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.