4900, Medicaid and Medicare

Revision 22-1; Effective Nov. 28, 2022

4910 Medicaid Eligibility Guidelines

Revision 22-1; Effective Nov. 28, 2022

HHSC requires all people to meet Medicaid eligibility for PASRR. Eligibility must be attained and maintained for the person to continue receiving PASRR specialized services. People eligible for certain types of Medicaid coverage are eligible for PASRR. However, not all types of Medicaid coverage ensure eligibility.

Every person certified for Medicaid benefits has a "TOA code" and a "program code" assigned to their Medicaid record. See the table below for the appropriate coverage codes for participation in PASRR. CARE Screen C63 (Medicaid Eligibility Search), Screen 192 and Screen 193 (Medicaid Eligibility Information) can be used to verify a person’s current and past Medicaid records.

Required Medicaid Codes

TOA CodeProgram CodeTOA CodeProgram CodeTOA CodeProgram Code

Contact your local HHSC office by calling 211, or visiting the HHSC website for specific questions about Medicaid coverage. 

4920 Responsibility to Reestablish Medicaid Eligibility

Revision 22-1; Effective Nov. 28, 2022

If a person loses Medicaid eligibility or is delayed in having Medicaid eligibility determined or re-determined, a NF and LIDDA may be unable to receive authorizations or bill for PASRR specialized services, including habilitation coordination. It is the responsibility of the representative payee to contact the appropriate entity to determine the necessary action to reinstate benefits.

If the individual or family is the representative payee, the habilitation coordinator must assist, if requested.

If the NF is the representative payee, the NF is responsible for ensuring action is taken to reestablish Medicaid eligibility. In most circumstances, assisting people with Medicaid eligibility determinations, re-determinations, and MCO selection is allowable as a medically related social service, which is a service provided by the NF that help the individual in attaining the highest practicable physical, mental, or psychosocial well-being.

If needed, the LIDDA is expected to work with the NF to help a person reestablish Medicaid eligibility. Failure of a representative payee to help reestablish Medicaid eligibility may be reported to HHSC Complaint and Incident Intake.

To minimize billing issues about habilitation coordination, LIDDAs should review the service authorization in Medicaid Eligibility Service Authorization Verification (MESAV) to verify that the person is admitted into the correct Medicaid program.

4930 MCO Selection

Revision 22-1; Effective Nov. 28, 2022

STAR+PLUS is the Texas Medicaid managed care program for people who live in NFs. A NF resident must select a STAR+PLUS managed care organization (MCO). If a NF resident fails to select an MCO, the resident will be assigned an MCO.  

A person enrolled with an MCO is assigned a service coordinator. The MCO service coordinator has responsibility for coordinating and ensuring the delivery of NF add-on services and acute care services. An MCO service coordinator must conduct quarterly visits with the individual. MCO service coordinators also work with the individual, families, habilitation coordinators, and other service coordinators or case managers to ensure a smooth transition to the community, when appropriate. The individual’s MCO service coordinator should be a part of the care planning process and is a member of the IDT and SPT, if the individual does not object. The habilitation coordinator should ask the individual or LAR, if applicable, directly whether they are okay with or object to the MCO service coordinator’s attendance at IDT and SPT meetings and must document evidence of this discussion in the individual’s record. 

4930.1 Individual Does Not Have an MCO

Revision 22-1; Effective Nov. 28, 2022

If a LIDDA becomes aware that a person is not assigned an MCO, the LIDDA must contact the NF and request the NF give information and guidance to the person or LAR on how to select and enroll in an MCO. The LIDDA must not delay transition planning activities if the person does not have an MCO and is ready to transition to the community.

Note: As part of medically related social services, a NF may provide information to a person or the person’s LAR about available MCOs and guidance on how to enroll in the preferred MCO. A NF may not choose an MCO on behalf of the individual.

4940 Individual is Dual Eligible

Revision 22-1; Effective Nov. 28, 2022

Many people who live in NFs are eligible for both Medicaid and Medicare. A NF stay for a person admitting from an acute care hospital may initially be funded by Medicare. However, the person’s Medicaid eligibility, and therefore their eligibility for PASRR, does not change. If the person is Medicaid-eligible and meets the other criteria for habilitation coordination, he or she must not be refused access to those services whether or not the current stay is paid for by Medicare or Medicaid.