11000, Maintaining Medicaid Eligibility

11100 Financial Eligibility Guidelines for Texas Home Living and Home and Community-based Services

Revision 25-1; Effective April 29, 2025

The Texas Health and Human Services Commission (HHSC) requires that every person meet financial eligibility for enrollment in the Texas Home Living (TxHmL) or Home and Community-based Services (HCS) waiver program. After enrollment, financial eligibility must be maintained for the person to continue participation in the program. People eligible for certain types of Medicaid coverage are financially eligible for the program. Not all types of Medicaid coverage, however, ensure eligibility.

There are several ways to meet the financial eligibility requirement for the TxHmL or HCS program through Medicaid certification.

• People who receive Supplemental Security Income (SSI) from the Social Security Administration (SSA) are categorically eligible for SSI Medicaid.
• People in certain adoption or foster care cases through the Department of Family and Protective Services (DFPS) are eligible for DFPS Medicaid.
• People certified for Medicaid for the Elderly and People with Disabilities (MEPD), Texas Works Temporary Assistance for Needy Families (TANF) and certain other Medicaid programs in HHSC are eligible.

Every person certified for Medicaid benefits has a coverage code and a type program assigned to the person’s Medicaid record. The appropriate coverage code for participation in the TxHmL or HCS waiver program is R, regular Medicaid or P, three months prior coverage. No other coverage codes are acceptable. The following chart indicates the acceptable Medicaid coverage codes and program types for HCS and TxHmL.

Required Medicaid Codes and Type Program

For specific questions about SSI, contact your local SSA office, call 800-772-1213 or visit the SSA website at www.ssa.gov.For specific questions about MEPD or Texas Works, contact your local HHSC office, call 211 or visit the HHSC website at hhs.texas.gov or Your Texas Benefits. You may search for your local HHSC office here.

For specific questions about DFPS, call 512-929-6900 or visit its website at www.dfps.texas.gov.

11200, Responsibility to Reestablish Medicaid Eligibility

Revision 25-1; Effective April 29, 2025

If a person loses Medicaid eligibility, it is the responsibility of the representative payee or authorized representative to contact the appropriate entity to determine necessary action to reinstate benefits.

If the HCS Program provider is the representative payee or authorized representative, the provider is responsible for making sure action is taken to reestablish Medicaid eligibility.

If a person manages their Medicaid coverage or the person’s family is the representative payee or authorized representative, the service coordinator must assist if requested.

11300, Responsibility to Monitor Medicaid Eligibility

Revision 25-1; Effective April 29, 2025

Program providers must monitor Medicaid eligibility for the people they serve. LIDDAs are also encouraged to monitor Medicaid eligibility for the people they serve.

Program providers and LIDDAs can monitor Medicaid Eligibility on the Texas Medicaid & Healthcare Partnership (TMHP) LTCOP Dashboard for all enrolled people in their HCS or TxHmL contract area. The Medicaid Eligibility reports can be used to identify whose Medicaid eligibility had ended or will end at the month and to prepare for Medicaid renewal due within one year.

In addition to the TMHP LTCOP Dashboard, Medicaid Eligibility can be checked with the following applications:

• Client Assignment and Registration (CARE) System screen C63,
• Medicaid Eligibility Search,
• TMHP TexMed Connect - Medicaid Eligibility and Service Authorization Verification (MESAV) system, or
• Medicaid Client Portal (MCP).