Revision 12-3; Effective September 1, 2012
When an SSI recipient enters a Medicaid facility and the SSI cash benefit will be denied because the income is greater than the reduced federal benefit rate, and:
- If contacted by the recipient/authorized representative (AR), inform the recipient/AR to notify SSA of the entry to the Medicaid facility. Send Form H1200, Application for Assistance – Your Texas Benefits, to the recipient/AR to complete and return to HHSC.
- If contacted by the Medicaid facility, inform the facility to notify SSA of the entry to the Medicaid facility. Obtain the AR's information, including mailing address, and send Form H1200 to the AR to complete and return to HHSC.
TIERS is notified by the State Data Exchange (SDX) system when SSI cash benefits have been denied because of income that is greater than the reduced SSI federal benefit rate. Once the SDX denial notice is received by TIERS, the SSI Medicaid will be denied by the system.
There is no overlay option in TIERS. Certification for MEPD benefits cannot occur until the SSI is denied. This may require delay in certification, closing and re-opening applications until the SSI is denied.
When SSI has been denied and an MEPD application has not been filed, and:
- If contacted by the recipient/AR, send Form H1200 to the recipient/AR to complete and return to HHSC.
- If contacted by the Medicaid facility, obtain the AR's information, including mailing address. Send Form H1200 to the AR to complete and return to HHSC.
Reference: See Section B-7210, Ensuring Continuous Medicaid Coverage.
After receipt of Form H1200, determine the recipient's financial eligibility for MEPD using the special income limit beginning with the first month after SSI denial. Also determine whether the recipient has an approved medical necessity or level of care and meets all other eligibility requirements. If the recipient has been denied a medical necessity or level of care but remains in the Medicaid facility (Medicare-SNF, NF or ICF/IID), or if the recipient does not remain in a Medicaid facility (Medicare-SNF, NF or ICF/IID) for 30 consecutive days, deny the MEPD application and refer the recipient back to SSI for reinstatement of full SSI benefits. If the recipient will not be reinstated for full SSI benefits, test eligibility for other Medicaid-funded programs, such as QMB, ME-Pickle, etc.
- If the MEPD application is not returned, the eligibility specialist contacts the recipient/authorized representative to attempt to obtain information to determine continued Medicaid eligibility. The eligibility specialist uses Form H1200 as a recording document, if necessary.
- Follow the procedures for SSI to MEPD transfer, unless continued SSI eligibility occurs under temporary provisions. If that situation occurs, do not process an institutional Medicaid application unless the SSI benefits are denied and the recipient is still in the facility.
Reference: See Chapter H, Co-Payment, for exceptions to reduced SSI payment standard.
B-7210 Ensuring Continuous Medicaid Coverage
Revision 13-4; Effective December 1, 2013
When a recipient is eligible for institutional Medicaid coverage, the medical effective date (MED) is the day after the date of SSI denial, when the SSI denial is due to entry into an institution. This ensures continuous Medicaid coverage.
Note: To ensure continuous Medicaid coverage for SSI recipients who enter institutions, the coverage may be more than three months from the application file date. For example, SSI was denied March 31, 2013. The individual applied for ME-Nursing Facility on Sept. 10, 2013. The MED can go back to April 1, 2013, which is more than three months prior.