, 60 or older (1st claimant)
D1	Widower, 60 or older (1st claimant)
D2	Widow, 60 or older (2nd claimant)
D3	Widower, 60 or older (2nd claimant)
D4	Widow (remarried after turning 60) (1st claimant)
D5	Widower (remarried after turning 60) (1st claimant)
D6	Surviving divorced wife, 60 or older (1st claimant)
D7	Surviving divorced wife, 60 or older (2nd claimant)
D8	Widow, 60 or older (3rd claimant)
D9	Widow (remarried after turning 60) (2nd claimant)
DA	Widow (remarried after turning 60) (3rd claimant)
DC	Surviving divorced husband, 60 or older (1st claimant)
DD	Widow, 60 or older (4th claimant)
DG	Widow, 60 or older (5th claimant)
DH	Widower, 60 or older (3rd claimant)
DJ	Widower, 60 or older (4th claimant)
DK	Widower, 60 or older (5th claimant)
DL	Widow (remarried after turning 60) (4th claimant)
DM	Surviving divorced husband, 60 or older (2nd claimant)
DN	Widow (remarried after turning 60) (5th claimant)
DP	Widower (remarried after turning 60) (2nd claimant)
DQ	Widower (remarried after turning 60) (3rd claimant)
DR	Widower (remarried after turning 60) (4th claimant)
DS	Surviving divorced husband, 60 or older (3rd claimant)
DT	Widower (remarried after turning 60) (5th claimant)
DV	Surviving divorced wife, 60 or older (3rd claimant)
DW	Surviving divorced wife, 60 or older (4th claimant)
DX	Surviving divorced husband, 60 or older (4th claimant)
DY	Surviving divorced wife, 60 or older (5th claimant)
DZ	Surviving divorced husband, 60 or older (5th claimant)
E	Mother (widow) (1st claimant)
E1	Surviving divorced mother (1st claimant)
E2	Mother (widow) (2nd claimant)
E3	Surviving divorced mother (2nd claimant)
E4	Father (widower) (1st claimant)
E5	Surviving divorced father (1st claimant)
E6	Father (widower) (2nd claimant)
E7	Mother (widow) (3rd claimant)
E8	Mother (widow) (4th claimant)
E9	Surviving divorced father (2nd claimant)
EA	Mother (widow) (5th claimant)
EB	Surviving divorced mother (3rd claimant)
EC	Surviving divorced mother (4th claimant)
ED	Surviving divorced mother (5th claimant)
EF	Father (widower) (3rd claimant)
EG	Father (widower) (4th claimant)
EH	Father (widower) (5th claimant)
EJ	Surviving divorced father (3rd claimant)
EK	Surviving divorced father (4th claimant)
EM	Surviving divorced father (5th claimant)
F1	Father
F2	Mother
F3	Stepfather
F4	Stepmother
F5	Adopting father
F6	Adopting mother
F7	Second alleged father
F8	Second alleged mother
G1-G9	Claimants of lump-sum death payments
J1	Primary PROUTY entitled to HIB (less than 3 Q.C.) (General Fund) See Note 2
J2	Primary PROUTY entitled to HIB (over 2 Q.C.) (RSI Trust Fund)
J3	Primary PROUTY not entitled to HIB (less than 3 Q.C.) (General Fund)
J4	Primary PROUTY not entitled to HIB (over 2 Q.C.) (RSI Trust Fund)
K1	PROUTY wife entitled to HIB (less than 3 Q.C.) (General Fund)
K2	PROUTY wife entitled to HIB (over 2 Q.C.) (RSI Trust Fund)
K3	PROUTY wife not entitled to HIB (less than 3 Q.C.) (General Fund)
K4	PROUTY wife not entitled to HIB (over 2 Q.C.) (RSI Trust Fund)
K5	PROUTY wife entitled to HIB (less than 3 Q.C.) (2nd claimant) (General Fund)
K6	PROUTY wife entitled to HIB (over 2 Q.C.) (2nd claimant) (RSI Trust Fund)
K7	PROUTY wife not entitled to HIB (less than 3 Q.C.) (2nd claimant) (General Fund)
K8	PROUTY wife not entitled to HIB (over 2 Q.C.) (2nd claimant) (RSI Trust Fund)
K9	PROUTY wife entitled to HIB (less than 3 Q.C.) (3rd claimant) (General Fund)
KA	PROUTY wife entitled to HIB (over 2 Q.C.) (3rd claimant) (RSI Trust Fund)
KB	PROUTY wife not entitled to HIB (less than 3 Q.C.) (3rd claimant) (General Fund)
KC	PROUTY wife not entitled to HIB (over 2 Q.C.) (3rd claimant) (RSI Trust Fund)
KD	PROUTY wife entitled to HIB (less than 3 Q.C.) (4th claimant) (General Fund)
KE	PROUTY wife entitled to HIB (over 2 Q.C.) (4th claimant) (RSI Trust Fund)
KF	PROUTY wife not entitled to HIB (less than 3 Q.C.) (4th claimant) (General Fund)
KG	PROUTY wife not entitled to HIB (over 2 Q.C.) (4th claimant) (RSI Trust Fund)
KH	PROUTY wife entitled to HIB (less than 3 Q.C.) (5th claimant) (General Fund)
KJ	PROUTY wife entitled to HIB (over 2 Q.C.) (5th claimant) (RSI Trust Fund)
KL	PROUTY wife not entitled to HIB (less than 3 Q.C.) (5th claimant) (General Fund)
KM	PROUTY wife not entitled to HIB (over 2 Q.C.) (5th claimant) (RSI Trust Fund)
LM	Black lung miner (1st claimant)
LW	Black lung miner's widow (1st claimant)
M	Beneficiary not entitled to Title II or monthly benefits (Not qualified for automatic free Part A – HIB)
M1	Similar to M, but qualified for automatic free Part A – HIB, but elects to file for Part B – SMIB only
T	Fully insured beneficiaries who have elected entitlement only to HIB (usually but not always along with SMIB) End Stage Renal Disease (ESRD) filing for Medicare only Deemed insured (hospital insurance only)
T2-T9	Multiple eligible children (Medicare Qualified Government Employment (MQGE) childhood disability benefits) (2nd – 9th claimant)
TA	MQGE primary beneficiary
TB	MQGE aged spouse (1st claimant)
TC	MQGE childhood disability benefits (1st claimant)
TD	MQGE aged widow or widower (1st claimant)
TF	MQGE father
TG, TH, TJ, TK	Multiple eligible MQGE aged spouses
TL, TM, TN, TP	Multiple eligible MQGE aged widow(er)s
TQ	MQGE mother
TE, TR, TS, TT , TU	Multiple eligible MQGE young widow(er)s
TV, TW, TX, TY, TZ	Multiple eligible MQGE disabled widow(er)s
W	Disabled widow, 50 or older (1st claimant)
W1	Disabled widower, 50 or older (1st claimant)
W2	Disabled widow, 50 or older (2nd claimant)
W3	Disabled widower, 50 or older (2nd claimant)
W4	Disabled widow, 50 or older 3rd claimant)
W5	Disabled widower, 50 or older 3rd claimant)
W6	Disabled surviving divorced wife (1st claimant)
W7	Disabled surviving divorced wife (2nd claimant)
W8	Disabled surviving divorced wife (3rd claimant)
W9	Disabled widow, 50 or older (4th claimant)
WB	Disabled widower, 50 or older (4th claimant)
WC	Disabled surviving divorced wife (4th claimant)
WF	Disabled widow, 50 or older (5th claimant)
WG	Disabled widower, 50 or older (5th claimant)
WJ	Disabled surviving divorced wife (5th claimant)
WR	Disabled surviving divorced husband (1st claimant)
WT	Disabled surviving divorced husband (2nd claimant)

 

Note 1: Youngest child is assigned suffix "1." If there are more than nine children in an Eligibility Determination Group (EDG), the 10th child is coded with an A rather than 10, the 11th child is coded with a B, etc.

Note 2: Quarters of covered employment.

Revision 12-1; Effective March 1, 2012

 

All Programs

A B C D E F G H I J K L M N O P R S T U V W Y Z

County	Code	Region
Anderson	001	04
Andrews	002	09
Angelina	003	05
Aransas	004	11
Archer	005	02
Armstrong	006	01
Atascosa	007	08
Austin	008	06

A B C D E F G H I J K L M N O P R S T U V W Y Z

County	Code	Region
Bailey	009	01
Bandera	010	08
Bastrop	011	07
Baylor	012	02
Bee	013	11
Bell	014	07
Bexar	015	08
Blanco	016	07
Borden	017	09
Bosque	018	07
Bowie	019	04
Brazoria	020	06
Brazos	021	07
Brewster	022	10
Briscoe	023	01
Brooks	024	11
Brown	025	02
Burleson	026	07
Burnet	027	07

A B C D E F G H I J K L M N O P R S T U V W Y Z

County	Code	Region
Caldwell	028	07
Calhoun	029	08
Callahan	030	02
Cameron	031	11
Camp	032	04
Carson	033	01
Cass	034	04
Castro	035	01
Chambers	036	06
Cherokee	037	04
Childress	038	01
Clay	039	02
Cochran	040	01
Coke	041	09
Coleman	042	02
Collin	043	03
Collingsworth	044	01
Colorado	045	06
Comal	046	08
Comanche	047	02
Concho	048	09
Cooke	049	03
Coryell	050	07
Cottle	051	02
Crane	052	09
Crockett	053	09
Crosby	054	01
Culberson	055	10

A B C D E F G H I J K L M N O P R S T U V W Y Z

County	Code	Region
Dallam	056	01
Dallas	057	03
Dawson	058	09
Deaf Smith	059	01
Delta	060	04
Denton	061	03
DeWitt	062	08
Dickens	063	01
Dimmit	064	08
Donley	065	01
Duval	066	11

A B C D E F G H I J K L M N O P R S T U V W Y Z

County	Code	Region
Eastland	067	02
Ector	068	09
Edwards	069	08
Ellis	070	03
El Paso	071	10
Erath	072	03

A B C D E F G H I J K L M N O P R S T U V W Y Z

County	Code	Region
Falls	073	07
Fannin	074	03
Fayette	075	07
Fisher	076	02
Floyd	077	01
Foard	078	02
Fort Bend	079	06
Franklin	080	04
Freestone	081	07
Frio	082	08

A B C D E F G H I J K L M N O P R S T U V W Y Z

County	Code	Region
Gaines	083	09
Galveston	084	06
Garza	085	01
Gillespie	086	08
Glasscock	087	09
Goliad	088	08
Gonzales	089	08
Gray	090	01
Grayson	091	03
Gregg	092	04
Grimes	093	07
Guadalupe	094	08

A B C D E F G H I J K L M N O P R S T U V W Y Z

A B C D E F G H I J K L M N O P R S T U V W Y Z

County	Code	Region
Irion	118	09

A B C D E F G H I J K L M N O P R S T U V W Y Z

County	Code	Region
Jack	119	02
Jackson	120	08
Jasper	121	05
Jeff Davis	122	10
Jefferson	123	05
Jim Hogg	124	11
Jim Wells	125	11
Johnson	126	03
Jones	127	02

A B C D E F G H I J K L M N O P R S T U V W Y Z

County	Code	Region
Karnes	128	08
Kaufman	129	03
Kendall	130	08
Kenedy	131	11
Kent	132	02
Kerr	133	08
Kimble	134	09
King	135	01
Kinney	136	08
Kleberg	137	11
Knox	138	02

A B C D E F G H I J K L M N O P R S T U V W Y Z

County	Code	Region
Lamar	139	04
Lamb	140	01
Lampasas	141	07
LaSalle	142	08
Lavaca	143	08
Lee	144	07
Leon	145	07
Liberty	146	06
Limestone	147	07
Lipscomb	148	01
Live Oak	149	11
Llano	150	07
Loving	151	09
Lubbock	152	01
Lynn	153	01

A B C D E F G H I J K L M N O P R S T U V W Y Z

County	Code	Region
Madison	154	07
Marion	155	04
Martin	156	09
Mason	157	09
Matagorda	158	06
Maverick	159	08
McCulloch	160	09
McLennan	161	07
McMullen	162	11
Medina	163	08
Menard	164	09
Midland	165	09
Milam	166	07
Mills	167	07
Mitchell	168	02
Montague	169	02
Montgomery	170	06
Moore	171	01
Morris	172	04
Motley	173	01

A B C D E F G H I J K L M N O P R S T U V W Y Z

County	Code	Region
Nacogdoches	174	05
Navarro	175	03
Newton	176	05
Nolan	177	02
Nueces	178	11

A B C D E F G H I J K L M N O P R S T U V W Y Z

County	Code	Region
Ochiltree	179	01
Oldham	180	01
Orange	181	05

A B C D E F G H I J K L M N O P R S T U V W Y Z

County	Code	Region
Palo Pinto	182	03
Panola	183	04
Parker	184	03
Parmer	185	01
Pecos	186	09
Polk	187	05
Potter	188	01
Presidio	189	10

A B C D E F G H I J K L M N O P R S T U V W Y Z

County	Code	Region
Rains	190	04
Randall	191	01
Reagan	192	09
Real	193	08
Red River	194	04
Reeves	195	09
Refugio	196	11
Roberts	197	01
Robertson	198	07
Rockwall	199	03
Runnels	200	02
Rusk	201	04

A B C D E F G H I J K L M N O P R S T U V W Y Z

County	Code	Region
Sabine	202	05
San Augustine	203	05
San Jacinto	204	05
San Patricio	205	11
San Saba	206	07
Schleicher	207	09
Scurry	208	02
Shackelford	209	02
Shelby	210	05
Sherman	211	01
Smith	212	04
Somervell	213	03
Starr	214	11
Stephens	215	02
Sterling	216	09
Stonewall	217	02
Sutton	218	09
Swisher	219	01

A B C D E F G H I J K L M N O P R S T U V W Y Z

County	Code	Region
Tarrant	220	03
Taylor	221	02
Terrell	222	09
Terry	223	01
Throckmorton	224	02
Titus	225	04
Tom Green	226	09
Travis	227	07
Trinity	228	05
Tyler	229	05

A B C D E F G H I J K L M N O P R S T U V W Y Z

County	Code	Region
Upshur	230	04
Upton	231	09
Uvalde	232	08

A B C D E F G H I J K L M N O P R S T U V W Y Z

County	Code	Region
Val Verde	233	08
Van Zandt	234	04
Victoria	235	08

A B C D E F G H I J K L M N O P R S T U V W Y Z

County	Code	Region
Walker	236	06
Waller	237	06
Ward	238	09
Washington	239	07
Webb	240	11
Wharton	241	06
Wheeler	242	01
Wichita	243	02
Wilbarger	244	02
Willacy	245	11
Williamson	246	07
Wilson	247	08
Winkler	248	09
Wise	249	03
Wood	250	04

A B C D E F G H I J K L M N O P R S T U V W Y Z

County	Code	Region
Yoakum	251	01
Young	252	02

A B C D E F G H I J K L M N O P R S T U V W Y Z

County	Code	Region
Zapata	253	11
Zavala	254	08

Revision 21-4; Effective December 1, 2021

 

Appendix is available for staff use on the LOOP.

Revision 23-2; Effective June 1, 2023

Note: The following information is effective March 1, 2023.

Eligibility as a Qualified Medicare Beneficiary (QMB)

Medicare Entitlement

Must be entitled to Medicare Part A.

Income — Maximum gross monthly income

• $1,215 Individual
• $1,643 Couple

Income can equal the maximum gross monthly income or be less than this limit. Use the couple income limit when both spouses are applying for the same program. If both are not eligible, use the individual income limit to test eligibility for each spouse separately. A portion of the spouse's income may also be considered as part of the applicant's income.

Income limit amounts do not include the $20 general income disregard.

What counts as income?

• Social Security benefits
• Railroad retirement benefits
• State or local retirement benefits
• Interest or dividends
• Gifts or contributions
• Civil service annuities
• Veterans benefits
• Private pension benefits
• Royalty and rental payments
• Earnings or wages
• Value of food, clothing or shelter paid by someone else

Resources — Maximum countable resources

• $9,090 Individual
• $13,630 Couple

What is a resource?

• Bank accounts and certificates of deposit (CDs)
• Real property
• Life insurance policies
• Burial funds
• Individual retirement accounts (IRAs)
• Stocks and bonds
• Oil, gas or mineral rights
• Jewelry and antiques
• Cars and other vehicles
• Boats and recreational vehicles

What can be excluded?

• Texas homestead where a person lives that they consider their principal place of residence
• Life insurance if the face value is $1,500 or less
• Separately identifiable burial funds of $1,500 (less any excluded life insurance or irrevocable arrangement for burial) for the applicant and the applicant's spouse
• Car
• Burial spaces

Benefits

QMB covers Medicare premiums (both Parts A and B), deductibles and coinsurance fees for Medicare services. As a QMB, a person does not get regular Medicaid benefits. The state sends a special identification card to people who are eligible for QMB for them to show their medical service providers.

Eligibility as Specified Low-Income Medicare Beneficiaries (SLMB)

Medicare Entitlement

Must be entitled to Medicare Part A.

Income

The income range for a person is equal to a minimum monthly amount of $1,215.01 to a maximum monthly amount of less than $1,458.

The income range for a couple is equal to a minimum monthly amount of $1,643.01 to a maximum monthly amount of less than $1,972.

Use the couple income range when both spouses are applying for the same program. If both are not eligible, use the individual income range to test eligibility for each spouse separately. A portion of the spouse's income may also be considered as part of the applicant's income.

Income limit amounts do not include the $20 general income disregard.

What counts as income?

• Social Security benefits
• Railroad retirement benefits
• State or local retirement benefits
• Interest or dividends
• Gifts or contributions
• Civil service annuities
• Veterans benefits
• Private pension benefits
• Royalty and rental payments
• Earnings or wages
• Value of food, clothing or shelter paid by someone else

Resources — Maximum countable resources

• $9,090 Individual
• $13,630 Couple

What is a resource?

• Bank accounts and CDs
• Real property
• Life insurance policies
• Burial funds
• IRAs
• Stocks and bonds
• Oil, gas or mineral rights
• Jewelry and antiques
• Cars and other vehicles
• Boats and recreational vehicles 

What can be excluded?

• Texas homestead where a person lives that they consider their principal place of residence
• Life insurance if the face value is $1,500 or less
• Separately identifiable burial funds of $1,500 (less any excluded life insurance or irrevocable arrangement for burial) for the applicant and the applicant's spouse
• Car
• Burial spaces

Benefits

SLMB covers only the payment of Medicare Part B premiums. An SLMB-eligible person does not get regular Medicaid benefits or a monthly medical identification card.

Eligibility for the Qualifying Individuals Program (QI-1)

Entitlement

• Must be entitled to Medicare Part A.
• Must not otherwise be receiving Medicaid.

Income

The income range for a person is equal to a minimum monthly amount of $1,458 to a maximum monthly amount of less than $1,640.

The income range for a couple is equal to a minimum monthly amount of $1,972 to a maximum monthly amount of less than $2,219.

Use the couple income range when both spouses are applying for the same program. If both are not eligible, use the individual income range to test eligibility for each spouse separately. A portion of the spouse's income may also be considered as part of the applicant's income.

Income limit amounts do not include the $20 general income disregard.

What counts as income?

• Social Security benefits
• Railroad retirement benefits
• State or local retirement benefits
• Interest or dividends
• Gifts or contributions
• Civil service annuities
• Veterans benefits
• Private pension benefits
• Royalty and rental payments
• Earnings or wages
• Value of food, clothing or shelter paid by someone else

Resources — Maximum countable resources

• $9,090 Individual
• $13,630 Couple

What is a resource?

• Bank accounts and CDs
• Real property
• Life insurance policies
• Burial funds
• IRAs
• Stocks and bonds
• Oil, gas or mineral rights
• Jewelry and antiques
• Cars and other vehicles
• Boats and recreational vehicles

What can be excluded?

• Texas homestead where a person lives that they consider their principal place of residence
• Life insurance if the face value is $1,500 or less
• Separately identifiable burial funds of $1,500 (less any excluded life insurance or irrevocable arrangement for burial) for the applicant and the applicant's spouse
• Car
• Burial spaces

Benefits

QI-1 covers only the payment of Medicare Part B premiums. A QI-1-eligible person does not get regular Medicaid benefits or a medical identification card. A person cannot receive QI-1 benefits if receiving benefits under any other Medicaid-funded program.

Qualified Disabled and Working Individuals Program (QDWI)

Entitlement

• Must be entitled to enroll in Medicare Part A.
• Must be under 65 and not otherwise receiving Medicaid.

Income — Maximum gross monthly income

• $2,430 Individual
• $3,287 Couple

Income can be less than or equal to the maximum limit. Use the couple income limit when both spouses are applying for the same program. If both are not eligible, use the individual income limit to test eligibility for each spouse separately. A portion of the spouse's income may also be considered as part of the applicant's income.

Income limit amounts do not include the $20 general income disregard.

What counts as income?

• Social Security benefits
• Railroad retirement benefits
• State or local retirement benefits
• Interest or dividends
• Gifts or contributions
• Civil service annuities
• Veterans benefits
• Private pension benefits
• Royalty and rental payments
• Earnings or wages
• Value of food, clothing or shelter paid by someone else

Resources — Maximum countable resources

• $4,000 Individual
• $6,000 Couple

What is a resource?

• Bank accounts and CDs
• Real property
• Life insurance policies
• Burial funds
• IRAs
• Stocks and bonds
• Oil, gas or mineral rights
• Jewelry and antiques
• Cars and other vehicles
• Boats and recreational vehicles

What can be excluded?

• Texas homestead where a person lives that they consider their principal place of residence
• Life insurance if the face value is $1,500 or less
• Separately identifiable burial funds of $1,500 (less any excluded life insurance or irrevocable arrangement for burial) for the applicant and the applicant's spouse
• Car
• Burial spaces

Benefits

QDWI covers only Medicare Part A premiums. A QDWI-eligible person does not get regular Medicaid benefits or a medical identification card.

Revision 12-3; Effective September 1, 2012

 

Age	Life Estate	Remainder
0	.97188	.02812
1	.98988	.01012
2	.99017	.00983
3	.99008	.00992
4	.98981	.01019
5	.98938	.01062
6	.98884	.01116
7	.98822	.01178
8	.98748	.01252
9	.98663	.01337
10	.98565	.01435
11	.98453	.01547
12	.98329	.01671
13	.98198	.01802
14	.98066	.01934
15	.97937	.02063
16	.97815	.02185
17	.97700	.02300
18	.97590	.02410
19	.97480	.02520
20	.97365	.02635
21	.97245	.02755
22	.97120	.02880
23	.96986	.03014
24	.96841	.03159
25	.96678	.03322
26	.96495	.03505
27	.96290	.03710
28	.96062	.03938
29	.95813	.04187
30	.95543	.04457
31	.95254	.04746
32	.94942	.05058
33	.94608	.05392
34	.94250	.05750
35	.93868	.06132
36	.93460	.06540
37	.93026	.06974
38	.92567	.07433
39	.92083	.07917
40	.91571	.08429
41	.91030	.08970
42	.90457	.09543
43	.89855	.10145
44	.89221	.10779
45	.88558	.11442
46	.87863	.12137
47	.87137	.12863
48	.86374	.13626
49	.85578	.14422
50	.84743	.15257
51	.83674	.16126
52	.82969	.17031
53	.82028	.17972
54	.81054	.18946
55	.80046	.19954
56	.79006	.20994
57	.77931	.22069
58	.76822	.23178
59	.75675	.24325
60	.74491	.25509
61	.73267	.26733
62	.72002	.27998
63	.70696	.29304
64	.69352	.30648
65	.67970	.32030
66	.66551	.33449
67	.65098	.34902
68	.63610	.36390
69	.62086	.37914
70	.60522	.39478
71	.58914	.41086
72	.57261	.42739
73	.55571	.44429
74	.53862	.46138
75	.52149	.47851
76	.50441	.49559
77	.48742	.51258
78	.47049	.52951
79	.45357	.54643
80	.43659	.56341
81	.41967	.58033
82	.40295	.59705
83	.38642	.61358
84	.36998	.63002
85	.35359	.64641
86	.33764	.66236
87	.32262	.67738
88	.30859	.69141
89	.29526	.70474
90	.28221	.71779
91	.26955	.73045
92	.25771	.74229
93	.24692	.75308
94	.23728	.76272
95	.22887	.77113
96	.22181	.77819
97	.21550	.78450
98	.21000	.79000
99	.20486	.79514
100	.19975	.80025
101	.19532	.80468
102	.19054	.80946
103	.18437	.81563
104	.17856	.82144
105	.16962	.83038
106	.15488	.84512
107	.13409	.86591
108	.10068	.89932
109	.04545	.95455

Revision 20-3; Effective September 1, 2020

Revision 23-1; Effective March 1, 2023

Note: The following information is effective Jan. 1, 2023.

Medicaid Eligibility for the Nursing Facility Program and the Home and Community-Based Services Waiver Programs

Income — Maximum gross monthly income

• $2,742 Individual
• $5,484 Couple

Note: The income of parents and spouses is not considered for determining eligibility.

What counts as income?

• Social Security benefits
• Certain veteran's benefits
• Private pensions
• Interest or dividends
• Royalty and rental payments
• Federal employee annuities
• Railroad benefits
• State or local retirement benefits
• Gifts or contributions
• Earnings and wages

Resources — Maximum countable resources

• $2,000 Individual
• $3,000 Couple

What is a resource?

• Bank accounts and certificates of deposit (CDs)
• Real property
• Life insurance policies
• Burial funds
• Individual retirement accounts (IRAs)
• Stocks and bonds
• Oil, gas or mineral rights
• Jewelry and antiques
• Cars and other vehicles
• Boats and recreational vehicles

What can be excluded?

• A homestead in Texas where the person intends to return.
• Life insurance, if the face value is $1,500 or less per insured person.
• Separately identifiable burial funds of $1,500 (less any excluded life insurance) or more, if irrevocable, for the applicant and the applicant’s spouse.
• One vehicle is excluded, regardless of value.

Protected resources amount for a spouse in the community

$29,724 minimum to $148,620 maximum (excludes value of homestead, household goods, personal goods, one car and burial funds)

Other Eligibility Requirements

Nursing Facility

• Be 65 or older or meet SSA’s definition of disability.
• Meet medical necessity criteria.
• Be a resident of Texas and a U.S. citizen or alien with approved status such as a legalized or permanent resident alien.
• Live in a Medicaid-contracted long-term care facility for at least 30 consecutive days.

Co-payment

Individual — Total gross income, less $60 for personal needs.

Individual with a spouse in the community — Total gross couple income, less:

• $60 for personal needs;
• amount up to $3,715.50 for community spouse; and
• certain amount for dependents living with community spouse.

Couple — Total gross income, less $120 for personal needs.

Note: Certain other expenses, such as health insurance premiums, guardianship fees and incurred medical expenses if the Medicaid program does not cover direct payment for the services, may be deducted if the person meets program policy requirements.

Home and Community-Based Services

• Be 65 or older or meet SSA’s definition of disability.
• Meet nursing facility medical criteria or ICF/IID-RC level of care criteria.
• Be a resident of Texas and a U.S. citizen or alien with approved status such as a legalized or permanent resident alien.
• Have an approved plan of care within the cost ceiling.
• Meet waiver requirements.

Co-payment

In certain situations, a recipient may be required to pay a co-payment based on income.

Revision 19-3; Effective September 1, 2019

 

Revision 16-4; Effective December 1, 2016

 

Appendix is available for staff use, here.

 

 

Revision 07-3; Effective July 1, 2007

Insert for Application and Redetermination Packets

Beginning July 1, 2006, each U.S. citizen eligible for Medicaid will be required to provide proof of citizenship and identity. This is due to a new federal law.

You will not have to provide any additional documents to prove citizenship and identity if you:

• Receive SSI or have received SSI in the past.
• Are entitled to and/or enrolled in Medicare currently or have been in the past.
• Are a newborn to a mother who is Medicaid eligible.

If you are required to provide documents to prove citizenship and identity, the lists below will help you decide the best way to do this. 

For individuals born in Texas, we may be able to get the birth certificate electronically, and you will not need to provide it to prove citizenship. However you will need to provide proof of identity. 

The following documents prove both citizenship and identity. You need to provide only one of these documents.

• U.S. passport
• Certificate of Naturalization
• Certificate of U.S. citizenship

If you do not have one of the documents listed above, then you will need to provide one document from each of the lists below. This means you will need to provide two documents with your application or recertification.

To Verify Citizenship U.S. birth certificate U.S. citizen identification card American Indian card with a classification code "KIC" Northern Mariana identification card Hospital record of birth Religious record of birth with date and place of birth, such as baptismal record Affidavit from two adults, regardless of blood relationship to the individual, establishing the date and place of birth in the United States

To Verify Identity Current driver license with picture Department of Public Safety identification card with picture Work or school identification card with picture

There may be other documents we can accept to prove citizenship or identity. Please contact your local office to discuss other possibilities. If you are currently receiving Medicaid and are unable to provide proof of citizenship, you may be given extra time to obtain and provide proof before your Medicaid benefits are denied.

You may use an affidavit only as a last resort if you cannot provide any other proof. If you want to provide an affidavit to prove citizenship or identity, you can get a form at your local HHSC benefits office or online at www.hhsc.state.tx.us. You can dial 2-1-1 and request the location of the nearest HHSC benefits office.

Anexo para los paquetes de solicitud y de redeterminación

A partir del 1 de julio de 2006, todos los ciudadanos estadounidenses que reúnan los requisitos para recibir Medicaid deberán presentar pruebas de ciudadanía e identidad. Esto se debe a una nueva ley federal. 

No tendrá que presentar ningún documento adicional para demostrar su ciudadanía e identidad si:

• Recibe SSI o ha recibido SSI en el pasado.
• Tiene derecho a Medicare o está o estuvo inscrito en él antes.
• Es un recién nacido cuya madre llena los requisitos de Medicaid.

Si tiene que presentar algún documento para demostrar su ciudadanía e identidad, las siguientes listas le ayudarán a determinar cuál es la mejor manera de hacerlo. 

Quizás podamos obtener un acta de nacimiento electrónica de las personas que nacieron en Texas y usted no necesite presentarla para demostrar su ciudadanía. Sin embargo, deberá presentar pruebas de identidad. 

Los siguientes documentos demuestran tanto la ciudadanía como la identidad. Solo tendrá que presentar uno de estos documentos.

• Pasaporte de Estados Unidos
• Certificado de naturalización
• Certificado de ciudadanía estadounidense

Si no tiene ninguno de los documentos de la lista anterior, tendrá que presentar un documento de cada una de las siguientes listas. Esto significa que tendrá que presentar dos documentos con su solicitud o recertificación.

Para verificar la ciudadanía  Acta de nacimiento de Estados Unidos Tarjeta de identificación de ciudadanía de Estados Unidos Tarjeta de indio americano con un código de clasificación de "KIC" Tarjeta de identificación de Mariana del Norte Registro de nacimiento del hospital Registro religioso de nacimiento con fecha y lugar de nacimiento, como la fe de bautismo Declaración jurada de dos adultos, sin importar el parentesco con la persona, que establezcan la fecha y el lugar del nacimiento en Estados Unidos

Para verificar la identidad Licencia para manejar vigente con foto Tarjeta de identificación del Departamento de Seguridad Pública, con foto Tarjeta de identificación del trabajo o la escuela con foto

Puede haber otros documentos que se acepten para demostrar la ciudadanía o la identidad. Por favor, llame a la oficina local para hablar sobre otras posibilidades. Si está recibiendo Medicaid en este momento y no puede presentar la prueba de ciudadanía, es posible que reciba un plazo adicional para obtenerla y presentarla antes de negarle los beneficios de Medicaid.

Solo puede utilizar la declaración jurada como último recurso si no puede proporcionar otra prueba. Si quiere presentar una declaración jurada para demostrar su ciudadanía o identidad, puede conseguir la forma en la oficina local de beneficios de la Comisión de Salud o Servicios Humanos (HHSC) o en línea en www.hhsc.state.tx.us. Puede marcar el 2-11 y pedir la dirección de la oficina de beneficios de la HHSC más cercana.

Revision 23-3; Effective Sept. 1, 2023

This guide gives documentation expectations and suggested sources for obtaining information that have proven to result in quality, accurate cases. This document is comprehensive, but not all-inclusive and is subject to change. When supervisor approval is suggested, written or documented, verbal contact is acceptable.

Casework Hints: Hints are good, proven casework practices.

Prudent Person Principle: Case record documentation based on eligibility specialist judgment or knowledge is an option but is not a requirement.

Case Record Documentation: The Case Record Documentation column in the chart below includes information entered by Texas Integrated Eligibility Redesign System (TIERS) data entry screens. Only use case comments as needed and for information not covered by TIERS data entry or to clarify TIERS entries.

Verification and Sources: Each bullet in the Verification and Sources column is an acceptable source of verification unless otherwise stated. Remember, documents the specialist receives or generates in the local office must be sent for imaging for them to become part of the case record.

Electronic Data Verifications: Staff must attempt to verify eligibility criteria using information from electronic sources. Staff may not request more information or documentation unless such information is not available electronically or the information obtained electronically is not consistent with the information on the application.

Element Policy Section	Case Record Documentation	Verification and Sources
General Acceptable  Documentation	Documentation must be sufficient to support the eligibility determination and give enough detail that someone not familiar with the case will understand computations and eligibility decisions. Client Statement: When selecting "client statement" as a verification source, the information must be on the application/renewal form, imaged documents or telephone/in person contact documentation and must be documented in case comments. Third-Party Contacts by Telephone or In Person (including client and authorized representative [AR] contacts): Telephone Document the following: Telephone number called Person(s) contacted, including title (authority to release information being requested) Date of call Reported information, including dates, values and/or balances, descriptions, and source(s) the responder references In Person Document the following: Date Reported information, including dates, values and/or balances, descriptions, and source(s) the responder references Other Acceptable: Document in case comments the source used to verify the element if there is no field to enter information on the individual TIERS Logical Unit of Work (LUW) page. Note: Other forms of verification may be acceptable with proper, complete documentation and program approval. For example, use of Kelly Blue Book, savings bond verification, etc. Blanks on Most Recent Application/Review: Documentation must address how items left blank on the most recent application or review are cleared. Note: If an application has only client identifying information and a valid signature, telephone contact may be needed to get an explanation of the incomplete items. It is not sufficient to assume a client has no income or resources or that none of the questions apply and to request only a State Online Query (SOLQ) inquiry.	Only one type of verification is required unless noted otherwise. Example: If all required information is on the bank statement, there is no need to request Form H1239, Request for Verification of Bank Accounts.
Case Comments	Document the following in case comments: Complete name and area (MEPD) of the person making the comments. Any open tickets, including the ticket number, date of ticket and the reason for the ticket. The reason for reopening the application, with an explanation of the new file date. If a denial was made in error or the previous worker did not clearly document the denial reason, then document the reason for denial. The reviewer (supervisor/worker III) must document the reason when approving the reopening of an application with a protected file date. Explain the file date chosen if there are several dates stamped or written on the application form or if an incorrect file date was used. If email correspondence is received, image the email. If eligibility cascades to an incorrect program, document the reason eligibility is denied for the correct program. (For example: Application for waiver Medicaid denied due to excess income, cascaded to TANF Level Family. Sent to Texas Works for disposal.) The reason for using the override function. When the second-party reviewer does not approve whatever is being reviewed, then the reviewer (supervisor/worker III) would need to document why it is not approved. Enough detail to explain the use of a contingency processing method (CPM) when one is needed due to a defect or because the policy has not yet been programmed into TIERS. If the CPM gives instructions on specific information to include in the explanation, then document the information. Document the CPM number. Resolutions to any discrepancies, questionable information or special situations for any eligibility element. The person’s response to clear discrepant Data Broker information, or a notation that the person disagrees with the information, as required by policy in Appendix IV, Data Broker. If an application indicates the person requested interpreter services, document when the services were provided and how they were provided, as required by policy indicated on Form H1200, Application for Assistance — Your Texas Benefits. Document the name of the interpreter. Any contact made with the applicant/recipient or his authorized representative, including the date of the call, the name of the person contacted, that person’s relationship to the applicant/recipient and authority to release information, and the phone number called. Document the reasons for delays in processing an application and the eligibility specialist’s actions, as explained in B-6420, Missing Information Due Dates, specifically in the subsection titled “Delay in Certification.”
SOLQ/WTPY Use and Documentation	SOLQ/Wire Third-Party Query (WTPY) can verify several things regarding an applicant’s/recipient’s eligibility and co-payment. Examples: Name on Social Security Administration (SSA) record Date of birth (DOB) Citizenship Medicare Parts A, B, C and D Social Security amounts Dual entitlement to Medicare and Medicaid This list is not all-inclusive. Use SOLQ as the primary verification tool when possible. To comply with SSA safeguarding requirements, do not print (and/or send for imaging) or copy and paste SOLQ data directly into case comments. In case comments, document the date or dates SOLQ was viewed. If SOLQ does not provide all information needed, request a WTPY. To comply with SSA safeguarding requirements, do not print (and/or send for imaging) or copy and paste WTPY data directly into case comments. In case comments, document the need for a WTPY, the WTPY request number, date viewed and information verified by WTPY rather than SOLQ.	SOLQ/WTPY Record SOLQ/WTPY correctly on screens where using SOLQ/WTPY as a verification source. (Since SOLQ is the primary source of verification and TIERS treats SOLQ/WTPY as one verification source, document in case comments when WTPY was used instead of SOLQ.)
Streamlining Methods for Community-Based Applications	Use this procedure for community-based programs, including: all cost-of-living adjustment (COLA) disregard programs, such as Pickle, Disabled Adult Child (DAC), and Widow/Widower; all Medicare Savings Programs; and the Community Attendant Services (CAS) program. Do not use this procedure when a person is applying for or requesting a program transfer to: an institution, a Home and Community-based Services waiver, Medicaid Buy-In, or Medicaid Buy-In for Children.	This procedure is available online on the Office of Social Services (OSS) website for Medicaid for the Elderly and People with Disabilities (MEPD). Look for the bulleted item State Processes under Policy on the left side of the webpage. The title of the document is Simplification for Community Based Programs (PDF).
Streamlining Methods for Redeterminations B-8440	Apply the three options to redeterminations for both institutional cases and community-based cases.
Customized Redetermination Driver Flow (CRDF)	CRDF can be used for MEPD redeterminations when the case is active and in ongoing mode and the packet received date is on or before the redetermination date.	CRDF does not preclude the requirement for documentation and verification of eligibility elements.
Guardians and Other Agents F-1231, B-3220, B-3300	If there is no guardian or power of attorney (POA), determine if there is any other fiduciary agent. If there is no family, friends or attorney, Form H0003, Agreement to Release Your Facts, should be completed. Note: When a guardianship exists, only that person can act on the individual's behalf to sign applications and review forms.	Obtain a copy of the guardianship or POA document.
Citizenship/Identity, Residence, Alien Status D-3000, D-5000, D-8000	If Level 1 evidence of citizenship is not used, document the reason a more reliable source is not used. If citizenship is verified by sources other than SOLQ: Bureau of vital statistics (BVS) — Document the birth certificate number, as TIERS does not automatically retain the certificate number. Birth certificate, naturalization papers or other sources used — Ensure the image is available in the portal. If viewing the original document, be sure to send a copy for imaging and return the original document to the individual. Alien status needs to be verified through Systematic Alien Verification for Entitlements (SAVE) in Data Broker. Identity verification must also be documented. Copies of documents are acceptable if they are legible and not questionable. Hint: Ensure copies of alien status cards are legible by adjusting the print quality on the copier.	See Appendix V, Levels of Evidence of Citizenship and Acceptable Evidence of Identity Reference Guide, for acceptable documentation. If citizenship or alien status verification is the only information that is not provided, do not delay certification or deny the application. Form TF0001, Notice of Case Action, informs the applicant that citizenship or alien status verification will be required within 95 days and lists the name of each individual who must provide citizenship or alien status verification.
Excess Income or Resources	Hint: The notification of denial should explain that denial is based on applicant/recipient declaration. Document the name and type of contact, date, time and any additional comments to substantiate the decision. Excess Resources: If excess resources can be designated as burial funds, allow the person the opportunity to do so. See F-4227, Burial Funds. If a person is determined ineligible because of excess funds in a joint account, allow the person an opportunity to disprove the presumed ownership of all or part of the funds. The person must also be allowed to disprove ownership of joint accounts that do not currently affect eligibility, but may in the future. See F-4121, Joint Bank Accounts. Excess Income: See the following: G-6200, Special Income Limit for the Eligibility Budget F-6800, Qualified Income Trust (QIT) Appendix XXXVI, Qualified Income Trusts (QITs) and Medicaid for the Elderly and People with Disabilities (MEPD) Information B-2500, Explaining Policy vs. Giving Advice Hint: If denial is based on applicant/recipient declaration, both the notification of denial and case comments should include the name and type of contact, date and any additional comments to substantiate the decision.
Third-Party Resources D-7000	Ensure that the TPR LUW is completed fully and accurately to ensure correct information is submitted to Provider Claims. State/MEPD Specialist Judgment Call: Assignability of the policy may be pursued on a follow-up basis if it appears reasonable that the policy is assignable. Casework Hints: Check bank drafts for premiums for third-party resource (TPR) policies. Check employment history/retirement income for possible TPRs.	Verify the names, addresses and policy numbers of insurance policies (assignability). Sources for verifying insurance policies: Copy of policy Form H1253, Verification of Health Insurance Policy Copy of insurance card Verify the amount of the premium and obtain proof that premiums are being paid and that the policy is in force. Copies of canceled checks are very good proof of payment of an insurance premium.
Incurred Medical Expenses Chapter H, Co-Payment	Incurred medical expenses (IMEs) should be properly determined (co-payment issue). Is the IME being paid by the applicant/recipient? Do not allow an IME deduction if there is no proof that the applicant/recipient paid the insurance premium and/or incurred other medical expenses. If someone else has been paying the insurance premium and/or medical expenses and the applicant/recipient clearly plans to make the payment, schedule a special review to consider the IME deduction. Obtain a completed, signed and dated Form H1263, Certification of Medical Necessity. See Appendix XXXII, Incurred Medical Expenses (IME) Deductions for Medicare Rx Drugs, for information about IME treatment and processes.	Verify the names, addresses and policy numbers of insurance policies. Verify the names and addresses of other medical providers the applicant/recipient may be paying, such as a dentist. For what is the charge? Is it for an allowable medical expense? How many payments will be required for complete payoff? How much has been agreed to be paid? Is there any private health insurance that might pay the expenses? If there is no documentation field present in TIERS, use case comments to record this information. Verify the name and address of any other source of payment. Copies of canceled checks are very good proof of payment of a medical bill. Do not allow deductions for nonassignable health or nonassignable dental insurance policies. Assignable insurance policies must be reported on Form H1039, Medical Insurance Input, and sent to the Office of Inspector General (OIG), Third-Party Resources Unit. Remember to set a special review date to monitor IMEs.
Transfer of Assets Chapter I	Evaluate that the transfer took place. Document the when, what, how much was it worth as of 12:01 a.m. on the first day in the month of transfer, how much was received, and the “from(s)” and “to(s).” Document the date of transfer. Establish the look-back period. Were assets transferred within the look-back period? Presume the transfer took place for Medicaid eligibility. Is there any value that is uncompensated? Evaluate the transfer for exceptions. Document applicable exceptions as needed. Document the value of the resource at the time of transfer and the amount of income being transferred. Offer an opportunity for rebuttal. Document the compensation received to offset the value transferred. Document that an opportunity for rebuttal was offered and record the time frames observed. Were the rebuttal notices properly sent? If the individual attempts a rebuttal, document the evidence used during the rebuttal process. Document the factors used to determine the validity of the rebuttal. Document supervisor concurrence of the rebuttal decision. Bank statements that are provided or requested need to be reviewed for possible transfers. If transfers are noted, additional bank statements and other verification can be requested to determine and verify whether additional transfers have occurred. See I-3000, Exceptions to the Transfer of Assets. See also: F-6500, Irrevocable Trusts F-6800, Qualified Income Trust (QIT) F-7000, Annuities E-4400, Other Annuities, Pensions and Retirement Plans E-3320, Alimony and Support Payments E-3370, Gifts and Inheritances E-3372, Effective Date of Receipt of Inheritance; Disclaimers	Sources for verifying validity of a transfer: Copies of documents transferring assets. (Documentation from viewing documents is acceptable if copies cannot be obtained. Document the reason a copy could not be obtained.) Contact with companies or firms, such as a financial institution, that are knowledgeable of the transfer. (The contact must be documented using telephone contact documentation.) Verify the fair market value according to handbook requirements for the asset transferred. Can request up to 60 months of bank statements or other verification if a transfer has occurred. Sources for verifying the amount of compensation offered: If compensation is other than cash, document the formula used for determining the value of the tendered compensation. Verification should include a copy of the sales document or agreement. If an oral agreement was made, obtain a written statement from the applicant/recipient and the person who received the transferred asset. If more than one source of verification is required (for example, one to verify transfer and another to verify compensated value), document the additional sources and pertinent information in case comments. Receipts used to verify compensation: Bank deposit slips or bank statements (for verification of the amount only).
Cash  F-4110	Cash is a countable resource. Accept the person's statement as to the amount of cash on hand. Address the amount as of 12:01 a.m. on the first day of the month.	Accept the person’s statement as verification.
Bank Accounts F-4120	Document the name of the financial institution, complete account number and account accessibility by the applicant/recipient. Document the account balance as of 12:01 a.m. on the first day of the appropriate month(s). Give consideration to encumbered funds. Give consideration to the timing of consistent income deposits. Is interest being paid on the account? If so, document the amount and frequency of payment and the source of verification. For information about the treatment of interest paid, see the Interest and Dividends section of this chart, as well as handbook sections regarding the treatment of interest in eligibility and co-payment budgets. Identify the source of all deposits. All questionable deposits should be verified. Identify withdrawals that reoccurred at least three times a month. Identify the payees of all bank drafts. Do not develop a transfer penalty when the total amount of all transfers per month is $200 or less, as outlined in I-3600, Administrative Procedures of Transfers of Nominal Amounts. Document information in case comments on all deposits and withdrawals, as identified above. If these deposits and withdrawals are numerous, it may be advisable to document on a separate sheet the identity of each deposit and withdrawal (bank, date and amount). Be sure to send the completed sheet to be imaged. Applications: Obtain bank statements covering the month of application and the three prior months to substantiate financial flow/management and statements regarding potential transfers of assets. If transfers have occurred, request as many bank statements as needed (up to 60 months) to determine how far back the transfers may go. Reviews: Verify resources as of 12:01 a.m. on the first day of the month that Form H1200, Application for Assistance — Your Texas Benefits or Form H1200-A, Medical Assistance Only (MAO) Recertification, was received; the preceding two months; or any month up to the month the review is completed. Reminder: All resources must be verified as of 12:01 a.m. on the same month.	Verify an applicant's/recipient's bank account balance using one of the following methods: Bank statements or a completed Form H1239, Request for Verification of Bank Accounts. Payment for completion of the form cannot be made by the Texas Health and Human Services Commission (HHSC). Letter from the financial institution. Telephone contact with an employee of the financial institution, using telephone contact documentation. Pursue written follow-up if unable to obtain information by telephone call or if this information results in the applicant/recipient being ineligible. The following three pieces of information must be in the case record: Name of the financial institution Account number(s) Amount of the balance as of 12:01 a.m. for the appropriate month(s) If the verification that the person provides does not meet the three criteria above, ask specifically for the information that is missing. For example, request a copy of the bank statement that will indicate (1) the name of the financial institution, (2) the account number, and (3) the balance as of 12:01 a.m. for [the appropriate] month(s). Hint: For institutional cases, including waiver cases, bank statements are preferred over Form H1239 for verification purposes due to possible transfers and drafts.
Joint Bank Accounts F-4121	Document the name of the financial institution and the complete account number. Document the name of the person(s) with access to the account. If disproving ownership, obtain a completed Form H1299, Request for Joint Bank Account Information, or a written statement by the applicant/recipient (or from the applicant's/recipient's authorized representative if not listed as an owner of the account) as to the applicant’s/recipient's ownership of the funds in the account. (An authorized representative’s statement can be accepted if no other statement is available and there is additional evidence to support the statement, such as deposits and canceled checks.) Whose funds were used to establish the account? Whose income was used to make subsequent deposits, and who made withdrawals? Use case comments to document how and when ownership is disproved. Obtain written statements from co-holders of the account verifying the applicant’s/recipient's statement. A third party's statement may be necessary if either party is mentally incompetent. Obtain evidence that a change has been made to restrict the applicant's/recipient's accessibility to the account (funds) or to establish separate accounts. If the account is not disproved, follow the guidelines for case record documentation for bank accounts. If all monies belong to the applicant/recipient, no Form H1299 is required. Follow the guidelines for case record documentation for bank accounts.	Verify the name of the financial institution and account number. Verify the name of the owner (or owners) of the account. The applicant/recipient must be given the opportunity to disprove or prove ownership of part or all funds/income in the account, before denial.
Trusts F-6100 through F-6900	Document the type of trust. Is the trust revocable or irrevocable? Document whether the trust is revocable or irrevocable. If it is irrevocable, review the transfer of assets treatment in F-6500, Irrevocable Trusts; F-6713, Transfer of Assets; and Chapter I, Transfer of Assets. Is the trust a qualifying income trust (QIT)? Are deposits being made to a trust account? Determine the source(s) of deposits to the account. Who is the beneficiary? Document the value of the trust corpus. Document the amount and frequency of income being produced by the trust, and the amount of the corpus and income available to the applicant/recipient. Determine and document the countability of the corpus and income being produced. Document the source of verification.	Send copies of trusts to regional legal staff for interpretation. Sources for verifying trusts: Copy of the trust agreement. For special needs trusts, the source of the assets used to fund the trust. Copy of the will, if the trust is a testamentary trust. For wills, a copy of the Order Probating the Will or a copy of the Letters Testamentary issued when the will was probated. This is actually needed for any resource type where the individual may have inherited an interest in property, for example, a will granting a life estate or other interest in property. Statement from the financial institution, trust management company or attorney. Legal staff interpretation. (Contact with legal staff should occur via designated procedures.) Note: If the trust is exempt, document the basis for the exemption.
Patient Trust Funds F-4123	Document whether the applicant/recipient maintains a trust fund at the facility and the balance in the account as of 12:01 a.m. on the first day of appropriate month(s). Is interest being paid on the account? If so, document the amount and frequency of payment and the source of verification. For information about the treatment of interest paid, see the Interest and Dividends section of this chart. If the applicant/recipient resided in another nursing facility and indicates that a trust fund was maintained at the previous facility, contact must be made with that facility to determine if the applicant/recipient owns a trust fund at that facility and to verify that funds have been transferred to the current facility.	Use one of the verification sources listed below: Documented viewing of the facility's records Copy of the statements provided by the facility Contact with a knowledgeable representative at the facility, such as a telephone call to the facility bookkeeper, using telephone contact documentation
Stocks F-4130	Document the following: Name of the company, number of shares and type of shares. Document in case comments the: number of shares, type of shares, and calculations of countable value. Market value as of 12:01 a.m. on the first day of the appropriate month. Source of verification.	Use one of the following sources for verifying the closing prices of stocks: Newspaper Statement from a brokerage firm Research department of a local library Documented contact with the issuing company, using telephone contact documentation Use one of the following sources to verify ownership of stock: Copies of stock certificates Written statement from an authorized employee of the brokerage firm or issuing company Documented contact with the brokerage firm or issuing company, using telephone contact documentation
Bonds F-4140	Document the following: Name of the company, type of bond and the serial number. The serial number is required to verify the face value. Document the serial number in case comments. Market value as of 12:01 a.m. on the first day of the appropriate month. Source of verification. Note: There is no need to redetermine the value of a bond if there is evidence that the value will not change from year to year.	Verify ownership by examining the front of a bond. Use one of the following sources for verifying the cash value of municipal, corporate and government bonds: Newspaper (closing price on the last day of the month before the appropriate month[s]) Statement from an authorized employee of a savings or banking institution or a brokerage or securities firm Research department of a local library Use one of the following sources for verifying the cash value of U.S. savings bonds: Table of redemption values for U.S. savings bonds (the table may be available at a savings or banking institution) Statement from an authorized employee of a savings or banking institution Copy of bond
Promissory Notes, Loans and Property Agreements F-4150 (for resource treatment) I-6200 (cross reference for transfer of assets)	Document the following: Ownership of the note. Accessibility by the applicant/recipient. Whether the note is negotiable. If non-negotiable, why? Does a transfer of assets exist? Whether the note is an excluded resource. If the note is excluded, the reason for exclusion. If the note is a countable resource, the current market value of the note. Amount of income (interest) generated by the note. Source of verification. State/MEPD Specialist Judgment Call: If the appraisal value is $0, based on the reason given by the appraising entity, document your evaluation of the validity of the appraisal. Note: The applicant/recipient must own the note. Notes that the applicant/recipient owes are not a resource.	Send copies of notes, loans and property agreements to legal for interpretation. Use one of the following sources for verifying ownership of a promissory note, loan or property agreement: Copy of the instrument (note, mortgage or agreement) Statements from the purchaser and noteholder Use one of the following sources for verifying negotiability of a promissory note, loan or property agreement: Copy of the instrument that indicates whether it is negotiable Statement from a bank or other financial institution, private investor, or real estate agent Use one of the following sources for verifying the value of a promissory note, loan or property agreement: Copy of the instrument Amortization schedule For a statement from a bank or other financial institution, private investor, or real estate agent (if the fair market value is being rebutted), the following information must be included: Current principal owed Appraised market value (if value is $0, document the reason) Date the original instrument was signed Interest rate Payment schedule Note: If the appraisal value is not likely to change, there is no need to reverify the value each year unless circumstances involving the resource change.
Home as an Excluded Resource F-3000	Document the address or location description of the home. Verify and document one of the following reasons for exclusion: Principal place of residence Spouse residing in home Dependent relative residing in home Home is placed for sale Life estate/remainder interest (also see the Life Estates and Remainder Interests section in this chart) Intent to return The primary evidence of an applicant's/recipient's intent to return home is the applicant's/recipient's statement, as documented on a signed Form H1245, Statement of Intent to Return to Home, or a written statement from the applicant's/recipient's spouse or authorized representative. Document the source of verification. Remember, a home placed in an irrevocable trust loses its homestead exclusion. A home placed in a revocable trust loses its homestead exclusion, but if it is removed from the trust, it can once again be excluded as a homestead if it meets the exclusion reasons. See F-3200, The Home and Resources in a Trust, through F-3300, The Home as a Countable Resource.	Verify the current residence address of the applicant/recipient and/or spouse (prior to nursing facility admission). Sources for verifying the exclusion are as follows: For a spouse/dependent relative residing in the home: Document the person’s statement establishing the residence as the spouse's/dependent relative's primary residence. Use case comments for documentation. For intent to return: Form H1245 or comparable written statement on intent to return to the described residence. Document receipt of the form in case comments. For a home placed for sale: Copy of the real estate listing agreement Newspaper ad Picture of a visible “for sale” sign on the property Collateral contact with someone viewing a visible “for sale” sign on the property, using telephone contact documentation Document these sources in case comments. Review the status of a home placed for sale at each annual review. If a shorter time frame is referenced in the real estate listing agreement, set a special review to monitor at the specified time.
The Home as a Countable Resource F-3300	Document the location and ownership of the homestead. If the property does not meet exclusion requirements, determine the current equity value of the homestead or the applicant's/recipient's equity interest in the homestead. Document in case comments the applicant's/recipient's ownership interest, if less than 100 percent, and the formula used for determining the countable equity value. Document the source of verification. See I-3000, Exceptions to the Transfer of Assets. See F-3800, The Home and Transfer of Assets.	Use one of the following sources for verifying location, ownership and current market value of a home: Tax statement with the current assessment, if using 100 percent evaluation Copy of the appraisal from the local taxing authority or appraisal district Statement from a local knowledgeable source (for example, a realtor) Telephone contact with a previously listed source, using telephone contact documentation Use one of the following sources for verifying the equity value of a home: Copy of a lien, note or other outstanding debt Statement from the mortgage company or a copy of the amortization schedule Statement from the tax office (if taxes are in arrears) In TIERS, “court record or other legal document” includes a copy of a lien, note or other outstanding debt, a statement from the mortgage company, or a copy of the amortization schedule.
Proceeds from Sale of Home or Other Real Property F-3400, F-4260	Determine the type of resource sold and whether the recipient received the current market value. If the current market value was not received, follow transfer-of-resources policy. Document the following: Selling price of the home or other real property. Gross amount received from and the expenses involved in the sale of the home/property. Itemize the expenses involved. Whether the applicant/recipient is purchasing a replacement home and the time frame for excluding the proceeds from the sale of the original home. Set a special review to monitor.	Sources for verifying the sale and amount received include: Copy of the deed Real estate contract or agreement Statement from the mortgage company or a copy of the amortization schedule Statement from the tax office (if taxes are in arrears) Copy of the appraisal from the local taxing authority or appraisal district Statement from a local knowledgeable source (for example, a realtor) Sales receipt or contract Bank deposit slip or copy of check/form of payment Sources for verifying expenses related to the sale of a resource include: Bill for repairs or services Copy of a lien or note that had to be paid to effect the sale (the copy should show the final settlement)
Home Equity F-3600	Treatment of a homestead as a resource in F-3000, Home, continues, but it does not impact the determination of disqualification for vendor payment in an institution or denial of waiver services due to substantial home equity. Evaluation of the substantial home equity is required for institutional or waiver services at application and redetermination. Consider reverse mortgage and home equity loans when determining the equity value. Consider undue hardship.	Obtain verification of the home equity value, including a copy of the reverse mortgage or home equity loan, if applicable, for the case record. Thoroughly document in case comments the home equity value and information about the reverse mortgage or home equity loan, if applicable.
Continuing Care Retirement Community (CCRC) F-3700	The entrance fee in a continuing care retirement community or life care community must be evaluated for consideration as a resource if certain criteria are met. Document the following: CCRC contract date CCRC facility name CCRC entry date Is the resource accessible? (yes/no) Does the contract specify that the fee be used to pay for care? (yes/no) Is the person eligible for a refund upon termination of the contract or departure from the CCRC? (yes/no) CCRC entrance fee value Amount of entrance fee spent on care Refundable amount	Obtain a copy of the CCRC contract.
Other Real Property F-4210	Document the following: Location and description of the property. Ownership interest in the property. Whether the property is excluded. If the property is excluded, the reason for exclusion. Current equity value of the applicant's/recipient's interest in the property. If the applicant's/recipient's ownership interest is less than 100 percent, document in case comments the percentage of ownership and the formula used for determining the value of the applicant’s/recipient’s interest. Source of verification.	Sources for verification include: Ownership interest in the property Tax statement with the current assessment, if using 100 percent evaluation Copy of the appraisal from the local taxing authority or appraisal district Statement from a local knowledgeable source about the value (for example, a realtor) Telephone contact with a previously listed source with knowledge of the property in the area, using telephone contact documentation Copy of the deed or will to verify ownership State/MEPD Specialist Judgment Call: If the property is inherited via descent and distribution, the recipient's statement on the degree of ownership may be used if no other documentation is available. Obtain the assistance of legal staff to determine the degree of ownership. Sources for verifying the equity value of other real property are as follows: Copy of a lien, note or other outstanding debt Statement from the mortgage company or a copy of the amortization schedule Statement from the tax office (if taxes are in arrears) In TIERS, “court record or other legal document” includes a copy of a lien, note or other outstanding debt, a statement from the mortgage company, or a copy of the amortization schedule.
Life Estates and Remainder Interests F-4212	Document the location of the life estate property. Document whether the life estate is excluded as a resource, such as a home. In TIERS, for a remainder interest, use life estate as the real property type and document this action in case comments. If the resource is excludable, document the reason for exclusion. If the resource is countable, document the current equity value. See Appendix X, Life Estate and Remainder Interest Tables, for information about calculating life estate and remainder interest values. Calculate the equity value and document in case comments the formula used for determining the value. Document the source used to verify the value. Note: Clearance of a life estate is required for subsequent reviews if the recipient is over the resource limit and older than when the value was initially determined. Record whether the applicant/recipient chooses to rebut the value, the basis of the rebuttal, the value from a knowledgeable source used for the rebuttal, and the verification used to support the rebuttal. For the purchase of a life estate, see I-6100, Purchase of a Life Estate. See F-3800, The Home and Transfer of Assets.	Sources for verifying ownership of a life estate or remainder interest: Copy of the deed. Copy of the will, court record or other legal document showing that the applicant/recipient has been granted a life estate or remainder interest. If the terms of the will, court record or other legal document are difficult to understand, obtain the assistance of legal staff. Sources for verifying the current market value of a life estate or remainder interest: If a statement from a knowledgeable source is obtained, the MEPD formula for determining value is not necessary. Current tax statement or assessment notice. Statement from a local appraisal district office. Statement from a realtor or an authorized employee of a savings or banking institution. Sources for verifying the equity value of a life estate or remainder interest: Copy of a lien, note or other outstanding debt Statement from the mortgagee or a copy of the amortization schedule Statement from the tax office (if taxes are in arrears) Copies of bills for essential repairs Copy of a bill for legal fees For rebuttals, written verification from a knowledgeable source Note: Life estates cannot be inherited via descent and distribution, as the life estate would end at death. One cannot inherit another person's life estate.
Life Settlement Contract F-4225.1	For the life insurance policy, document the following: Name of the life insurance company, the policy number and the face value Date the life insurance policy was converted to a life settlement contract For the life settlement contract, document the following: Name of the life settlement company Amount of proceeds from the life settlement contract Irrevocable/revocable assignment Name of the financial institution Account number Any allowable disbursements, as indicated in the account agreement Amount of funds reserved for the death benefit After certification, send an encrypted email to OESMEPDIC@hhsc.state.tx.us (listed as HHSC OES MEPD IC in the Outlook Global Address List) and document in case comments the date the email was sent. Title the email "LIFE SETTLEMENT" in all caps. In the body of the email, include all of the following: Case name Case number Document Control Number (DCN) for the life settlement contract and supporting documentation Disposition date Result of the disposition (certified or denied) Total proceeds of the life settlement contract	Sources of verification include: Copy of a contract or written agreement from the life settlement company Copy of the account agreement from the bank Bank account statement indicating deposits and withdrawals Written statement from the life insurance company indicating change of ownership
Life Insurance F-4223	Document the following: Name of the insurance company, the policy number and the face value. Type of insurance coverage. Whether or not the insurance is excluded as a resource. If the insurance is excluded, the reason for exclusion. Whether or not the insurance is a participating policy. If an applicant/recipient has a participating policy, determine and document whether the dividends are used to: Purchase additional insurance — Treat as an additional life insurance policy. Increase the value of existing insurance policy coverage — Verify whether the face value or cash value is increased. Apply toward the payment of premiums — Disregard the dividends as income or resources. Pay cash to the policyholders — Verify how often cash is paid, the amount of the payment and how the cash is used. Balance of any dividend accumulation and interest. For TIERS, if dividends are accumulating and are considered in eligibility, add the countable value of the dividends to the cash value of the policy and enter this total in the cash value section of the life insurance screen. Use case comments to document the actual value of the policy and the value of the dividends separately. Do not utilize the interest/dividend field on the life insurance screen. If the insurance is a countable resource, the current cash value. Source used to verify the value. Casework Hints: Check the bank drafts for life insurance premiums. Check the insurance policy for an Application for Life Insurance page for indicators of other life insurance policies.	Sources of verification include: Copy of the insurance policy Completed Form H1238, Verification of Insurance Policies Letter from the insurance company Telephone contact with the insurance company's representative, using telephone contact documentation Note: For term insurance, no further verification is necessary. Note: On reviews, if a total face value equal to or less than $1,500 was previously verified and the policy is not participating, no further verification is needed.
Burial Spaces F-4214	Document the name of the cemetery and the number of spaces. All burial spaces are excluded regardless of designation. However, if the person acknowledges that the spaces are purchased as an investment, count the equity value. Ownership of a burial plot in another state does not affect residency requirements or excludability.	If the burial spaces are not an investment, accept the person’s statement as verification. If the burial spaces are an investment, sources for verifying the location and number of spaces include: Applicant's/recipient's statement Cemetery association Funeral home (if associated with a particular cemetery or if it sells plots) Review the purchase contract for the burial spaces.
Burial Funds F-4227, F-4228, F-4229 Preneed Contracts F-4160, F-4170	Document the type of resource being designated. Document the total amount of assets being designated. Document the amount of the asset that is excludable under the designated burial fund exclusion. Unless the designated resource is a prepaid burial contract or a bank account styled "for burial," obtain a written statement from the applicant/recipient or his authorized representative designating the assets for burial. Verbal designation is acceptable when the applicant/recipient or authorized representative is designating life insurance insuring the applicant/recipient (or spouse) and the case is due. The recipient/authorized representative must follow up with a written statement, however, to continue the burial fund designation. For preneed contracts, document: the name of the funeral home or insurance company; how the policy is funded (e.g., life insurance, cash); whether the policy is revocable or irrevocable; the face value of the contract and who owns it; the cash value, if it is owned by the applicant/recipient; the face value, if it is irrevocable or owned by someone else; the reason for exclusion, if it is excluded; and the source of verification. May substitute another source of verification. See Appendix XXXIV, Burial Resources, for information about calculating the countable amount of preneed. Burial spaces can be excluded for anyone. However, only allow the designated burial fund exclusion for the person and the person’s spouse.	Use one of the following sources for verifying the designation of burial funds: Form H1252, Designation of Burial Funds. A written statement from the applicant/recipient or his authorized representative containing the same information requested on Form H1252. For a life insurance designation, a verbal statement from the applicant/recipient or his authorized representative containing the same information requested on Form H1252 can be utilized to certify a case on a timely basis when a written statement or a completed Form H1252 is not received prior to the certification deadline. The case also must reflect a special review to follow up for the written statement of designation. If the written verification is not received by the due date, redetermine eligibility based on the resource not being designated. Copy of the ownership papers or the financial institution's record showing the burial fund designation. If the designated burial funds are in the form of an irrevocable trust or arrangement, obtain a copy of the burial trust or agreement document. Note: Burial space items are not excludable on insurance-funded burial contracts. However, if the insurance-funded burial contract is irrevocable and fully paid, the value of the burial space item is disregarded when determining the amount of the irrevocable arrangement that reduces the burial fund designation. Exception: If the irrevocable burial contract is owned by someone other than the applicant/recipient, do not make a deduction for the burial space items regardless of whether the contract is paid in full or not; reduce the burial fund designation by the face value of the contract. For preneed contract verification, obtain one of the following: Completed Form H1238-A, Verification of Pre-Need Information Copy of the contract or a letter from the funeral home, or document verbal contact with a funeral home representative using telephone contact documentation Although contact with a funeral home representative can be used to complete a case near the delinquency deadline, immediately follow up with verification by obtaining a copy of the contract or a letter from the funeral home. For insurance-funded preneeds, verification, including irrevocable assignment, must come from the insurance company, not the funeral home.
Automobiles F-4221	Document the year, make and model of all vehicles. Exclude one vehicle regardless of value. If the household is made up of more than one person and the additional member of the household requires an additional vehicle for transportation to and from work, exclude the additional vehicle for that member for work transportation. If the household is made up of more than one person and there is an additional member of the household who requires handicap-accessible transportation, exclude an additional vehicle if the vehicle is specially equipped for that additional member of the household. For all other vehicles, use the current market value. If the applicant/recipient still owes on the vehicle, consider the current market value and equity value. If the equity value is less than the market value, document the formula used to determine the countable value. Indicate the source used to verify the current market value and equity value.	Verify the market value of a vehicle in any of the following situations: The applicant's/recipient's statement is not reasonable. The applicant/recipient owns more than one the vehicle. Sources for verifying the value of a vehicle include: Kelley Blue Book or NADA guidebook (trade-in wholesale value) Hearst Corporation Black Book Statement from an automobile dealer Newspaper ads Source knowledgeable about antique cars (in TIERS, use “other acceptable” and document in case comments) Note: If the vehicle is being declared as "junk" (not running or fixable), a $0 default value may be assigned.
Land Resources F-4213, E-3333 This includes:  Mineral Rights (oil, gas, etc.)  Surface Rights (grass, timber, etc.)	Document the following: Location/address of the property (document in case comments). Percentage of ownership interest in the land resources (document in case comments). Applicant’s/recipient’s accessibility to the interest in the land resources. Whether the land resources are excluded as a resource. If the land resources are excluded, the reason for exclusion. If the land resources are not excluded, the current equity value of the applicant's/recipient's interest in the land resources. Document in case comments the calculation of countable equity value. Source of verification. Notes: Clearance of value is not required for subsequent reviews unless circumstances occur that may change the countability or value. If the mineral rights are non-producing, assign a $100 "default value." Document in case comments the reason for the $100 default value. If the default value negatively impacts eligibility, verify a specific value.	Sources for verifying the value of land resources: Tax statement, if assessed. Contact with a knowledgeable source in the community, using telephone contact documentation. (Sources include oil and gas producers, tax assessors/collectors, and petroleum lease agents/ landmen.) Form H1242, Verification of Mineral Rights, completed by an authorized employee of the producing company. Internal Revenue Service formula for assessing the value of mineral rights for inheritance purposes — 40 times the average monthly payout (to be used only when no other source is available). In TIERS, use “other acceptable” and document this information in case comments. Sources to verify ownership include: Copies of deeds, wills or leases. If the terms of the deeds, wills or leases are difficult to understand, obtain the assistance of legal staff. Copy of royalty statement. Division order, if the mineral rights are producing. Statement from the applicant/recipient about the amount of interest (ownership). Completed Form H1242.
Sources of Earned Income E-3100 (includes royalties from book publications)	Document the following: Gross earned income (if income fluctuates, use amounts for the previous six months or the number of months available). Source of earnings. Calculations used to determine average earned income, if appropriate. Amount of the protected earned income allowance, if appropriate. Source of verification. Date of special review, if appropriate. Amount of mandatory payroll deductions. In TIERS, identify these payroll deductions on the expenses screen using case comments.	Use one of the following sources for verifying the gross earned income for the immediately preceding six months (or less, depending on the review schedule): Statement from the employer about wages (signed and dated) Copies of check stubs (for the entire period if there is fluctuating earned income) The Work Number (TWN) earned income and employment information provided through the Federal Data Services Hub (FDSH)  Written statement furnished by the ICF/IID provider, only if verification cannot be obtained from the employer Completed and signed Form H1028, Employment Verification
In-kind Support and Maintenance (Non-Vendor Only) Situations E-8000	Document the name of the person(s) who provided the support and maintenance and the type of in-kind benefit given to the applicant/recipient. Document the amount of any payment or contribution made or received by the applicant/recipient. If the applicant/recipient rebuts the presumed maximum value, document the countable value of the in-kind benefit and any calculations used to determine the countable value. Verify the stated income is sufficient to provide for known living expenses. If manipulating entries on the detail screens in order to calculate in-kind support and maintenance (ISM) correctly, thoroughly document the ISM details in case comments.	Sources of verification include: Statement from the owner as to the current market rental value Statements from the applicant/recipient and the head of household or authorized representative (use statement from Form H1200, Application for Assistance — Your Texas Benefits, if reasonable) Copies of checks for payments made by the applicant/recipient Copies of household bills (utilities, rent, etc.)
Farm Income E-3130	Document the type of farm income, the applicant's/recipient's interest in the farm income, and the accessibility of the income to the applicant/recipient. If not fully owned by the applicant/recipient, document in case comments the applicant's/recipient's ownership interest. Obtain the most recent income tax return, including Schedule F. Note: Project income based on the countable income declared on the most recent income tax return; depreciation is not an allowable expense. A review should be scheduled for six months to determine if the farm income for the period has changed significantly. If not, the projected income from the tax return should be continued until the annual review. A special review may be scheduled to obtain the next income tax return and put the annual review cycle in line with the filing of the return. In the absence of a recent (previous year) income tax return, use the amount of gross income and allowable expenses from the previous six months. Obtain this information from records provided by the applicant/recipient. If the amount of income is expected to change, document in case comments the reason for the difference in income. Document the amount of net countable income and the calculations used to arrive at countable income. See E-3120, Self-Employment, and E-6000, Self-Employment Income, for allowable expenses/deductions. Itemize these expenses/deductions and document them in case comments. Document the source of verification.	Verify gross annual income and expenses, as appropriate. If the farmland is not part of the applicant's/recipient's homestead, verify that the income is at least 6 percent of the equity value to ensure the farmland is exempt. Note: If the farm qualifies as the applicant's/recipient's business, it can be excluded regardless of the value or the rate of return (see F-4300, Resources Essential to Self-Support). Sources of verification include: Income tax return Receipts, payments and statements from other knowledgeable sources (for example, a county agent or a co-op)
Self-Employment Income E-3120, E-6000	Document the following: type of self-employment income; most recent income tax return; and amount of gross income and expenses from the previous months (if income tax return is not available or earnings are expected to be significantly different). If staff is determining earnings using the applicant's/recipient's tax return, identify if the earnings are anticipated to change significantly. Continue to use the earnings determined from the income tax return for the following six months or until the next income tax return is filed.  If staff is determining earnings using the applicant's/recipient's IRS Schedule C form, staff will be directed to the Schedule C page in TIERS to enter the applicable fields from the applicant's/recipient's IRS Schedule C form. TIERS will calculate the monthly expense amount automatically. Note: An income tax return should not be used for projecting income for more than one year. If the applicant/recipient fails to file a timely tax return, projected income must be determined based on the income and expenses from the previous six months. If the amount of income is expected to change, explain the reason. Document this information in case comments. Document in case comments the amount of net countable income and the calculations used to arrive at countable income if not using a tax return, an IRS Schedule C form, or an IRS Schedule F form.  Document the source of verification. Set a six-month special review for variable earnings income.	Verify gross earnings and expenses for the past six months. (See E-5000, Variable Income, and E-6000, Self-Employment Income, regarding the averaging of earned income every six months. For treatment in the eligibility budget, see G-2200, Variable Income, and for treatment in the co-payment budget, see H-3400, How to Budget at Reviews. Note the income tax return exception.)  Sources for verification include: most recent year's income tax return; IRS Schedule C, Form 1040- Profit or Loss from Business; IRS Schedule F, Form 1040- Profit or Loss from Farming; and   receipts maintained by the applicant/recipient Note: Reconciliation must be done when a new tax return, an IRS Schedule C form, or an IRS Schedule F form is used for projecting the recipient's income or a change in the recipient's income is noted at the six-month review. Hint: If the applicant/recipient cannot provide income records (income tax receipts, etc.), have the applicant/recipient provide a written self-declaration of projected income, or use Form H1049, Client's Statement of Self-Employment Income. Use that statement to project income for one month. Explain to the applicant/recipient the information needed to establish the applicant's/recipient's true income; set a one-month special review to obtain the necessary information. Use the information gathered at the special review to project the applicant’s/recipient's earnings for six months.
Social Security Benefits E-4100	Document the gross benefit amount and, if appropriate, the supplemental medical insurance benefits (SMIB) premium amount. If, according to SOLQ/WTPY, the difference between the RSDI gross and net benefit amounts is greater than the Medicare Part B premium, document the amount of and reason for the difference (e.g., overpayment, child support, etc.). Document the claim number. Document the source of verification. For applications, verify gross benefits. For reviews, if the recipient's statement agrees with the conversion amount and there is no indication that the RSDI benefit has changed, no further verification is needed. Document in case comments the date SOLQ/WTPY was viewed. Helpful Hint: Check for dual entitlement.	Verify the amount of Social Security benefits by one or more of the following methods: View or obtain a copy of the applicant's/recipient's award notice (letter) from the SSA. Obtain an SOLQ/WTPY. Contact a representative of the Social Security Administration, using telephone contact documentation. View or obtain a copy of the applicant’s/recipient's most recent benefit check or direct deposit slip. This method is least desirable, because the check/direct deposit slip may not show the gross benefit amount. At review, use the conversion amount in the system of record if there is no indication that the RSDI benefit is different from the converted amount.
Railroad Retirement Benefits E-4200	Document the gross benefit amount and, if appropriate, the SMIB premium amount. In TIERS, document deductions on the expenses screen and utilize case comments to explain the deductions. Check the deductions for potential life/health insurance. If a deduction is for health/life insurance, then pursue verifying and documenting the insurance policy. (See the Third-Party Resources and Life Insurance sections of this chart.) Document the railroad retirement claim number. Document the source of verification. If a special review is needed for an annual cost-of-living increase (not automated) or an anticipated change in the health insurance premium, document the date of the special review.	Verification sources include: Obtain a completed Form H1026, Verification of Railroad Retirement Benefits, to furnish information. View or obtain a copy of the applicant's/recipient's award notice issued by the Railroad Retirement Board. Contact a representative of the Railroad Retirement Board, using telephone contact documentation. View or obtain a copy of the applicant's/recipient's most recent benefit check or direct deposit slip. This method is least desirable, because the check/direct deposit slip may not show the gross benefit amount. Send a follow-up letter to the payor.
Department of Veterans Affairs (VA) Compensation and Pensions E-4300	Document the gross benefit amount and, if appropriate, the amount of any VA allowance not considered in the eligibility and co-payment budgets (i.e., aid and attendance [A&A], housebound benefits, or reimbursements for unusual or continuing medical expenses). In TIERS, if the pension is not full A&A, make two entries for VA income: one entry for the VA pension and the other entry for A&A. Document the VA claim number. Document the source of verification. Note: If the recipient's VA compensation is capped at $90, there is no need to reverify it at the recipient's review or at the COLA review. There is no need to reverify old-law benefits at the review if the recipient or authorized representative indicates there has been no change. If a special review is needed for an annual cost-of-living increase (not automated), document the date of the special review.	Verify VA benefits by one or more of the following methods: Obtain a completed Form H1240, Request for Information from Bureau of Veterans Affairs and Client's Authorization. Contact an appropriate VA representative, using telephone contact documentation. View or obtain a copy of the applicant's/recipient's award notice issued by the VA. View or obtain a copy of the most recent benefit check or direct deposit slip. This method is least desirable, because the check/direct deposit slip may not show whether the funds include aid and attendance, a housebound allowance, or reimbursements for unusual or continuing medical expenses. Send a follow-up letter to the payor.
Other Annuities, Pensions and Retirement Plans E-4400	Document the source of payments. Document the gross benefit amount and the amounts of any deductions from the gross benefit. In TIERS, document deductions on the expenses screen and utilize case comments to explain the deductions. Check the deductions for potential life/health insurance. If a deduction is for health/life insurance, then pursue verifying and documenting the insurance policy. (See the Third-Party Resources and Life Insurance sections of this chart.) If the source of payment is a civil service annuity, document the claim number. Document tape matches. Additional verification is not needed if the tape matches agree with the recipient's statement. Document the source of verification. If a change in the health insurance premium or an increase in benefits is anticipated (e.g., a cost-of-living increase for civil service annuities or a potential raise in Teacher Retirement System [TRS] or Employee Retirement System [ERS] benefits), document the date of the special review. See F-7000, Annuities.	Verify payments by one or more of the following methods: Obtain a letter from the organization providing the payments. Contact a representative of the organization, using telephone contact documentation. Obtain a completed Form H1243, Verification of Civil Services Benefits, if the payments are from that source. Obtain a completed Form H1297, Request for Information from Teacher Retirement System of Texas, if the payments are from that source. Obtain a completed Form H1214, Request for Pension Information, for other types of pensions. View or obtain a copy of the applicant's/recipient's award notice. View or obtain a copy of the applicant's/recipient's most recent check or direct deposit slip. This method is least desirable, because the check/direct deposit slip may not show the gross benefit amount and/or deductions. Send a follow-up letter to the payor. View tape matches, such as ERS or TRS.
Application for Other Benefits D-6300	If the applicant/recipient enters a Medicaid nursing facility, the administrator of the facility must notify SSA to initiate an application for Supplemental Security Income (SSI). See H-6260, Facility Administrator Responsibilities. Inquire about and document the following for potential entitlement to other benefits: Military service time for applicant, spouse or child Applicant's employment history Applicant's previous marriages Note: If there is any indication the applicant/recipient may be entitled to other benefits (e.g., VA benefits), the applicant/recipient must apply for the benefits and provide proof of application for and/or receipt of the benefits within 30 days of receiving written notice from HHSC. The caseworker must set a special review to check whether the applicant/recipient has made application to the VA or other benefit provider. See D-6300, Application for Other Benefits Requirement, for information about monitoring applications for and/or receipt of benefits.	Check with the facility administrator and system of record. The applicant’s/recipient’s declaration is acceptable. For complete policy regarding the verification and documentation of potential benefits, refer to the appropriate sections of this documentation guide and the MEPD Handbook.
Interest and Dividends E-3330	Document the following: Name of the financial institution, company or other source of interest or dividend income. If the income is received from a financial institution, the account number. If the income is received from an insurance company, the policy number. The information used for projecting income, including the interest amount and dates paid (must be verified at each review subject to variable income review policy). If the income is excludable, the reason for exclusion. If the income is countable, any calculations used to arrive at an average amount. Source of verification. If a special review is needed, the date of the special review.	Sources of verification include: Copies of bank statements Written statement from the company or financial institution making the payments Copies of dividend check stubs Completed Form H1239, Request for Verification of Bank Accounts Contact with a representative of the company or financial institution, using telephone contact documentation Completed Form H1238, Verification of Insurance Policies, if received from an insurance company
Rents E-3340	Document the type of rental income, the applicant's/recipient's interest in the rental income, and the accessibility of the income to the applicant/recipient. Document in case comments the applicant's/recipient's interest in the income. Obtain the most recent year's income tax return (depreciation is not allowable) for persons who have established rent records. Note: Income may be projected using the most recent year's income tax return, but a review is required at six months to determine if there has been a significant change in the applicant’s/recipient's income. If not using the income tax return to project income, use the amount of gross income and expenses from the previous six months to project the income and expenses for the next six months. If the amount of income is expected to change, document in case comments the reason for the difference in income. Document the amount of net countable income and the calculations used to arrive at countable income. Document in case comments the types of expenses or deductions. Document the source of verification. If a special review is needed, document the date of the special review.	Sources for verification include: Income tax return Receipts, payments, bank deposit slips and canceled checks Statements from the applicant/recipient and the renter
Royalties (from land resources) E-3330	Document the following; Name of the payor and the reason for payment. Verification of the amounts and receipt dates used in the calculation of average income. If the royalties are excludable, the reason for exclusion. If the royalties are countable, the calculations used to arrive at an average amount. Source of verification. If a special review is needed, the date of the special review.	Use one of the following methods of verification: Copies of check stubs. Completed Form H1242, Verification of Mineral Rights. Ensure the reported payments reflect when royalties were received and not when they were earned. Contact with a representative of the lease company (must be documented using telephone contact documentation). Automated telephone information is acceptable and a very good source of information, but it must be documented using telephone contact documentation.
Gifts, Inheritances, Support and Alimony E-3320, E-3370 Cross reference: Chapter I, Transfer of Assets	Document the following: Amount of the gift, support, alimony or inheritance. Whether the income will be treated as a lump-sum payment, infrequent or irregular income, or regular and predictable income. Source of the income. Frequency the income is received. Whether the income is expected to continue.	Verify a gift, an inheritance, or support and alimony payments by one or more of the following methods: Obtain a statement from the person or organization providing the item. Use “other acceptable” in TIERS and document in case comments. View or obtain copies of the court order, court records or will. If the terms and/or conditions of the agreement do not clearly identify income, obtain the assistance of legal staff. Obtain a fair market value of gift items from a knowledgeable source or through newspaper advertisement. Use other appropriate methods, depending on the nature of the item.
Notes and Mortgages E-1750, E-3331, F-4150	Document the following: Name of the person making the note payments and whether the income is accessible to the applicant/recipient. Document in case comments the name of the person making the note payments. Amount of the note payment and the frequency of payments. Whether or not the note is negotiable. Whether or not payments are countable as income and, if so, the portion of the note payment that must be considered as income. Source of verification. If a special review is needed, the date of the special review. See I-6200, Purchase of a Promissory Note, Loan or Mortgage.	Sources of verification include: Amortization schedule. Copy of contract. Copy of note or mortgage document giving the terms of repayment. If the terms and/or conditions of the agreement do not clearly identify income, obtain the assistance of legal staff. Statements from the applicant/recipient and the person who makes the payments. Use “purchaser/noteholder” in TIERS. Contact with the bank, using telephone contact documentation.
Prizes and Awards E-3360	Document in case comments the type of prize or award and the name of the awarding company. Document on the expense screen or in case comments any legal or medical expenses involved in obtaining the award. Document the value of the prize or award.	Verify prizes and awards by one or more of the following methods: Obtain a copy of the applicant's/recipient's notice of the prize or award. Contact a representative of the organization, using telephone contact documentation. View or obtain a copy of the applicant’s/recipient's check. Obtain estimates of the value if the prize or award is not cash. Obtain proof of any legal or medical expenses involved in obtaining an award.
Medical Necessity (MN)/Level of Care (LOC) Determination for Applications B-7420 Hospice A-5200	In TIERS, the interface auto-populates MN/LOC information. If the interface is not responding, the caseworker can populate TIERS screens with information verified by the Texas Medicaid and Healthcare Partnership (TMHP) or by the nursing facility (NF) if the person is receiving Medicare. If a person has elected hospice care, Form 3071, Individual Election/Cancellation/Update, serves as verification of MN.	Use one of the following methods for verification: Long-term Services and Supports (LTSS) summary screen in TIERS, populated by the interface Telephone contact with TMHP or the NF, documenting the name of the person and the date and time of contact
Thirty-Consecutive Day-Stay Rule G-6000, G-6200, O-1100, O-5000	Document in case comments that an applicant/recipient has met the 30-consecutive-days requirement, including verification and sources. If the person is eligible only because of the special income limit, the person must be admitted to a Medicaid-approved long-term care facility (Medicare-SNF, NF or ICF/IID) for the 30-consecutive-day time frame to begin. Note: A full or regular Medicaid recipient who enters a Medicaid-approved long-term care facility does not have to meet the 30-consecutive-day time frame.	Verify the applicant's/recipient's stay using one of the following methods: Contact with facility staff no sooner than the 31st day of the applicant's/recipient's stay, using telephone contact documentation Proof of admission and/or discharge due to death via the LTSS summary screen interface Contact with TMHP, using telephone contact documentation Contact with providers, using telephone contact documentation Contact with waiver staff, using telephone contact documentation
Special Review Requirement B-8200, B-8430	Hint: This list is not all-inclusive. Special reviews are set for many reasons depending on the information needed. Monitor eligibility at least every three months if the applicant’s/recipient's total countable income is within $10 of the income limit. Monitor eligibility at least every three months if the applicant’s/recipient's countable resources are within $100 of the resources limit. Special reviews are needed every six months for the following: All IMEs Variable income Other situations requiring a special review include the following: Potential benefits — Set a special review 30 days from the date of notice to apply for other benefits. Known changes, such as an increase in income or TPR amount, loss of benefits, etc. Enter in case comments the following information: Date of the special review Why a special review is being set What information needs to be requested to complete the special review The following information must be included in the case record documentation: Whether a special review is needed Specific details regarding the special review Months and source of verification relevant to the special review Date the special review will be conducted All special reviews must be entered into TIERS.

Revision 21-4; Effective December 1, 2021

 

Appendix is available for staff use on the LOOP.

Revision 16-4; Effective December 1, 2016

 

Appendix is available for staff use, here.

 

 

Revision 19-2; Effective June 1, 2019

Revision 16-4; Effective December 1, 2016

 

Appendix is available for staff use, here.

 

 

 

Revision 09-4; Effective December 1, 2009

Revision 23-3; Effective Sept. 1, 2023

Note: This information is effective Sept. 1, 2023.

Appendix is available for staff use on the LOOP.

Revision 18-1; Effective March 1, 2018

 

Appendix is available for staff use, here.

Revision 16-4; Effective December 1, 2016

Appendix is available for staff use, here.

Revision 16-4; Effective December 1, 2016

 

Appendix is available for staff use, here.

 

 

Revision 16-4; Effective December 1, 2016

 

Appendix is available for staff use, here.

 

 

Revision 16-4; Effective December 1, 2016

 

Appendix is available for staff use, here.

Revision 23-2; Effective June 1, 2023

Note: The following information is effective March 1, 2023.

Step	Spouse-to-Spouse Procedure	Budget		Budget		Budget
Pretest	Applicant or recipient must first be eligible based on the applicant's or recipient's own income in the pretest. Determine if the applicant or recipient meets the pretest. Use G-5100, Individual and Couple Noninstitutional Budgets, or G-7000, Prior Coverage, as appropriate. If eligible as an individual in the pretest, use the following steps when deeming from an ineligible spouse to the applicant or recipient.
1	Determine the appropriate income limit.			QMB		SLMB
2	Determine the nonexempt and non-excludable gross earned and unearned income of the ineligible spouse; Reference E-1700, Things That Are Not Income, E-2440, Certain Health-Related Payments, E-3170, Census Bureau Wages, E-4300, VA Benefits, E-4318, VA Contracts, E-7200, When Deeming Procedures Are Not Used, and E-7300, When Deeming Procedures Begin.	gross earned	unearned	gross earned	unearned	gross earned	unearned
3	Determine the number of children.
	If no ineligible children and countable income is less than the program-specific living allowance allocation, skip to 4a.
	Program-Specific Living Allowance Allocation: Community MEPD $457; CA $457; QMB $428; SLMB $514; QI-1 $579; QDWI $857;
	Determine the non-exempt income of the ineligible children. See MEPD references in Step 2.
	Deduct from the ineligible spouse's countable income the program-specific living allowance for each ineligible child reduced by the ineligible child's gross amount of income. If the child's own income exceeds the allowance, there is no deduction and the child and their income is disregarded in the budget. The living allowance allocations are first deducted from the ineligible spouse's unearned income. If the ineligible spouse does not have enough unearned income to cover the allocation, the balance of the allocation is deducted from the ineligible spouse's earned income. Reference Appendix XXXI, Budget Reference Chart.
4a	If remaining income (unearned or earned) of the ineligible spouse is no greater than the program-specific living allowance, stop. No income is deemed.
4b	If remaining income (both earned and unearned) of the ineligible spouse exceeds the program-specific living allowance allocation, the applicant or recipient and the ineligible spouse are treated as an eligible couple in the deeming process. Continue with Step 5.
5	Determine applicant's or recipient's monthly gross earned income and monthly unearned income, including the applicant's or recipient's support and maintenance. Because support and maintenance is exempt for the ineligible spouse, use the appropriate companion amount in Appendix XXXI. Reference E-8000, Support and Maintenance.	gross earned	unearned	gross earned	unearned	gross earned	unearned
	Combine the remainder of the ineligible spouse's unearned income with the applicant's or recipient's unearned income and the ineligible spouse's earned income with the applicant's or recipient's earned income.
6	From the combined unearned income, deduct $20. If there is less than $20 unearned income, the remaining portion of the $20 exclusion is applied to earned income; Note: The $20 disregard is not applicable for Special Income Limit cases Spouse-to-Spouse Deeming (CAS, institutional and Waiver programs). Reference G-4110, Twenty-Dollar General Exclusion.
7	From the combined earned income, deduct up to $65 plus half of the remaining earned income. Note: not applicable for Special Income Limit cases for Spouse-to-Spouse Deeming (CAS, Institutional and Waiver programs). Reference G-4120, Earned Income Exclusion.
	Deduct applicant's or recipient's COLA(s) for Pickle, DAC or Widow or Widowers. G-4300, Special Income Exclusion for COLA Disregard.
	Deduct applicant's or recipient's Social Security COLA(s) for January and February of each year if the current countable budgeted income exceeds the appropriate QMB, SLMB, QI-1 Income Limit. See Q-1400, MSPs and Cost-of-Living Adjustments (COLAs).
	Remainder is countable income.
8	Compare to the appropriate income limit for an eligible couple.
	If an unmet need of 1 cent or more exists, the individual is eligible.
	For the Special Income Limit or the QMB Limit, if the income is no greater than these limits, the individual is eligible.

Reference Appendix XXXI for income, resource and budget amounts. If eligible on individual pretest for QMB but not eligible for QMB in the special deeming eligibility test, re-budget appropriate programs for SLMB or QI-1. The minimum income requirement for SLMB or QI-1 does not apply when the applicant is ineligible due to deeming. For parent-to-child deeming, see G-2312, Parent-to-Child Noninstitutional Deeming.

Revision 19-1; Effective March 1, 2019

 

Note: This document is effective Jan. 1, 2012.

Community Based

Type Program	MED
ME – Pickle	For ME - SSI to medical assistance only (MAO) program overlays or program transfers, the MED may be the first day of the month following the last month of Supplemental Security Income (SSI) eligibility. 3MP constraints apply (Form H1200, Application for Assistance – Your Texas Benefits, file date).
ME – Disabled Adult Child	For ME - SSI to MAO program overlays or program transfers, the MED may be the first day of the month following the last month of SSI eligibility. 3MP constraints apply (Form H1200, Application for Assistance – Your Texas Benefits, file date).
ME – Disabled/Early Aged Widow(er)	For ME - SSI to MAO program overlays or program transfers, the MED may be the first day of the month following the last month of SSI eligibility. 3MP constraints apply (Form H1200, Application for Assistance – Your Texas Benefits, file date).
ME – SSI Prior	For certified SSI clients, Medicaid coverage automatically begins with the month prior to the first month of SSI payment. For ME – SSI Prior applications, the MED may be as early as the first day of the month, two months prior to the SSI gap month. (SSI Begin Date = Payment Month) For denied SSI applicants, the MED may be as early as the three months prior to the SSI application month.
ME – Waivers	For waiver eligibility, the effective date for medical assistance is either: the first day of the month of nursing facility (NF), intermediate care facility for individuals with intellectual disabilities or related conditions (ICF/IID) or state supported living center entry if the applicant filed a Medicaid application during that month, then requested a program transfer before being certified, and met all eligibility criteria; the first day of the month if the applicant met all Waiver Eligibility Component and Financial Medicaid Eligibility Component criteria. See Section O-1100, Application for Waiver Programs; or the day after the effective date of denial (under ME - SSI), for people transferred from SSI assistance to MAO (excluding qualified Medicare beneficiaries). Notes: Consider potential three months prior to the application file date if the individual entered an NF, ICF/IID or state supported living center and then transitioned into a waiver setting before being certified. See Institutional Based section of this appendix. Also, see Section B-6300, Institutional Living Arrangement; Section B-7400, Application for Institutional Care; and Section J-4310, Determining the Assessment Date for a Home and Community-Based Services Waiver. The MED information for waivers would not apply if the waiver required Medicaid eligibility prior to waiver services consideration (for example, Texas Home Living Waiver).
ME – Community Attendant	Use the: first day of the month that the application was filed, if the provider started services during that month; first day of the month services started, if the application was filed by that date; or first day of the month that the eligibility decision was made.
MC – SLMB	MED is the first day of the month in which the application is filed as long as all eligibility factors are met. MED can be the first of any of the three months prior.
MC – Qualifying Individuals (QI-1)	MED is the first day of the month in which the application is filed as long as all eligibility factors are met. MED can be the first of any of the three months prior. 3MP cannot include previous calendar year unless the application was filed in the previous year.
MC – QMB	MED is the first day of the month following the month the case is processed and disposed in TIERS unless ensuring continuous Q.
ME – A and D - Emergency	MED is the date the emergency condition started. Use the date the practitioner entered on Form H3038, Emergency Medical Services Certification. There is also an end date. The practitioner will have also listed it on Form H3038. These are open/close cases.

 

Institutional Based

ME – Nursing Facility, ME – State School, ME – Non-state Group Home, ME – State Group Home, ME – State Hospital

Situation	Determination
Apply and Enter Nursing Facility (NF) in Same Month	Must meet 30 consecutive days in the facility. MED is the first day of the month of the month of entry to the facility.
Apply in Month following Month of Entry (Prior Months)	MED is potentially the first day of any of the three months prior to the application file date. Use the SSI income limit unless entry to a facility is during the month. If facility entry is in a prior month, use institutional income limit.
Subsequent Month	If individual is not resource eligible, the MED is the first day of the subsequent month in which all eligibility factors are met.

 

What to do if:

Situation	Determination
Applicant enters extended care facility (ECF) section of NF:	MED is the first day of the month of entry to ECF. ECF serves as the medical necessity (MN). At whatever point applicant moved from ECF or no longer meets Medicare care definition of skilled nursing facility, then MN is required. If time in ECF is in any prior months, the MED is the first day of any of the three months prior.
SSI client enters facility and SSI is denied:	MED is the first of the month following the last month of SSI eligibility.
SSI client enters facility and SSI is still active:	MED is the first of the month after the month SSI is denied. Email Data Integrity (DI) giving information of entry date. Once SSI shows denied the MEPD specialist can enter information for the applicable institutional EDG. If stay is temporary less than 90 days no change is needed. See Section B-7200 for specific details.
Individual enters NF from the community:	MED is potentially the first day of any of the three months prior to the application file date. Use the SSI income limit for income eligibility purposes if the individual was not in the facility any part of the month.
Individual enters facility from the hospital:	MED is potentially the first day of any of the three months prior to the application file date. Use the special income limit for the month of entry to the facility.

 

Continuous Coverage

Type Program	Time Frame
ME – Pickle	Continuous coverage is ensured if the application is filed by the end of April or the end of the fourth month after denial, if client continues to meet eligibility criteria and has unpaid or reimbursable medical bills during this prior time period.
ME – Disabled Adult Child	Continuous coverage is ensured if the application is filed by the end of April or the end of the fourth month after denial, if client continues to meet eligibility criteria and has unpaid or reimbursable medical bills during this prior time period.
ME – Disabled/Early Aged Widow(er)	Continuous coverage is ensured if the application is filed by the end of April or the end of the fourth month after denial, if client continues to meet eligibility criteria and has unpaid or reimbursable medical bills during this prior time period.
QMB	Continuous Qualified Medicare Beneficiary (QMB) Program coverage must be ensured, as well as Medicaid coverage. Retroactivity for continuous QMB may be as early as 24 months prior to the beginning of the current fiscal year (with September considered the start of a fiscal year), if appropriate.

Revision 23-3; Effective Sept. 1, 2023

Community-Based Programs Using SSI Limits (DAC, Pickle, Widow(er)s)

Income — Effective Jan. 1, 2023, total countable income must be less than the Supplemental Security Income (SSI) federal benefit rate (FBR) with the exclusion of certain increases in Social Security benefits:

• Individual — $914
• Couple — $1,371
• Deeming amount — $457

Resources — Total countable resources must be no more than the limit:

• Individual — $2,000
• Couple — $3,000
• Companion — $3,000

In-Kind Support and Maintenance (Community Living Arrangement)

Effective Jan. 1, 2023:

• One-third of the SSI FBR:
  • Individual — $304.66
  • Couple — $457.00
• One-third of the SSI FBR + $20:
  • Individual — $324.66
  • Couple — $477.00
• One-half of the couple 1/3 SSI FBR:
  • Companion — $228.50
• One-half of the couple 1/3 SSI FBR + $10:
  • Companion — $238.50

All Living Arrangements

Effective Jan. 1, 2023, the special income exemption for a student’s earned income, regardless of living arrangement, is:

• Monthly earnings — $2,220
• Annual earnings — $8,950

Related Policy

Student Earnings, E-2220

Medicare Savings Programs (MSP)

Income limits are based on the federal poverty level (FPL).

Income — Effective March 1, 2023, total countable income must be:

• QMB — Not more than 100% FPL:
  • Individual — $1,215
  • Couple — $1,643
  • Deeming amount — $428
  • Medicaid benefits are:
    • Part A premiums
    • Part B premiums
    • Deductibles
    • Coinsurance
• SLMB — Greater than 100% FPL, but less than 120% FPL:
  • Individual — $1,215.01 to < $1,458
  • Couple — $1,643.01 to < $1,972
  • Deeming amount — $514
  • Medicaid benefits are:
    • Part B premiums
• QI-1 — At least 120% FPL, but less than 135% FPL:
  • Individual — $1,458 to < $1,640
  • Couple — $1,972 to < $2,219
  • Deeming amount — $579
  • Medicaid benefits are:
    • Part B premiums
• QDWI — No more than 200% FPL:
  • Individual — $2,430
  • Couple — $3,287
  • Deeming amount — $857
  • Medicaid benefits are:
    • Part A premiums

Note: These income limits do not include the $20 disregard for MSP.

Resources — Effective Jan. 1, 2023, total countable resources must be:

• QMB, SLMB, QI-1 — No more than the limit:
  • Individual — $9,090
  • Couple — $13,630
• QDWI — No more than twice the SSI resource limit:
  • Individual — $4,000
  • Couple — $6,000

Medicaid Buy-In (MBI) Program

Income — Effective March 1, 2023:

• Income eligibility is based on earnings.
• Countable earned income must be less than the limit:
  • 250% of FPL — $3,038

Resources — Total countable resources must be no more than the limit of $2,000.

MBI Monthly Premiums: Countable Unearned Income Minus (−) SSI FBR of $914 Plus (+) Earned Income Premium

Unearned Income Premium
Countable Unearned Income Minus (−) SSI FBR $914

Earned Income Premium

Countable Earned Income Based on FPL Range
FPL	Dollar Range	Earned Income Premium
at or below 150% FPL	Less than or equal to $1,823	$0
150%–185% of FPL	Greater than $1,823 up to and including $2,248	$20
>185%–200% of FPL	Greater than $2,248 up to and including $2,430	$25
>200%–250% of FPL	Greater than $2,430 up to and including $3,038	$30
>250% of FPL	Greater than $3,038	$40

If the unearned income premium amount plus the earned income premium amount equals or exceeds $500, then the total monthly premium remains at $500.

Medicaid Buy-In for Children (MBIC) Program

Resources — No resource test for MBIC.

Income — Effective March 1, 2023:

• MBIC income exclusion — $85 plus one-half of the remaining income.
• Eligibility — No more than 150% FPL based on family size.

These amounts do not include the MBIC income exclusion.

FPL Amounts for Income Eligibility
Family Size	150% FPL
1	$1,823
2	$2,465
3	$3,108
4	$3,750
5	$4,393
6	$5,035
7	$5,678
8	$6,320

Ineligible sibling exclusion amount (150% FPL x 2 + $85) — $3,731

FPL Amounts for Premium Determination

Family Size	150% FPL	200% FPL	300% FPL
1	$1,823	$2,430	$3,645
2	$2,465	$3,287	$4,930
3	$3,108	$4,144	$6,215
4	$3,750	$5,000	$7,500
5	$4,393	$5,857	$8,785
6	$5,035	$6,714	$10,070
7	$5,678	$7,570	$11,355
8	$6,320	$8,427	$12,640

MBIC Premiums — No Employer-Sponsored Insurance (ESI)
Family Income	Family of 1 or 2 Premium Amount	Family of 3 or More Premium Amount
At or below 150% FPL	$0	$0
151–200% FPL	$90	$115
201–300% FPL	$180	$230

MBIC Premiums — ESI with State-Paid Health Insurance Premium Program (HIPP)

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

MBIC Premiums — ESI and No State-Paid HIPP

No MBIC premium.

Medicare Premiums

Effective Jan. 1, 2023

Part A Premium (Hospital Insurance):

• $0 — Most people do not pay a monthly Part A premium because they or a spouse has 40 or more quarters of Medicare-covered employment.
• $506 — Standard Medicare Part A monthly premium cost — The monthly Part A premium for people who are not otherwise eligible for premium-free hospital insurance and who have less than 30 quarters of Medicare-covered employment.
• $278 — Reduced Medicare Part A premium — The monthly Part A premium for people who have 30–39 quarters of Medicare-covered employment.

Part B Premium (Medical Insurance):

• $164.90 — 2023 standard Medicare Part B monthly premium.

Staff must use the Medicare Part B amount as verified in the State Online Query (SOLQ).

Related Policy

Medicare Part B Premium, H-1800

Community Attendant Services (CAS)

Income — Effective Jan. 1, 2023, total countable income must be no more than the special income limit:

• Individual — $2,742
• Couple — $5,484

Resources — Total countable resources must be no more than the limit:

• Individual — $2,000
• Couple — $3,000

Institutional Living Arrangement (Individuals residing in a Medicaid certified long-term care facility or receiving Home and Community Based Waiver services)

Individual or Couple Eligibility Budget

Special income limit — The special income limit for an individual is equal to or less than 300% of the SSI federal benefit rate.

Income — Effective Jan. 1, 2023, total countable income must be no more than the special income limit:

• Individual — $2,742
• Couple — $5,484

Resources —Total countable resources must be no more than the limit:

• Individual — $2,000
• Couple — $3,000
• Substantial home equity — $688,000.00
• Transfer of assets (TOA) divisor — $242.13 daily rate (effective Sept. 1, 2023)

Note: The Transfer of Assets daily rate is reviewed every other year.

Co-Payment

Individual or Couple Co-Payment Budget:

• Personal Needs Allowance (PNA) —
  • $60 (nursing facility recipient)
  • $60 plus the Protected Earned Income (PEI) amount (recipient in an ICF/IID facility)
  • $85 (recipient in foster care or assisted living)
  • $2,742 (HCBS waiver recipient)
• Guardianship Fees — Varies
• Dependent Allowance — $914
• Incurred Medical Expenses — Varies
• Deduction for Home Maintenance — Up to $914

Spousal Co-payment Budget:

• Personal Needs Allowance (PNA) —
  • $60 (nursing facility recipient)
  • $60 plus the Protected Earned Income (PEI) amount (recipient in an ICF/IID facility)
  • $85 (recipient in foster care or assisted living)
  • $2,742 (HCBS waiver recipient)
• Guardianship Fees — Varies
• Minimum Monthly Maintenance Needs Allowance (MMMNA) (Spousal allowance) — $3,715.50
• Spousal Impoverishment Dependent Allowance — $2,465 (effective July 1, 2023)
• Incurred Medical Expenses — Varies

Calculation of the Spousal Protected Resource Amount (SPRA):

• SPRA is the greater of:
  • one-half of the couple's combined countable resources; or
  • the minimum resource amount set by federal law (SPRA minimum — $29,724); but
  • SPRA is not to exceed the maximum resource amount set by federal law (SPRA maximum — $148,620).

Income-first minimum monthly maintenance needs allowance (MMMNA) for SPRA expansion (Spousal Allowance) — $3,715.50

Related Policy

Personal Needs Allowance (PNA), H-1500
Guardianship Fees, H-1550
Dependent Allowance, H-1600
Deduction for Home Maintenance, H-1700
Incurred Medical Expenses, H-2000
Spousal Impoverishment Dependent Allowance, J-7400

Revision 16-2; Effective June 1, 2016 

 

Revision 21-1; Effective March 1, 2021

Introduction

Assistance is available to help pay for medical care and supportive services for people with limited income and resources. The following information explains some of the requirements used to determine if you are eligible for help and what must be done to get help.

If you are interested in getting Medicaid to pay for medical and supportive services, you need to file an application. Depending on your income, you will file an application with either the Social Security Administration for Supplemental Security Income (SSI) or with the Texas Health and Human Services Commission (HHSC). If the Social Security Administration determines you are eligible for SSI, you will also be eligible for Medicaid without having to file a separate application with HHSC.

At HHSC, eligibility staff are responsible for determining the financial eligibility for Medicaid. This Medicaid assistance is available for those who do not have SSI and need care:

• in a nursing facility;
• in an intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID);
• in an institution for mental diseases (IMD); or
• through a home and community-based waiver program (these programs offer services and supports to help you live in the community).

Depending on your income, assistance is also available to help pay for your Medicare premiums (Part A, Part B or both), deductibles and coinsurance costs through a Medicare Savings Programs, Qualified Medicare Beneficiary (QMB), Specified Low-Income Medicare Beneficiary (SLMB) or Qualifying Individuals-1 (QI-1).

You or your representative must complete an application for Medicaid and furnish the proof needed to make an eligibility determination. HHSC will determine your eligibility for Medicaid based on the information you provide on the application, documents you send in, and information that you orally explain.

By federal law, HHSC must also use your Social Security number to compare information with other state and federal agencies, such as the Internal Revenue Service, Social Security Administration, Texas Workforce Commission, and any others to ensure that your benefits are correctly determined. If you meet all eligibility requirements, HHSC is required to completely review your circumstances at least once a year to make sure you are still eligible for help.

You have the responsibility to let HHSC know, within 10 days, of any changes in your circumstances, including changes in your address and living arrangements, your income and resources, and your private health insurance premium amounts.

Non-Financial Eligibility

• Age and Disability — You must be at least 65 or older or, if under 65, you must get Social Security or Railroad Retirement disability benefits. If you are not getting a disability benefit, HHSC will complete a disability determination using your medical, education, and work history information.
• Citizenship — You must be a U.S. citizen or a qualified legal alien. Qualified legal aliens include those who have been lawfully admitted for permanent residence, active-duty military or honorably discharged veterans (or the spouses or dependent children of veterans), certain refugees or asylees, and certain people for whom deportation has been deferred. Unless you already have Medicaid or Medicare, a U.S. public birth certificate showing birth in one of the 50 states, the District of Columbia, Puerto Rico (if born on or after Jan. 13, 1941), Guam (on or after April 10, 1899), the Virgin Islands of the U.S. (on or after Jan. 17, 1917), American Samoa, Swain’s Island or the Northern Mariana Islands (after Nov. 4, 1986) may be necessary to prove your citizenship. You may also need proof of earning 40 quarters of Social Security credit or proof of 10 years of verifiable work credit to prove your alien status.
• Residence — You must be a resident of the U.S. and Texas.
• Medicare Savings Programs — You must be entitled to Medicare Part A for QMB, SLMB and QI-1. You will need a Medicare card, award letter, or some other document from the Social Security Administration as proof of your Medicare Part A entitlement.
• Medical Necessity, Level of Care for Nursing Facility, ICF/IID and Waiver Programs — Your need for medical care available in a Medicaid facility or a Medicaid waiver program will need to be determined.
• 30 Consecutive Days in an Institution — This applies after admission to a nursing facility, ICF/IID or IMD (if 65 or older). If you want help paying for care in a facility, you must stay in a facility that has a Medicaid contract for 30 consecutive days. If you must go to the hospital before the end of 30 days, but return directly to a Medicaid facility, the hospital stay counts toward the 30 days. If you meet all other eligibility criteria from the day you are first admitted to a facility, Medicaid can pay for care beginning the day of admission, once 30 days has passed.

Income

HHSC must consider your income from all sources. Gross income is usually used for the eligibility determination. Therefore, when comparing your income to the income limit for a program, deductions that are withheld from your income before you get it may be included.

If you get your income less frequently than monthly, it may or may not be countable. An example of income that may not be countable is a small amount of interest you receive quarterly.

Certain types of income may be exempt or excluded for the eligibility determination. An example of exempt income is a refund of federal income taxes relating to the earned income tax credit a person receives from the Internal Revenue Service (IRS).

Proof of Income

HHSC requires proof of income and deductions from income, such as award letters, check stubs from pension checks, check stubs from mineral rights payments, amortization schedules, bank statements listing interest or dividend payments, rent receipts (tax, insurance, and repair expense receipts), and copies of checks.

It may take some time to gather all the needed proof and more proof may be needed to verify your eligibility. Any of the above items that you send in with an application may speed up the eligibility decision.

If you are determined to be eligible, proof of your income may also be needed whenever there is a change in the amounts and at least once a year when your circumstances must be completely reviewed.

Resources

Resources are things that you own or are buying. The resources of both you and your spouse must be reported, regardless if the resources are owned by your or your spouse individually or together. The total value of resources that must be counted cannot exceed certain resource limits. Resource values are determined as of 12:01 a.m. on the first day of the month(s) that eligibility is determined. Some resources may not be counted.

For a waiver program, resources of a parent(s) are not considered.

Examples of Excluded Resources — The following are examples of some resources that HHSC does not count when determining eligibility:

• Homestead — If you, your spouse, or a dependent relative live in the home, the value of the home is not counted. Absence from a homestead may result in loss of its homestead status and exclusion unless you have an intent to return. If you have an intent to return to a homestead in another state, you do not meet the Texas residency requirement. If the value of your home exceeds a certain amount, you may not qualify for payment of nursing facility or waiver services.
• Vehicle — One vehicle is excluded, regardless of value. If your household has more than one person and the additional member of the household requires an additional vehicle for transportation to and from work, the additional vehicle is excluded for that member for work transportation. If your household has more than one person and there is an additional member of the household who requires disability accessible transportation, an additional vehicle is excluded if the vehicle is specially equipped for that additional member of the household. For all other vehicles, HHSC counts the current market value or, if you still owe on the vehicle, the current equity value as a resource.
• Life Insurance — Life insurance policies that you own with a total face value of $1,500 or less per insured person are excluded. If the face value of all policies per person exceeds $1,500, the cash value is counted as a resource. Term insurance is excluded.
• Burial Spaces —All burial spaces are excluded, unless you purchased them as an investment, in which case the equity value is counted.
• Burial Funds —Up to $1,500 of the funds identified for burial may be excluded, if kept separate from other resources. This exclusion is only for you and your spouse. This amount is reduced by the face value of any excluded life insurance and the value of any irrevocable arrangements for the individual's burial.

Examples of Countable Resources — The following are examples of resources you may own that are counted when determining eligibility:

• Checking accounts, savings accounts, certificates of deposit, money market accounts, individual retirements accounts (IRAs), stocks, bonds, land, lots or houses (other than homestead), and oil, gas, and mineral rights.
• Prepaid Burial Contracts — Prepaid burial contracts may or may not be excluded depending on the terms of the contract, how the contract is paid, ownership of life insurance, and the value of any other burial arrangements you own or another person owns that is for you.
• Other resources may or may not be countable depending on ownership and the use of items. Examples are antiques, jewelry, livestock, promissory notes, loans, property agreements, annuities, and trusts.

Spousal Impoverishment

The term "spousal impoverishment" is used to identify a federal law that allows a spouse still living at home to keep additional income and resources so they can continue to live independently.

If you apply for Medicaid in a nursing facility, ICF/IID, IMD or for a waiver program and have a spouse living in the community, a Spousal Protected Resource Allowance (SPRA) is determined for your spouse. The SPRA is determined as of the month you are admitted to a facility or the month you apply for waiver services.

The value of all resources owned by you and your spouse is combined and divided in half. The value of a homestead, one vehicle, personal goods, and certain burial funds for both you and your spouse is not included in the resource total.  Your spouse who continues to live in the community is allowed to keep up to half of the total countable resources subject to the minimum and maximum allowable amounts, which change annually.

The amount of resources not protected for your spouse is your countable resource amount. Your countable resources cannot exceed the $2,000 resource limit to be eligible for medical assistance.

The SPRA exclusion ends at the first annual redetermination of your circumstances. At that time, all resources that remain in your name are considered in determining eligibility. Your total countable resources cannot exceed the $2,000 resource limit for you to stay eligible for medical assistance.

Proof of Resources

Proof of the ownership and value of resources is required. Examples of proof include bank statements, copies of notes, stocks, bonds, property deeds, loans, mortgages, insurance policies, prepaid burial contracts, annuities, letters from appraisers, and trust instruments.

It may take some time to gather all the needed proof and additional proof may be needed to determine the resource amount for specific months. Any of the above items that you send in with your application may help to speed up the eligibility decision. Proof of your resources will also be needed whenever there is a change in the ownership or the value of items you own and at least once a year when your circumstances must be completely reviewed.

Transfer of Assets

Giving away things you own for no compensation or refusing to accept income or reducing income you could receive may result in a penalty of non-payment for nursing facility services, ICF/IID facility services, or ineligibility for waiver program services or state supported living center services.

For income and resources that you transfer, the look-back time is up to 60 months before you apply for institutionalization or waiver services.

Cost of Care Responsibility

If you are eligible for Medicaid in a nursing facility, ICF/IID facility, IMD (if 65 or older) or for waiver program services, you may have to pay toward the cost of your care. This is referred to as your copayment. From your total income, you are allowed to keep a standard personal needs allowance. The amount of this allowance is different for different programs. Certain medical expenses you may pay, such as general health insurance premiums, Medicare premiums, deductibles and coinsurance, certain dental fees or prescription drug costs, may also be deducted. HHSC staff will calculate your copayment and notify you and your case manager or your service provider of the amount. The arrangement for your portion of the payment is between you, your case manager or the service provider. Medicaid payments for your care will be made directly to the service provider.

To access the Medicaid eligibility rules on the Internet, follow the steps below:

• Go to www.sos.state.tx.us/tac.
• Under Points of Interest, select View the current Texas Administrative Code.
• A menu will appear entitled Texas Administrative Code: Titles. Select Title 1, Administration.
• Select Part 15, Texas Health and Human Services Commission.
• Select Chapter 358, Medicaid Eligibility for the Elderly and People with Disabilities.
• Select the subchapter you desire.

This information is a general overview about Medicaid financial eligibility determinations and may not specifically cover your situation. The information is dated because the eligibility policies may be changed by federal, state, and agency rules. If you have questions about your situation, please contact 211.

Current Income and Resource Limits

Current budget limits are available in Appendix XXXI, Budget Reference Chart, of the Medicaid for the Elderly and People with Disabilities Handbook.

Revision 16-4; Effective December 1, 2016

 

Appendix is available for staff use, here.

 

 

Revision 16-4; Effective December 1, 2016

 

Appendix is available for staff use, here.

 

 

Revision 23-1; Effective March 1, 2023

The Texas Health and Human Services Commission (HHSC) offers this information. It helps prospective Medicaid applicants and their attorneys by describing basic information on using a qualifying income trust (QIT), sometimes referred to as a "Miller" Trust, in meeting MEPD eligibility requirements. The end of the document shows a model instrument. It gives an example of a QIT that meets MEPD requirements when properly completed. This form meets the basic MEPD requirements for a QIT, but it is not the only acceptable QIT form, and it may have consequences beyond Medicaid eligibility that an applicant would want to consider.

HHSC attorneys are prohibited from giving legal advice to the public. HHSC staff, supervisors and other HHSC non-attorneys are prohibited from recommending specific actions to become eligible for Medicaid as doing so may constitute the unauthorized practice of law.

HHSC staff must inform applicants and other people of MEPD requirements. This information is not intended as legal advice. People seeking information on the legal consequences of these documents can consult a lawyer of their choice. HHSC will only review trust documents connected with the processing of a Medicaid application. The review by HHSC is limited to a determination of whether the trust meets the requirements for a Medicaid QIT.

People with low or limited income may be able to get legal counsel through their local legal aid office, local area agency on aging, local bar association, National Academy of Elder Law Attorneys, lawyer referral service, Advocacy Inc. or the State Bar of Texas.

Background

Eligibility for Medicaid institutional or home and community-based waiver services in Texas includes a requirement that the applicant's countable income not exceed the special income limit. The special income limit for a person is equal to or less than 300 percent of the full individual Supplemental Security Income (SSI) benefit rate. The special income limit for a couple is twice the special income limit for an individual. Effective Jan. 1, 2023, the special income limit is $ 2,742 per month for an individual and $5,484 per month for a couple.

HHSC's current estimate of the average daily cost of a private pay nursing home stay in Texas for an individual is $237.93 — an amount that is significantly more than the individual special income limit.

Thus, Texas residents who need nursing home care and who have monthly income above the special income limit but below the private pay cost of the care, may have insufficient funds to pay for the needed care. To address this problem, Congress in 1993 amended Section 1917 of the Social Security Act. It provides for an income diversion trust, or QIT (see 42 USC Section 1396p(d)(4)(B)). The proper use of a QIT allows a person to legally divert the individual's income into a trust, after which the income is not counted for purposes of the MEPD institutional and home and community-based waiver special income limit.

Caution

Do not confuse a QIT with other types of trusts often used in connection with the receipt of Medicaid or other public benefits. This information does not address these other types of trusts, such as a "Special Needs" trust. A special needs trust may be created for a person with a disability, under 65, who wishes to shelter assets to become or stay eligible for Medicaid or other public benefits. HHSC does not count income that is properly diverted through a QIT to determine Medicaid eligibility for institutional or home and community-based waiver services. HHSC does count this income to determine eligibility for other Medicaid benefits, such as:

• non-institutional assistance other than home and community-based waiver services; or 
• Medicare Savings Programs.  

You may count such income in determining eligibility for non-Medicaid public benefits programs. 

Although the use of a QIT can overcome the special income limit for Medicaid eligibility, a QIT will not address other eligibility requirements for institutional and home and community-based waiver services, such as:

• citizenship;
• residency;
• medical necessity; and 
• the applicant's countable resources.  

A person with more than $2,000 in countable resources is not eligible for benefits. The use of a QIT does not affect this resource eligibility requirement.

This information is based in part on informal guidance by the federal Centers for Medicare & Medicaid Services (CMS). CMS has not adopted any federal regulations relating to QITs. Therefore, CMS' guidance and interpretations could change without advance public notice or any opportunity for advance public comment.

Necessity

The Texas MEPD special income limit applies only to an applicant's countable income. Therefore, to determine the need for a QIT, first ask whether the income is countable for purposes of Medicaid eligibility, and then ask whether a prospective applicant's income will stay the same upon getting Medicaid assistance for nursing facility care. For example, certain types of Veterans Affairs (VA) benefits do not count. Also, some types of income, such as VA pensions, are subject to automatic reduction when a person living in a Medicaid-certified nursing facility becomes eligible for MEPD. In addition, when retirement income has been legally divided between spouses through a Qualified Domestic Relations Order and each spouse gets a check in their own name, the income of one spouse is not generally counted with respect to the other spouse. Texas follows a "name on the check" rule in counting the income of applicants for nursing home MEPD assistance.

Characteristics of the Trust

Only pension, Social Security, and other income may be placed in a QIT. An applicant's resources may not be put into this type of trust. Since the trust has no "corpus" as that term is generally understood in the trust field, the need for much of the standard trust language about management of the trust principal is eliminated, and the language of the written trust instrument may be shortened accordingly. A prospective MEPD applicant may divert all their income into a QIT, or if they have income from multiple sources, only the income from certain sources. However, income from any given source must go entirely into the QIT, or not at all.

VA aid and attendance benefits, housebound allowances, and reimbursements for unusual or continuing medical expenses are exempt from both eligibility and co-payment. However, if a person deposits these payments into a QIT account, they are countable for co-payment. If a person receives a VA pension that includes aid and attendance benefits, housebound allowances, or reimbursements for unusual or continuing medical expenses, the person may separate the aid and attendance benefits, housebound allowances, or reimbursements for unusual or continuing medical expenses from the VA pension before depositing the VA pension into the QIT account. Aid and attendance benefits, housebound allowances, or reimbursements for unusual or continuing medical expenses are not income for Medicaid eligibility determinations.

The trust must be irrevocable. CMS has advised that a trust instrument that states the trust is irrevocable, but allows the trust to be revoked through court action, does not meet the irrevocability requirement.

The trust instrument may provide for successor or co-trustees, waive bond, and incorporate the Texas Trust Act provisions regarding the powers of the trustees. The statutory authority for a QIT is silent on who may serve as the trustee, but HHSC recommends that the beneficiary not also serve as the trustee. Among other concerns, HHSC has encountered many instances where a beneficiary did not follow the trust requirements, resulting in the beneficiary losing Medicaid eligibility.

The trust instrument must have a reversion clause stating that at the death of the trust beneficiary, the trustee must pay to the state of Texas any funds still in the trust account, up to the full amount of Medicaid assistance that was given to the beneficiary and not otherwise repaid. Payments made to HHSC, as the residuary beneficiary, should be in whole dollar amounts and by cashier's check, money order or personal check. These payments are receipted on Form 4100, Money Receipt.

A QIT instrument must require that the trustee pay:

• a monthly personal needs allowance to the beneficiary;
• court ordered guardianship fees;
• a sum sufficient to give a minimum monthly maintenance needs allowance to the spouse (if any) of the beneficiary; and
• the cost of medical assistance given to the beneficiary, from the funds remaining.

The income must be deposited into the trust account in the month it is received, and the trustee must make distributions from the trust account by the last day of the following month.

HHSC does not deduct any trust administration costs to determine the amount of the beneficiary's income that must be applied to the cost of the beneficiary's medical assistance. Also, HHSC determines the amount that must be applied to the cost of the beneficiary's medical assistance based on the beneficiary's total income, including any income that is not diverted to the QIT. If there are funds still in the trust account after the above distributions are made, such funds may be applied to the cost of trust administration.

Income paid from the trust to purchase institutional services, home and community-based waiver services, or other medical services for the beneficiary is not countable income for eligibility purposes. Income paid from the trust directly to the beneficiary, or otherwise spent for their benefit, is countable income for eligibility purposes.

Establishing a Bank or Other Financial Account as the QIT Account

In addition to a completed, signed, and dated trust instrument that meets the QIT requirements as determined by HHSC, there must be a trust account set up. A trust account is a bank account or other financial institution, such as a credit union, used to deposit the income from the sources listed in the QIT instrument. As noted above, the trust account must contain only income and cannot contain resources. Therefore, the bank account must be used only to deposit the income from the sources listed in the QIT instrument.

A person may use an existing account if they only use the account to deposit the QIT income. A person may need to open a new account if an existing account includes money from sources other than their QIT income. A person may also need to open a new account if an existing account is a joint account and other account holders make deposits to and withdraw from the joint account using the joint account holders' income and resources. If a joint account holder is on the account for convenience and does not use the account for the joint account holder's personal use, a person can use the account for the QIT.

If a person does need to open another account, some banks may require small deposits (for example, $10 to $20) to open a new account. HHSC allows a small amount of the beneficiary's money or money from another person to be deposited to open a new account. The money that a bank requires, as a deposit to open a new account, is not counted as a resource or income to the beneficiary.

Once the trust account is opened, only the beneficiary's income may be directed to the trust account. If the trustee directs to the trust account different sources of income than those identified in the QIT but directs entire sources and the countable income remains within the special income limit, eligibility is not affected. Any deposits made to the QIT bank account from other resources the beneficiary may own results in the bank account becoming a countable resource. Any deposits to the QIT bank account from another person may be countable income and result in all deposits to the account being countable income and the bank account becoming a countable resource.

Effective Date

HHSC disregards income for Medicaid eligibility purposes the first month that a valid written trust instrument is signed and properly executed, a trust bank account with the beneficiary's Social Security number is set up, and enough of the beneficiary's income is placed into the account to reduce any remaining income below the special income limit. The trust may be set up with any or all sources of a beneficiary's income, but an entire income source must be deposited. For the initial month that a QIT is established, a partial deposit of the income for which the trust is established will not invalidate the trust and the entire amount of the income source(s) will be disregarded from countable income for that month. A person may have used some of the monthly income to pay expenses before the date the QIT is established, so the entire source(s) may not be available to open the QIT account. The entire amount of the income source(s) for the established QIT must be deposited into the QIT account in all subsequent months or the QIT is considered invalidated.

These things may be done before the beneficiary applies for MEPD. If the applicant has set up a qualifying QIT, establish the effective date of the income disregard as much as three months before the application filing date if all other program requirements are met during the prior period.

Transfer of Assets

The phrase "transfer of assets" refers to the general prohibition against an MEPD applicant or recipient transferring assets without compensation. When a transfer of assets occurs, it may result in a penalty period for Medicaid payment for institutional care or ineligibility for MEPD.

Income that is diverted to a QIT is not a transfer of assets when used for payment of institutional services or home and community-based waiver services for the MEPD recipient. Also, any distributions to the recipient's spouse and allowable payments for trust administration as described above are not considered a transfer of assets. However, distributions from the trust that are not made to the MEPD recipient or community-based spouse, or for the benefit of either, are considered a transfer of assets.

In addition, if the trustee fails to make distributions from income deposited into the trust account in the month of receipt by the end of the following month, such failure to timely distribute the income is considered a transfer of assets.

Sample QIT

Revision 16-3; Effective September 1, 2016

 

This information assists Medicaid applicants and their attorneys in gaining a basic understanding of the Master Pooled Trust. The Texas Health and Human Services Enterprise attorneys are prohibited from providing legal advice to the public. The only circumstances under which legal staff will review trust documents is when HHSC agency staff have questions about a trust that has been submitted along with a Medicaid application.

Background

The Omnibus Budget Reconciliation Act of 1993 (COBRA 93), 42 USC 1396(d)(4)(c), allows nonprofit corporations such as the Arc of Texas to establish and manage a pooled trust for the benefit of individuals with disabilities. Pooled trust provisions are found in 1917(d)(4)(c) of the Social Security Act. A pooled trust:

• contains the assets of individuals with disabilities;
• maintains for each beneficiary a separate subaccount established by the disabled individual, parent/grandparent/guardian, or a court from the disabled individual's funds;
• is managed by a nonprofit association that pools the subaccounts for management/investment purposes; and
• includes a provision that, to the extent that amounts remaining in the individual's account at the individual's death are not retained by the trust, the state is reimbursed in an amount equal to the total amount Medicaid paid on the individual's behalf.

Caution

This information applies only to an individual who meets the definition of disabled according to the Social Security Administration. Based on a medical determination, an individual is considered disabled if they are unable to engage in any substantial, gainful activity because of a medically determinable physical or mental impairment that can be expected to result in death or has continued or can be expected to continue for at least 12 months. A child who is not engaged in substantial, gainful activity is considered disabled if the child suffers from any medically determinable physical or mental impairment of comparable severity to which would preclude an adult from engaging in substantial, gainful activity.

Transfer of Assets

Transfer-of-assets policy does not apply when a pooled trust is established for the benefit of an individual under age 65. Transfer-of-assets policy does apply when a pooled trust is established or when contributions are made to the pooled trust for an individual who is age 65 or older. Transfer-of-assets policy applies to individuals of any age when an individual's assets in the pooled trust are transferred to another party.

Necessity

The principal purpose and objective of this trust is to provide a system for the management, investment, and disbursement of trust assets to promote a beneficiary's comfort and happiness by providing supplemental care. It is not the purpose nor objective of this trust to provide for or to make expenditures for beneficiary's basic maintenance, support, medical, dental, or therapeutic care, or any other appropriate care or service that may be paid for or provided by other sources. It is not the trust's purpose or objective to provide disbursements for the support of any beneficiary.

Characteristics of the Trust

Disbursements for "special needs" or "supplemental needs" or "supplemental care" shall mean nonsupport disbursements and shall not include cash to the beneficiary or payments for food, clothing or shelter. It is not the intention to displace public or private financial assistance that may otherwise be available to any beneficiary. The trustee shall make disbursements only for the supplemental needs as directed by the manager within the manager's sole discretion. The trust is irrevocable upon acceptance of assets by the trustee. A separate trust subaccount shall be maintained for each beneficiary.

Disbursements

The assets in the trust are to be used only for supplemental needs of the beneficiary and shall not include cash to the beneficiary or payments for food, clothing or shelter. Distributions of income or principal from the trust for medical and social purposes are not counted as income. Distributions to the beneficiary of cash or payments for food, clothing and shelter will be treated as income to the beneficiary.

Reporting Procedures

The primary representative of the subaccount is responsible for reporting the establishment of a master pooled trust subaccount. The pooled trust manager maintains records of each disbursement for each subaccount. Medicaid eligibility specialists request records of disbursements made for the beneficiary as part of the eligibility determination process.

Examples of pooled trusts include:

• The ARC of Texas Master Pooled Trust, established in 1997; and
• the Declaration of Trust for the Travis County Master Trust; Founders Trust Company, Trustee, adopted by decree of the District Court of Travis County, Texas, 201st Judicial District, effective Aug. 1, 1993.

Revision 23-1; Effective March 1, 2023

Note: This information is effective Jan. 1, 2023.

Appendix is available for staff use on the LOOP.

Revision 23-2; Effective June 1, 2023

Note: This information is effective March 1, 2023.

Appendix is available for staff use on the LOOP.

Revision 12-3; Effective September 1, 2012

Note: This document is effective Jan. 1, 2010.

Medicare

Medicare is health insurance for people age 65 or older, under age 65 with certain disabilities and any age with permanent kidney failure (called end-stage renal disease). An individual must have entered the U.S. lawfully and have lived here for five years to be eligible for Medicare. Medicare has several parts.

• Medicare Part A (Hospital Insurance) – Helps pay for inpatient care in a hospital, skilled nursing facility or hospice, and for home health care if certain conditions are met. Most people do not have to pay a monthly premium for Medicare Part A because they or a spouse paid Medicare taxes while working in the U.S. If the Part A premium is not automatically free, an individual still may be able to enroll and pay a premium.
• Medicare Part B (Medical Insurance) – Helps pay for medically necessary doctors’ services and other outpatient care. It also pays for some preventive services (like flu shots), and some services that keep certain illnesses from getting worse. Most people pay the standard monthly Medicare Part B premium.
  
  See Appendix XXXI, Budget Reference Chart, for the current Medicare Part B premium amount.
• Medicare Part C, called Medicare Advantage Plans – An individual must have both Part A and Part B to join one of these plans. The plans provide all of the Part A and Part B services, and generally provide additional services as well. An individual usually pays a monthly premium, and co-payments that likely will be less than the coinsurance and deductibles under the original Medicare. In most cases, these plans offer Part D Prescription Drug Coverage as well. These plans are offered by private insurance companies approved by Medicare. Costs and benefits vary by plan.

Prescription Drug Coverage

Medicare Prescription Drug Coverage, called Medicare Part D – An individual can add Part D by joining a Medicare Prescription Drug Plan (PDP). An individual must pay a deductible and usually is charged coinsurance each time services are received. Insurance companies and other private companies approved by Medicare offer PDPs. Costs and benefits vary by plan.

Enrollment is voluntary. Beneficiaries who have other sources of drug coverage (former employer, union, etc.) may stay in that plan. If their coverage is at least as good as the new Medicare drug benefit (creditable coverage), they will avoid higher premium payments if they later sign up for Medicare Rx.

Medicare drug coverage will help by covering brand-name and generic drugs. Like other insurance, after the individual is enrolled, the individual generally will pay a monthly premium, which varies by plan. The individual also will pay a yearly deductible, which is between $0-$310 in 2010. The individual also will pay a part of the cost of prescriptions, including a co-payment or coinsurance. Costs will vary depending on which drug plan the individual chooses. Some plans may offer more coverage and additional drugs for a higher monthly premium. If the individual has limited income and resources, and the individual qualifies for extra help, the individual may not have to pay a premium or deductible.

For questions about Medicare or the Medicare health and prescription drug plans, visit www.medicare.gov online or call 1-800-MEDICARE (800-633-4227). TTY users should call 877-486-2048.

Extra Help for Prescription Drug Coverage

Extra help for prescription drug coverage is available for people with Medicare who have limited income and resources. If eligible for extra help, Medicare will pay for almost all prescription drug costs. Extra help provides a subsidy based on the amount of income and resources a person has.

Full Subsidy Benefits from Extra Help:

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

Other Low Income Subsidy Benefits from Extra Help:

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

An individual who has Medicare and Medicaid does not need to apply for extra help from Social Security. An individual who is eligible for the Medicare Savings Program (MSP) does not need to apply for extra help from Social Security. The MSP-eligible individual's information is sent to CMS automatically for the extra help.

Eligibility specialists ask, "Can I screen you for eligibility for Medicare Savings Program (MSP) since certification would include eligibility for extra help?"

If the caller does not want to be screened for MSP, refer the caller to the Centralized Benefit Services, 1-800-248-1078, for completion of subsidy application.

If an individual thinks personal information is being misused, call 1-800-MEDICARE (1-800-633-4227).

Apply for extra help or get more information about extra help subsidy by calling Social Security at 1-800-772-1213 (TTY 1-800-325-0778) or visiting www.ssa.gov.

Revision 20-1; Effective March 1, 2020

Revision 16-4; Effective December 1, 2016

 

Appendix is available for staff use, here.

 

 

Revision 17-1; Effective March 1, 2017

Revision 21-4; Effective December 1, 2021

 

 

 

Revision 11-2; Effective June 1, 2011 

Revision 16-4; Effective December 1, 2016

 

Appendix is available for staff use, here.

 

 

Revision 16-4; Effective December 1, 2016

 

Appendix is available for staff use, here.

 

 

Revision 16-4; Effective December 1, 2016

 

Appendix is available for staff use, here.

 

 

Revision 23-3; Effective Sept. 1, 2023

This chart lists the income and resource limits and deduction amounts, and other pertinent information in a simple, easy-to-read format.

Note: This information is effective Sept. 1, 2023.

Appendix is available for staff use on the LOOP.

Revision 12-3; Effective September 1, 2012

 

Basics of the SSP

The SSP located at www.yourtexasbenefits.com is available to individuals 24 hours a day, seven days a week. They can use this website to:

• Request or print a blank:
  • Form H1200, Medicaid for the Elderly and People with Disabilities Application for Assistance – Your Texas Benefits;
  • Form H1010, Texas Works Application for Assistance – Your Texas Benefits; and
  • Form H1014, Application for Children's Health Insurance Program (CHIP), Children's Medicaid, and CHIP Perinatal Coverage.
• Apply for the following benefits:
  • SNAP food benefits,
  • Medicaid,
  • TANF and TANF-Level Medicaid,
  • Medicare savings programs,
  • Long-term care.
• View Past and future interview date and times.
• View and print submitted applications.
• View case status (approve, denied. and/or terminated).
• View benefit amounts.
• View effective and review date.
• View pending information.
• Report changes:
  • address,
  • phone number,
  • household members,
  • employment income,
  • self-employment income,
  • unearned income,
  • liquid resources,
  • shelter expenses including utility,
  • dependent care expense.
• View Medicaid services and health history.
• Submit redeterminations.

Account Management

SSP provides the user with an option of Application Visibility or Case Visibility. Users with application visibility will be given the option to update to case visibility by going through advanced authentication.

Individuals must set up an SSP Case Visibility account in order to view case information and report changes by going through advanced authentication. If an individual loses their SSP password or is unable to set up a case visibility account because they cannot correctly respond to the authentication security questions via the SSP, they may request assistance from HHSC or the vendor.

If the individual is in the office requesting assistance with alternate account set-up/password reset, staff must verify the individual's identity and use the State Portal SSP account Management tab to grant case visibility access or password reset. See C-2220, In-Person Contact.

If the individual is on the phone, then staff should refer the individual to 2-1-1 for assistance.

For additional information see https://oss.txhhsc.txnet.state.tx.us/sites/tw/SitePages/State%20Processes.aspx, Group: Support Tools. Select Support Tool-SSP Application Registration.

 

Revision 17-1; Effective March 1, 2017

Revision 23-1; Effective March 1, 2023
 
Note: This information is effective Jan. 1, 2023.

Appendix is available for staff use on the LOOP.

Revision 16-4; Effective December 1, 2016

 

Appendix is available for staff use, here.

 

 

 

Revision 20-1; Effective March 1, 2020