Revision 11-2; Effective June 1, 2011

§361.101. Overview and Purpose.

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

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

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

§361.103. Definitions.

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

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

(2) Authorized representative — An individual:

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

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

(3) CFR — Code of Federal Regulations.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

(19) U.S.C. — United States Code.

§361.105. Applying and Providing Information.

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

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

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

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

§361.107. Nonfinancial Requirements.

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

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

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

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

(e) Living arrangement.

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

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

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

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

§361.109. Third-party Resources.

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

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

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

§361.111. Income.

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

(b) Countable income means:

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

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

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

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

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

(A) 18th birthday; or

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

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

(A) Total the following:

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

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

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

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

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

§361.113. Employer-sponsored Health Insurance.

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

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

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

§361.115. Cost Sharing.

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

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

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

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

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

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

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

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

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

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

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

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

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

(ii) an involuntary reduction in work hours;

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

(iv) a parent's death.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

§361.119. Medical Effective Date.

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

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

Revision 22-3; Effective September 1, 2022

The Medicaid Buy-In for Children (MBIC) program is a Medicaid program for children with disabilities up to 19 years old with family income up to 300% of the federal poverty level (FPL). A family may have to pay a monthly premium as a condition of eligibility. The amount of the premium is based on the family’s income and if a child is covered under a parent's employer-sponsored health insurance plan.

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

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

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

N-1310 MBIC and Nursing Facilities

Revision 21-4; Effective December 1, 2021

Medicaid Buy-In for Children (MBIC) is a community-based Medicaid program. If an MBIC recipient enters a nursing facility or an intermediate care facility for people with intellectual disability or related condition (ICF/IID), contact the authorized representative (AR) to determine how long the recipient’s is expected to remain in the facility. 

If the facility stay is expected to be less than 90 days, no action is required. 

If the facility stay is expected to be more than 90 days, obtain any additional eligibility verifications needed and complete a program transfer to facility Medicaid.

 

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

Revision 21-3; Effective September 1, 2021

Home and Community-Based Services waiver services such as Community Living Assistance and Support Services, are not paid under the MBIC systems eligibility codes. The exception is Texas Home Living (TxHmL). Therefore, if a referral for any other waiver is received, get a new Form H1200, Application for Assistance – Your Texas Benefits. Then gather any other verification needed to determine eligibility for ME-Waivers and complete a program transfer if all eligibility criteria are met.

Note: Medicaid Buy-In for Children (MBIC) will pay for TxHmL waiver services under MBIC systems eligibility codes.

 

N-1330 MBIC and Medicare Savings Programs

Revision 11-3; Effective September 1, 2011

An MBIC-eligible applicant/recipient can also have:

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

An MBIC-eligible applicant/recipient cannot have:

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

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

 

N-1340 Medicaid Estate Recovery Program (MERP)

Revision 11-3; Effective September 1, 2011

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