G-7200, Prior Coverage for Medical Assistance Only Applicants

Revision 12-3; Effective September 1, 2012

Applicants may be eligible for Medicaid coverage during any or all of the three months before the month of application for an ongoing MEPD program. An applicant must have unpaid or reimbursable charges or bills for Medicaid covered services during each month for which prior coverage is requested. He must meet all requirements applicable to the SSI or MEPD programs during each of the months he is eligible.

The department also explores possible three month's prior coverage based on the date of change in the individual's circumstances for an individual transferring from limited Medicaid programs, such as QMB or Community Attendant Services, to full Medicaid benefit programs.

Example: If a QMB individual entered a nursing facility on June 3, the eligibility specialist would explore possible three months prior coverage for March, April and May. The special income limit would potentially be used for June and the SSI income limit would be used for the prior months.

Note: For Title XIX facility payment only, it makes no difference whether the bill is paid or unpaid. Standards for participation mandate reimbursement if Medicaid is established.


G-7210 Prior Coverage for Deceased Applicants

Revision 18-3; Effective September 1, 2018

A bona-fide agent  may file an application with HHSC on behalf of a deceased person for Medicaid coverage for any or all of the three months before HHSC receives the application. During each month for which prior coverage is requested, the deceased person must:

  • meet all eligibility requirements applicable to the MEPD program;
  • meet SSI income and resource limits; and
  • have unpaid or reimbursable charges or bills for Medicaid-covered services.

A bona fide agent is a person who is knowledgeable of the decedent's circumstances and can report the required information for eligibility determination accurately and under penalty of perjury. If the  information does not establish a date of onset covering the period for which eligibility is being determined, request a disability determination from the HHSC Disability Determination Unit (DDU). Indicate on Form H3034, Disability Determination Socio-Economic Report, that the individual is deceased.

The time period for which eligibility is determined is the three months before the month an HHSC application is received from the decedent's bona fide agent.

When the eligibility determination is complete for the ME-SSI Prior, notify the bona fide agent of the decision using Form TF0001, Notice of Case Action.