3-2017

When a Medicaid for the Elderly and People with Disabilities (MEPD) Texas Integrated Eligibility Redesign System (TIERS) action is needed, complete Form H1746-A, MEPD Referral Cover Sheet.

Use the following chart to determine whether or not a new Form H1200, Application for Assistance – Your Texas Benefits, must be attached to the coversheet. If a type program does not appear in this table, submit Form H1746-A and the application, if needed.

Supplemental Security Income (SSI) Adding Any HHSC Program

TIERS Type of AssistanceProgram Name in TIERSMEPD ActionCase Worker Action
TA08ME – SSI State Group HomeNo worker interventionNo application needed
No Form H1746-A needed
TP12ME – Temp Manual SSINo worker interventionNo application needed
No Form H1746-A needed
TP13ME – SSINo worker interventionNo application needed
No Form H1746-A needed
TP38ME – SSI Nursing FacilityNo worker interventionNo application needed
No Form H1746-A needed
TP39ME – SSI State HospitalNo worker interventionNo application needed
No Form H1746-A needed
TA02ME – SSI WaiversNo worker interventionNo application needed
No Form H1746-A needed

SSI Denial to Medicaid Waiver

TIERS Type of AssistanceProgram Name in TIERSMEPD ActionCase Worker Action
TA02ME – SSI WaiversAdd MEPD Eligibility Determination Group (EDG)Submit Form H1200
Submit Form H1746-A

SSI Denials to Community Attendant Services (CAS)

TIERS Type of AssistanceProgram Name in TIERSMEPD ActionCase Worker Action
TA08ME – SSI State Group HomeAdd ME – Community Attendant EDGSubmit Form H1200
Submit Form H1746-A
TP12ME – Temp Manual SSIAdd ME – Community Attendant EDGSubmit Form H1200
Submit Form H1746-A
TP13ME – SSIAdd ME – Community Attendant EDGSubmit Form H1200
Submit Form H1746-A
TP38ME – SSI Nursing FacilityAdd ME – Community Attendant EDGSubmit Form H1200
Submit Form H1746-A
TP39ME – SSI State HospitalAdd ME – Community Attendant EDGSubmit Form H1200
Submit Form H1746-A
TP46ME – SSI State Supported Living CenterAdd ME – Community Attendant EDGSubmit Form H1200
Submit Form H1746-A
TA02ME – SSI WaiversAdd ME – Community Attendant EDGSubmit Form H1200
Submit Form H1746-A

SSI Denials to State Supported Living Center

TIERS Type of AssistanceProgram Name in TIERSMEPD ActionCase Worker Action
TA08ME – SSI State Group HomeAdd ME – State Supported Living Center EDGSubmit Form H1200-PFS, Medicaid Application for Assistance (for Residents of State Facilities) Property and Financial Statement
Submit Form H1746-A and Form H0090-I, Notice of Admission, Departure, Readmission or Death of an Applicant/Recipient of Supplemental Security Income and/or Assistance Only in a State Institution
TP12ME – Temporary Manual SSIAdd ME – State Supported Living Center EDGSubmit Form H1200-PFS, Medicaid Application for Assistance (for Residents of State Facilities) Property and Financial Statement
Submit Form H1746-A and Form H0090-I, Notice of Admission, Departure, Readmission or Death of an Applicant/Recipient of Supplemental Security Income and/or Assistance Only in a State Institution
TP13ME – SSIAdd ME – State Supported Living Center EDGSubmit Form H1200-PFS, Medicaid Application for Assistance (for Residents of State Facilities) Property and Financial Statement
Submit Form H1746-A and Form H0090-I, Notice of Admission, Departure, Readmission or Death of an Applicant/Recipient of Supplemental Security Income and/or Assistance Only in a State Institution
TP38ME – SSI Nursing FacilityAdd ME – State Supported Living Center EDGSubmit Form H1200-PFS, Medicaid Application for Assistance (for Residents of State Facilities) Property and Financial Statement
Submit Form H1746-A and Form H0090-I, Notice of Admission, Departure, Readmission or Death of an Applicant/Recipient of Supplemental Security Income and/or Assistance Only in a State Institution
TP39ME – SSI State HospitalAdd ME – State Supported Living Center EDGSubmit Form H1200-PFS, Medicaid Application for Assistance (for Residents of State Facilities) Property and Financial Statement
Submit Form H1746-A and Form H0090-I, Notice of Admission, Departure, Readmission or Death of an Applicant/Recipient of Supplemental Security Income and/or Assistance Only in a State Institution
TA02ME – SSI WaiversAdd ME – State Supported Living Center EDGSubmit Form H1200-PFS, Medicaid Application for Assistance (for Residents of State Facilities) Property and Financial Statement
Submit Form H1746-A and Form H0090-I, Notice of Admission, Departure, Readmission or Death of an Applicant/Recipient of Supplemental Security Income and/or Assistance Only in a State Institution

Qualified Medicare Beneficiaries (QMB)/Specified Low-Income Medicare Beneficiaries (SLMB) to CAS

TIERS Type of AssistanceProgram Name in TIERSMEPD ActionCase Worker Action
TP23MC – SLMBAdd MEPD – Community Attendant EDGNo application needed
Submit Form H1746-A
TP24MC – QMBAdd MEPD – Community Attendant EDGNo application needed
Submit Form H1746-A

QMB/SLMB to Waiver

TIERS Type of AssistanceProgram Name in TIERSMEPD ActionCase Worker Action
TP23MC – SLMBAdd MEPD EDG
Explore the impact of transfer of assets, home equity and spousal impoverishment
Submit Form H1200
Submit Form H1746-A
TP24MC – QMBAdd MEPD EDG
Explore the impact of transfer of assets, home equity and spousal impoverishment
Submit Form H1200
Submit Form H1746-A

QMB/SLMB to State Supported Living Center

TIERS Type of AssistanceProgram Name in TIERSMEPD ActionCase Worker Action
TP23MC – SLMBAdd MEPD – State Supported Living Center EDG
Explore the impact of transfer of assets, home equity and spousal impoverishment
Submit Form H1200-PFS
Submit Form H1746-A and Form H0090-I
TP24MC – QMBAdd MEPD – State Supported Living Center EDG
Explore the impact of transfer of assets, home equity and spousal impoverishment
Submit Form H1200-PFS
Submit Form H1746-A and Form H0090-I

Qualifying Individuals (QI-1) to CAS

TIERS Type of AssistanceProgram Name in TIERSMEPD ActionCase Worker Action
TP26MC – QI-1Add MEPD – Community Attendant EDG and end MC- QI-1 EDGNo application needed
Submit Form H1746-A
Include a statement that the individual is willing to give up QI-1 to obtain CAS

QI-1 to Waiver

TIERS Type of AssistanceProgram Name in TIERSMEPD ActionCase Worker Action
TP26MC – QI-1Add MEPD EDG and end MC-QI-1 EDG
Explore the impact of transfer of assets, home equity and spousal impoverishment
Submit Form H1200
Submit Form H1746-A
Include a statement that the individual is willing to give up QI-1 to obtain waiver

CAS to Waiver

TIERS Type of AssistanceProgram Name in TIERSMEPD ActionCase Worker Action
TP14ME – Community AttendantAdd MEPD EDG and end MEPD – Community Attendant EDG
Determine the impact of any transfer of assets and impact of home equity and spousal impoverishment on waiver eligibility
Submit Form H1200
Submit Form H1746-A

Nursing Facility to Waiver

TIERS Type of AssistanceProgram Name in TIERSMEPD ActionCase Worker Action
TP17ME – Nursing FacilityEnd MEPD – Nursing Facility EDG and add MEPD EDG
Determine the impact of any transfer of assets and impact of home equity on waiver eligibility
No application needed
Submit Form H1746-A
TP41ME – Skilled Nursing CareEnd MEPD – Nursing Facility EDG and add MEPD EDG
Determine the impact of any transfer of assets and impact of home equity on waiver eligibility
No application needed
Submit Form H1746-A

Intermediate Care Facility for Individuals with an Intellectual Disability or Related Condition (ICF/IID) to Waiver

TIERS Type of AssistanceProgram Name in TIERSMEPD ActionCase Worker Action
TA12ME – State Group HomeEnd appropriate ICF/IID EDG and add ME EDG Determine the impact of any transfer of assets and impact of home equity on waiver eligibility.No application needed
Submit Form H1746-A
TA26ME – SSI Non-State Group HomeEnd appropriate ICF/IID EDG and add ME EDG Determine the impact of any transfer of assets and impact of home equity on waiver eligibility.No application needed
Submit Form H1746-A
TP10ME – State Supported Living CenterEnd appropriate ICF/IID EDG and add ME EDG Determine the impact of any transfer of assets and impact of home equity on waiver eligibility.No application needed
Submit Form H1746-A
TP15ME – Non-State Group HomeEnd appropriate ICF/IID EDG and add ME EDG Determine the impact of any transfer of assets and impact of home equity on waiver eligibility.No application needed
Submit Form H1746-A
TP16ME – State HospitalEnd appropriate ICF/IID EDG and add ME EDG
Determine the impact of any transfer of assets and impact of home equity on waiver eligibility.
No application needed
Submit Form H1746-A

ICF/IID to State Supported Living Center

TIERS Type of AssistanceProgram Name in TIERSMEPD ActionCase Worker Action
TA12ME – State Group HomeEnd appropriate ICF/IID EDG and add ME – State Supported Living Center EDGNo application needed
Submit Form H1746-A and Form H0090-I
TA26ME – SSI Non-State Group HomeEnd appropriate ICF/IID EDG and add ME – State Supported Living Center EDGNo application needed
Submit Form H1746-A and Form H0090-I
TP10ME – State Supported Living CenterEnd appropriate ICF/IID EDG and add ME – State Supported Living Center EDGNo application needed
Submit Form H1746-A and Form H0090-I
TP15ME – Non-State Group HomeEnd appropriate ICF/IID EDG and add ME – State Supported Living Center EDGNo application needed
Submit Form H1746-A and Form H0090-I
TP16ME – State HospitalEnd appropriate ICF/IID EDG and add ME – State Supported Living Center EDGNo application needed
Submit Form H1746-A and Form H0090-I

Community Medical Assistance Only (MAO) to Waiver

TIERS Type of AssistanceProgram Name in TIERSMEPD ActionCase Worker Action
TA10ME – WaiversNo change to EDGNo application needed
No Form H1746-A needed
TA18ME – Grandfathered LTCNo change to EDGNo application needed
No Form H1746-A needed
TP03ME – PickleNo change to EDGNo application needed
No Form H1746-A needed
TP18ME – Disabled Adult ChildNo change to EDGNo application needed
No Form H1746-A needed
TP21ME – Disabled Widow(er)No change to EDGNo application needed
No Form H1746-A needed
TP22ME – Early Aged Widow(er)No change to EDGNo application needed
No Form H1746-A needed
TP87ME – Medicaid Buy In (MBI)No change to EDGNo application needed
No Form H1746-A needed

Community MAO to State Supported Living Center

TIERS Type of AssistanceProgram Name in TIERSMEPD ActionCase Worker Action
TA10ME – WaiversEnd ME EDG and add ME – State Supported Living Center EDG
Explore the impact of transfer of assets, home equity and spousal impoverishment
Submit Form H1200-PFS
Submit Form H1746-A and Form H0090-I
TA18ME – Grandfathered LTCEnd ME EDG and add ME – State Supported Living Center EDG
Explore the impact of transfer of assets, home equity and spousal impoverishment
Submit Form H1200-PFS
Submit Form H1746-A and Form H0090-I
TP03ME – PickleEnd ME EDG and add ME – State Supported Living Center EDG
Explore the impact of transfer of assets, home equity and spousal impoverishment
Submit Form H1200-PFS
Submit Form H1746-A and Form H0090-I
TP14ME – Community AttendantEnd ME EDG and add ME – State Supported Living Center EDG
Explore the impact of transfer of assets, home equity and spousal impoverishment
Submit Form H1200-PFS
Submit Form H1746-A and Form H0090-I
TP18ME – Disabled Adult ChildEnd ME EDG and add ME – State Supported Living Center EDG
Explore the impact of transfer of assets, home equity and spousal impoverishment
Submit Form H1200-PFS
Submit Form H1746-A and Form H0090-I
TP21ME – Disabled Widow(er)End ME EDG and add ME – State Supported Living Center EDG
Explore the impact of transfer of assets, home equity and spousal impoverishment
Submit Form H1200-PFS
Submit Form H1746-A and Form H0090-I
TP22ME – Early Aged Widow(er)End ME EDG and add ME – State Supported Living Center EDG
Explore the impact of transfer of assets, home equity and spousal impoverishment
Submit Form H1200-PFS
Submit Form H1746-A and Form H0090-I
TP87ME – Medicaid Buy-InEnd ME EDG and add ME – State Supported Living Center EDG
Explore the impact of transfer of assets, home equity and spousal impoverishment
Submit Form H1200-PFS
Submit Form H1746-A and Form H0090-I

Texas Works-Related Medicaid to Waiver

TIERS Type of AssistanceProgram Name in TIERSMEPD ActionCase Worker Action
TA31MA – Parents and Caretaker Relatives – EmergencyNo change to EDG.No application or Form H1746-A needed
TP02MA – Refugee Medical Assistance (RMA)No change to EDG.No application or Form H1746-A needed
TP07MA – Earnings TransitionalNo change to EDG.No application or Form H1746-A needed
TP08MA – Parents and Caretaker RelativesNo change to EDG.No application or Form H1746-A needed
TP20MA – Spousal Support TransitionalNo change to EDG.No application or Form H1746-A needed
TP40MA – Pregnant WomenNo change to EDG.No application or Form H1746-A needed
TP43MA – Children Under One YearNo change to EDG.No application or Form H1746-A needed
TP44MA – Children Six to 18 YearsNo change to EDG.No application or Form H1746-A needed
TP45MA – Newborn ChildrenNo change to EDG.No application or Form H1746-A needed
TP48MA – Children One to Five YearsNo change to EDG.No application or Form H1746-A needed
TP70Medicaid for the Transitioning Foster Care Youth (MTFCY)No change to EDG.No application or Form H1746-A needed
TP92Adoption Assistance - Federal Match - With CashNo change to EDG.No application or Form H1746-A needed
TP93Foster Care - Federal Match - No CashNo change to EDG.No application or Form H1746-A needed
TP94Foster Care - Federal Match - With CashNo change to EDG.No application or Form H1746-A needed
TP95Adoption Assistance - No Federal Assistance - No CashNo change to EDG.No application or Form H1746-A needed
TP96Adoption Assistance - No Federal Assistance - With CashNo change to EDG.No application or Form H1746-A needed
TP97Foster Care - No Federal Match - With CashNo change to EDG.No application or Form H1746-A needed
TP98Foster Care - No Federal Match - With CashNo change to EDG.No application or Form H1746-A needed
TP99MA - Non-AFDC Foster CareNo change to EDG.No application or Form H1746-A needed

CAS to QI-1

TIERS Type of AssistanceProgram Name in TIERSMEPD ActionCase Worker Action
TP14ME – Community AttendantEnd MEPD – Community Attendant EDG and add MC -QI-1 EDGNo application needed
Submit Form H1746-A
Include a statement that the individual is willing to give up CAS to obtain QI-1

Waiver to QI-1

TIERS Type of AssistanceProgram Name in TIERSMEPD ActionCase Worker Action
TA10ME –  WaiversEnd MEPD – Waiver EDG and add MC – QI-1 EDGNo application needed
Submit Form H1746-A
Include a statement that the individual is willing to give up waiver to obtain QI-1

Waiver to CAS

TIERS Type of AssistanceProgram Name in TIERSMEPD ActionCase Worker Action
TA10ME – WaiversEnd MEPD – Waiver EDG and add MEPD – Community Attendant EDGNo application needed
Submit Form H1746-A

Waiver to Nursing Facility

TIERS Type of AssistanceProgram Name in TIERSMEPD ActionCase Worker Action
TA10ME – WaiversEnd MEPD – Waiver EDG and add MEPD – Nursing Facility EDGNo application needed
No Form H1746-A needed

Waiver to ICF/IID

TIERS Type of AssistanceProgram Name in TIERSMEPD ActionCase Worker Action
TA10ME – WaiversEnd MEPD – Waiver EDG and add MEPD EDG for the ICF/IIDNo application needed
No Form H1746-A needed

Waiver to State Supported Living Center

TIERS Type of AssistanceProgram Name in TIERSMEPD ActionCase Worker Action
TA10ME – WaiversEnd MEPD – Waiver EDG and add MEPD – State Supported Living Center EDGNo application needed
Submit Form H1746-A and Form H0090-I

Medicaid Buy-In for Children to Waiver

TIERS Type of AssistanceProgram Name in TIERSMEPD ActionCase Worker Action
TP88ME – Medicaid Buy-In for ChildrenEnd MEPD-Medicaid Buy-In for Children EDG and add MEPD EDG
Explore the impact of transfer of assets, home equity and spousal impoverishment
Submit Form H1200
Submit Form H1746-A

Medicaid Buy-In to State Supported Living Center

TIERS Type of AssistanceProgram Name in TIERSMEPD ActionCase Worker Action
TP87ME – Medicaid Buy-InEnd MEPD EDG and add MEPD – State Supported Living Center EDG
Explore the impact of transfer of assets, home equity and spousal impoverishment
Submit Form H1200-PFS
Submit Form H1746-A and Form H0090-I
TP88ME – Medicaid Buy-In for ChildrenEnd MEPD EDG and add MEPD – State Supported Living Center EDG
Explore the impact of transfer of assets, home equity and spousal impoverishment
Submit Form H1200-PFS
Submit Form H1746-A and Form H0090-I

Texas Women's Health Program to Waiver

TIERS Type of AssistanceProgram Name in TIERSMEPD ActionCase Worker Action
TP41Health Care – Texas Women's Health Program (TWHP)Add MEPD EDG
Coordinate efforts with Texas Works
Do not discuss the TWHP with anyone other than the certified TWHP member.
Submit Form H1200
Submit Form H1746-A
Do not discuss the TWHP with anyone other than the certified TWHP member.

Texas Women's Health Program to CAS

TIERS Type of AssistanceProgram Name in TIERSMEPD ActionCase Worker Action
TP41Health Care – Texas Women's Health Program (TWHP)Add MEPD EDG
Do not discuss the TWHP with anyone other than the certified TWHP member.
Submit Form H1200
Submit Form H1746-A
Do not discuss the TWHP with anyone other than the certified TWHP member.

One Type Waiver to Another Type Waiver

TIERS Type of AssistanceProgram Name in TIERSMEPD ActionCase Worker Action
TA10ME – WaiversUpdate Long-term Services and Supports Summary Screen and Medicaid Waivers/Community Attendant ScreenNo application needed
Submit Form H1746-A

Foster Care to State Supported Living Center

TIERS Type of AssistanceProgram Name in TIERSMEPD ActionCase Worker Action
TP52MA – State Foster Care – ACoordinate efforts with the Texas Department of Family and Protective Services (DFPS)Submit Form H1200-PFS
Submit Form H1746-A
TP53MA – State Foster Care – BCoordinate efforts with the Texas Department of Family and Protective Services (DFPS)Submit Form H1200-PFS
Submit Form H1746-A
TP54MA – State Foster Care – 32Coordinate efforts with the Texas Department of Family and Protective Services (DFPS)Submit Form H1200-PFS
Submit Form H1746-A
TP57MA – State Foster Care – DCoordinate efforts with the Texas Department of Family and Protective Services (DFPS)Submit Form H1200-PFS
Submit Form H1746-A
TP58MA – State Foster Care – JPCCoordinate efforts with the Texas Department of Family and Protective Services (DFPS)Submit Form H1200-PFS
Submit Form H1746-A
TP88MA – Non-AFDC Foster Care – JPCCoordinate efforts with the Texas Department of Family and Protective Services (DFPS)Submit Form H1200-PFS
Submit Form H1746-A
TP90MA – State Foster CareCoordinate efforts with the Texas Department of Family and Protective Services (DFPS)Submit Form H1200-PFS
Submit Form H1746-A
TP93Foster Care – Federal Match – No CashCoordinate efforts with the Texas Department of Family and Protective Services (DFPS)Submit Form H1200-PFS
Submit Form H1746-A
TP94Foster Care – Federal Match – With CashCoordinate efforts with the Texas Department of Family and Protective Services (DFPS)Submit Form H1200-PFS
Submit Form H1746-A
TP97Foster Care – No Federal Match – No CashCoordinate efforts with the Texas Department of Family and Protective Services (DFPS)Submit Form H1200-PFS
Submit Form H1746-A
TP98Foster Care – No Federal Match – With CashCoordinate efforts with the Texas Department of Family and Protective Services (DFPS)Submit Form H1200-PFS
Submit Form H1746-A
TP99MA – Non-AFDC Foster CareCoordinate efforts with the Texas Department of Family and Protective Services (DFPS)Submit Form H1200-PFS
Submit Form H1746-A

Adoption Assistance to State Supported Living Center

TIERS Type of AssistanceProgram Name in TIERSMEPD ActionCase Worker Action
TP91Adoption Assistance – Federal Match – No CashCoordinate efforts with DFPSSubmit Form H1200-PFS
Submit Form H1746-A and Form H0090-I
TP92Adoption Assistance -Federal Match – With CashCoordinate efforts with DFPSSubmit Form H1200-PFS
Submit Form H1746-A and Form H0090-I
TP95Adoption Assistance – No Federal Assistance – No CashCoordinate efforts with DFPSSubmit Form H1200-PFS
Submit Form H1746-A and Form H0090-I
TP96Adoption Assistance – No Federal Assistance – With CashCoordinate efforts with DFPSSubmit Form H1200-PFS
Submit Form H1746-A and Form H0090-I