The certificate of insurance coverage is proof of a Medicaid recipient's most recent period of Medicaid coverage. The Department of State Health Services sends the certificate, a requirement of the Health Insurance Portability and Accountability Act (HIPAA) of 1996, to denied recipients. HIPAA mandates that prior health insurance coverage must be counted toward reducing or eliminating any applicable pre-existing condition exclusion period when a person enrolls in a new health insurance plan. Former Medicaid recipients may request a certificate within 24 months after their Medicaid is denied by calling 1-800-723-4789.
A recipient’s eligibility is redetermined:
- when necessary because of previously obtained information indicating an anticipated change;
- within 10 workdays after receipt of a report indicating changes that may affect eligibility or co-payment, including program transfers;
- within 30 workdays after receipt of a report indicating changes that affect neither eligibility nor co-payment;
- at periodic intervals not to exceed 12 months; and
- at least every six months, if income is averaged or an incurred medical expense is budgeted. The person's income is verified and documented and past co-payment is reconciled.
Note: For couple cases, including cases with spouses who may be certified under different type programs, redeterminations should be synchronized to minimize the redetermination process for the recipients and the workload for the eligibility specialist. A complete redetermination of each person's eligibility must be completed at least once every 12 months.
It is a recommended practice to review community-based cases at least every three months if the recipient's countable resources are within $100 of the resources limit.
Monitor eligibility at least every three months if the person's:
- countable resources are within $100 of the resources limit, or
- total countable income is within $10 of the income limit.
The following information must be included in the case record documentation:
- Whether a special review is needed
- Date special review will be conducted
- Method of monitoring for special review
- specific information regarding the reason a special review is set,
- which person is affected, and
- the eligibility area(s) subject to the review.
Example: If someone has a private pension and the pension amount is anticipated to increase in the future, a special review must be set for the anticipated change. The eligibility area will be income. Documentation must specify pension information that will need to be verified at the special review, including:
- date on which the anticipated change is to occur,
- type of pension,
- source of pension, and
- frequency of payment of pension that will need to be verified at the special review.
Use Form H1020, Request for Information or Action, and Form H1020-A, Sources of Proof, to request information from the person or authorized representative. When requesting missing information on a redetermination, allow 10 calendar days from the date the notice is mailed for the individual to provide the information. Do not deny the case for failure to furnish information before the due date listed on Form H1020.
Note: Monitor special reviews for resource or income elements through entry of the special review due date in the applicable TIERS screen.
Data Broker is not required on redeterminations, including the streamlined versions.
Revision 12-4; Effective December 1, 2012
Note: A person who may complete or sign a redetermination form for a recipient may possibly not be on the list of people to whom HHSC can release the recipient’s individually identifiable health information. See C-5000, Personal Representatives, for persons who may receive or authorize the release of a recipient’s individually identifiable health information under HIPAA privacy regulations.
See B-3220, Who May Sign an Application for Assistance, to determine who may sign a redetermination form. The requirements for signing a redetermination form are the same as the requirements for signing an application.
Note: A signature is not needed when the redetermination is passive or simplified. See B-8440, Streamlined Redetermination (Passive Redetermination).
Revision 23-4; Effective Dec. 1, 2023
Administrative Renewal Process
All MEPD types of assistance (TOAs) go through an annual administrative renewal process. The system starts the administrative renewal without staff action.
The automated administrative renewal process uses information from the existing case record and electronic data sources to determine if the person remains eligible for Medicaid benefits. The electronic data is requested the weekend before cutoff in the ninth month of the recipient’s certification period.
During the administrative renewal process, the system also checks for the required verification by program.
The administrative renewal process uses electronic data to automatically:
- assess the verification required by program type;
- determine the eligibility outcome; and
- send the renewal correspondence to the recipient, the authorized representative (AR) or both.
Note: This automated process does not change the verification requirements for renewals.
If there is enough information to verify continued eligibility, the person’s eligibility is renewed without any staff action.
If more verification is required, the system automatically generates and mails a renewal form to the recipient, AR or both. The renewal form and all required verification must be returned within 30 days to complete the redetermination.
The system generates the applicable correspondence from the list below per the eligibility outcome of the automated renewal process and the action needed by the person:
- Form H1211, It Is Time to Renew Your Health Care Benefits Cover Letter;
- Form H1233, Redetermination Cover Letter;
- Form H1233-MBIC, Redetermination Cover Letter (Medicaid Buy-In for Children);
- Form H1200, Application for Assistance – Your Texas Benefits;
- Form H1200-A, Medical Assistance Only (MAO) Recertification;
- Form H1200-EZ, Application for Assistance;
- Form H1200-MBIC-R, Application for Benefits – Medicaid Buy-In for Children;
- Form H1200-PFS, Medical Application for Assistance (for Residents of State Facilities);
- Form H1200-SR, MEPD Streamlined Redetermination;
- Form H1206ME, Health-Care Benefits Renewal;
The cover letter informs the recipient that it is time to renew benefits, provides instructions on how to complete and return the renewal form along with any required verification documents, and informs the recipient that the information must be returned within 30 days. If the recipient does not return the renewal form and required verification, eligibility is automatically terminated at cutoff in the 12th month for failure to provide the requested information.
Notes: Form H1211 and Form H1206ME are generated when the automated renewal process results in Eligibility Approved. Form H1211 informs the recipient to only return Form H1206ME if the information is incorrect or if there has been a change to their case.
Recipients are not required to return Form H1200-SR. The renewal cover letter informs the recipient that they do not need to return the renewal form if the information on Form H1200-SR is correct and has not changed.
For applicable MEPD programs, Asset Verification System (AVS) must be requested at every renewal.
If the renewal form indicates that the recipient wants to register to vote, complete the "Voter Registration Information" section of the "Citizen" tab in the Individual Demographics logical unit of work (LUW). Select “YES” in the "Send Voter Registration Application?" dropdown to send Form H0025, HHSC Application for Voter Registration, to the mailing address on file. If the recipient contacts the office declining to complete Form H0025, mail Form H1350, Opportunity to Register to Vote, to the recipient. Form H1350 records the recipient's decision about registering to vote.
Who May Complete an Application for Assistance, B-3210
Who May Sign an Application for Assistance, B-3220
Redetermination Cycles, B-8200
Streamlined Redetermination (Passive Redetermination), B-8440
Voter Registration, C-7000
Asset Verification System (AVS), R-3740
B-8410 Financial Management
Revision 09-4; Effective December 1, 2009
For redeterminations, explore financial management if there has been no activity in the person’s bank account, other than interest credited, since the last redetermination.
If a person does not report a bank account, trust fund or similar account on the application for assistance, ask the person or the authorized representative to explain how the person’s financial affairs are handled. This includes determining who cashes his checks and where, who pays his bills and how, and who keeps his money and how the funds are kept.
If the person reveals previously unreported liquid resources, determine the value, ownership and accessibility according to the requirements for the resource involved.
Sources for verifying financial management are as follows:
- Statements from the recipient and the person who handles the recipient’s funds.
- Statement from a knowledgeable third party (for example, an administrator or bookkeeper in facility usually knows who receives the recipient’s benefit payments and pays the bills).
Include the following information in the case record documentation:
- Where checks are cashed and how bills are paid.
- Who handles the person’s checks, pays the person’s bills and maintains the person’s money.
- How much money, if any, the person or anyone else keeps.
- How much has accumulated.
- Source of information.
B-8420 Notification of Changes as a Result of Redetermination
Revision 11-4; Effective December 1, 2011
On receipt of the completed, signed and dated H1200 series form, redetermine eligibility for MEPD. A review may result in no changes being made or one of the following situations:
- Decrease of co-payment
If a review results in a decrease in a recipient's co-payment, dispose of the case action and send Form TF0001, Notice of Case Action, to notify the recipient, and Form TF0001P, Provider Notice, to notify the facility. To correct co-payment for a previous period of time, complete Form H1259, Correction of Applied Income.
- Increase of co-payment
If a review results in an increase in the recipient's co-payment, dispose the case action and send Form TF0001 to the recipient and Form TF0001P to the facility. If the recipient does not indicate a desire to appeal by the end of the 12-day notification period, the increased co-payment remains.
- Denial of benefits
If a review results in a denial of benefits, send Form TF0001 to advise the recipient and Form TF0001P to notify the facility (if applicable). If the recipient does not indicate a desire to appeal by the end of the 12-day notification period, the benefits remain denied.
Note: Complete Form H1259 manually for notification if co-payment involves averaged income (raised or lowered) or incurred medical expenses. If all amounts are lower in the reconciliation shown on Form H1259, then adverse action is not required. In the above situations, ensure that if Form TF0001 and/or Form TF0001P is not sent automatically, a manual Form TF0001 and/or Form TF0001P is sent.
If there is no change in eligibility or co-payment, there is no mandate to send a notification to the recipient.
B-8430 Special Reviews
Revision 10-1; Effective March 1, 2010
A special review occurs between the annual review cycles to evaluate one or more eligibility elements without completing the annual review. The annual review (redetermination) packet is not required for a special review.
The need for a special review is based on policy, a reported change or the eligibility specialist's judgment.
Examples of when special reviews are needed for follow-up:
- On the person's action for applying for potential benefits. An initial 30-calendar day special review is required to evaluate if the person made application after the person has been notified to do so. This may occur before the application is completed. Another special review will be needed to follow up to see if the recipient continues to be eligible.
- When variable income and/or incurred medical expenses are averaged and projected. Special reviews are required at least every six months unless documentation substantiates an exception.
- Within a 90-day time frame when the total countable income is within $10 of the income limit.
- Within a 90-day time frame when the total countable resources are within $100 of the resource limit.
- When any change is anticipated to occur.
For special reviews, document clearly the detailed reason(s) for the special review. Documentation must include:
- specific information regarding the reason a special review is set;
- the name of the individual who is affected; and
- the eligibility area(s) subject to the review.
Include this information on correspondence sent to the person to request information concerning the special review. No redetermination packet is required.
For example, if someone has a private pension and the pension amount is anticipated to increase in the future, set a special review for the anticipated change. The eligibility area will be income. Documentation must specify pension information that will need to be verified at the special review. Include the:
- date on which the anticipated change is to occur;
- type of pension;
- source of pension; and
- frequency of payment of pension that will need to be verified at the special review.
Form H1020, Request for Information or Action, and Form H1020-A, Sources of Proof, are used to request information from the person or authorized representative. Include the due date on Form H1020 or H1020-A. If the recipient calls with questions, follow Appendix XVI, Documentation and Verification Guide, for acceptable verification sources.
George Black called this morning saying he received a letter requesting verification that he had applied for Veterans Affairs (VA) benefits. He stated that he had applied and was told that it would take at least six months to hear anything.
Document what Mr. Black said. Recipient declaration is acceptable verification that he has applied for additional benefits. Be sure to tell Mr. Black to call and report if he hears anything about his eligibility from the VA.
B-8440 Streamlined Redetermination (Passive Redetermination)
Revision 19-2; Effective June 1, 2019
For certain stable community-based cases, a redetermination may be completed without requiring a renewal form. The passive redetermination is completed based on information available in the case record or other information available through electronic data sources.
Community-based cases are considered stable and eligible for a passive redetermination if they have no more than:
- one bank account;
- excluded burial funds;
- excluded resources;
- income requiring no more than annual verification; and
- variable income not more than $4.99.
For community-based cases that meet the criteria for a passive redetermination, the Form H1200-SR, Streamlined Redetermination for Medicaid for the Elderly and People with Disabilities, is sent. If there are no changes in income or resources to report, a completed renewal form is not required and eligibility is automatically renewed based on existing case information.
If the recipient returns the Form H1200-SR, process the redetermination following regular redetermination policy and procedures.
At least one annual redetermination must be completed using a regular application or redetermination form (Form H1200, Form H1200-A or Form H1200-EZ) before a case may be considered for the passive renewal process.
The streamlined redetermination process only applies to the following Types of Assistances (TOA’s):
- TP-14-ME-CAS - Community Attendant Services
- TP-23-MC-SLMB - Specified Low-Income Medicare Beneficiaries
- TP-24-MC-QMB - Qualified Medicare Beneficiaries
- TP-25-MC-QDWI - Qualified Disabled and Working Individuals
- TP-26-MC-QI-1 - Qualifying Individuals.
AVS applicable TOAs are not eligible for a passive redetermination.
B-8450 Special Reviews when Facility Contract Closure or Cancellation Occurs
Revision 21-3; Effective September 1, 2021
When a facility’s Medicaid contract is terminated, the facility notifies the recipient and provides them with the option to move to a Medicaid covered facility.
If the Medicaid recipient continues to live in an uncontracted facility, deny Medicaid eligibility and send Form TF0001, Notice of Case Action, to the recipient and or authorized representative (AR) and TF0001P, Provider Notice of Case Action, to the facility. The person will then be responsible for the full vendor payment for that facility.
If the recipient relocates to a Medicaid contracted facility, process a change of address, verify the person continues to meet all Medicaid eligibility criteria and send out a new TF0001 to the recipient and or AR and TF0001P to the new facility.
B-8460 Changes and Program Transfers
Revision 21-4; Effective December 1, 2021
Changes are situations that may affect a person’s eligibility, continued eligibility or co-payment amount.
An applicant, recipient or authorized representative must report changes within ten days of the event, including the following:
- Change of address;
- Change in living arrangements;
- Change in income;
- Change in resources; and
- Change in marital status.
To ensure the most accurate information is on file, staff must act on reported changes:
- Within ten workdays for changes that may affect eligibility or co-payment; or
- Within 30 workdays for changes that do not affect eligibility or co-payment.
A program transfer occurs when a Medicaid or MSP recipient is determined eligible for another type of Medicaid due to a change in circumstances.
Example: A CAS recipient enters a nursing facility or requests waiver services.
A request for a program transfer to a new program or a request to add another type of Medicaid is considered a change. Process the change within ten workdays of receiving the request.
Redetermine eligibility and verify all required eligibility criteria for the new program, including the 30-day consecutive stay, transfer of assets, substantial home equity and spousal impoverishment, if applicable. Request AVS prior to disposing eligibility. If more information is needed, send Form H1020, Request for Information or Action. The due date for missing information or verifications should be 10 days from the date on Form H1020.
If an active recipient reports a spouse, process the change within 10 workdays. Request verification for the new person and redetermine eligibility as appropriate for a couple or companion case.
Medicaid Certified Person Enters Nursing Facility or Home and Community-Based Services Waiver Program, B-7450
Redetermination Cycles, B-8200
Responsibility to Provide Information and Report Changes, C-8000