Revision 24-4; Effective Dec. 1, 2024
Although often used interchangeably, denials and terminations are different types of adverse case actions.
- A denial refers to a determination of ineligibility for Medicaid benefits that a person is not currently receiving. A denial action may occur when processing an application, a request for a new type of benefit, or a program transfer request.
- A termination refers to a determination of ineligibility for ongoing Medicaid benefits that a person is currently receiving. A termination action may occur when processing a renewal or redetermination based on a change in circumstances.
Unless otherwise specified, the policy in the following sections applies to both denials and terminations.
Procedural Denials
A procedural denial occurs when a person is ineligible for benefits because they failed to provide all information needed to make an eligibility determination. Examples of actual procedural denial reasons on the TF0001, Notice of Case Action, include:
- Individuals was sent forms to renew benefits. They didn't return the forms by the due date.
- You failed to provide required information by the due date.
Non-Procedural Denials
A non-procedural denial occurs when a person is not eligible for benefits based on the information provided. They do not meet one or more specific financial or non-financial eligibility requirements, and there are no exceptions that would make them eligible. Examples of non-procedural denial reasons on the TF0001 notice include:
- The money Individuals gets (income) is more than allowed for this program.
- The value of the things this person is paying for or owns is more than allowed by program rules.
- [Client] didn't give proof showing that they live in Texas.
- [Client] has not shown that they are either a citizen or a non-citizen who is qualified to receive benefits.
Determine Medicaid Eligibility on All Bases
Consider Medicaid eligibility on all bases prior to denying or terminating Medicaid eligibility. Determine if the person is eligible for any other Medicaid and Medicare Savings Program (MSP) benefits, including both Modified Adjusted Gross Income (MAGI) and non-MAGI types of assistance (TOAs).
If the person is eligible for another type of Medicaid or MSP program, transfer to the new TOA without requiring a new application. If more information is needed to determine eligibility for another TOA, including transfers from a non-MAGI program to a MAGI program or vice versa, pend the case and request only the information needed. Do not request a new application or verification of information available through an electronic data source.
Example: A person submits Form H1200, Application for Assistance - Your Texas Benefits, to apply for Waiver Medicaid for a minor child. The child does not have an established disability determination and is not eligible for Waiver Medicaid. Based on the information provided, the system cascades to Children’s Medicaid (CMA). Confirm the eligibility determination is correct and certify the child for CMA without requiring a Form H1010, Texas Works Application for Assistance - Your Texas Benefits, or Form H1205, Texas Streamlined Application.
Related Policy
Previously Completed Application, B-5000
Denials, B-6500
Potential Resource Exclusions, F-5200