Revision 18-1; Effective March 1, 2018
Waiver eligibility determination involves two components:
- Waiver eligibility component
- Financial Medicaid eligibility component
HHSC is responsible for the waiver eligibility component criteria of and for the financial Medicaid eligibility component criteria of the eligibility determination for most waivers.
Intake for a waiver is also through HHSC or an HHSC contracted provider. The HHSC designee will assist with determining appropriate program services and will assist the person in the financial Medicaid eligibility component, if necessary.
In general, HHSC is responsible for ensuring that specific criteria for the waiver eligibility component have been met and that the person:
- is or will be residing in the community;
- meets the age requirement of the waiver, if applicable;
- has either a medical necessity (MN) or appropriate level of care (LOC) determination, as applicable;
- has an approved plan of care or service plan; and
- has a service begin date no later than 30 days from certification.
HHSC is normally responsible for financial Medicaid eligibility component criteria.
The financial Medicaid eligibility component criteria for most waivers are met if the person is a Supplemental Security Income (SSI) recipient or has full Medicaid coverage under another group in the Texas State Medicaid Plan.
Potentially, the financial Medicaid eligibility component criteria for most waivers are met if the person is a:
- Medicaid recipient certified under a Medicaid group within the Texas State Medicaid Plan. MEPD examples include ME – Pickle, ME – Disabled Adult Child and ME – Early Aged Widow(er);
- Medicaid recipient certified using the special income limit (see Appendix XXXI, Budget Reference Chart);
- Community Attendant Services (CAS) recipient; or
- Medicaid recipient based on a Texas Works Medicaid program.
Financial Medicaid eligibility for most waivers will require a review of the person's situation specifically relating to transfer of assets and substantial home equity. See Chapter I, Transfer of Assets, and Chapter F, Resources.
To meet the financial Medicaid eligibility component, if the person is not already a Medicaid recipient under another Texas Medicaid program or an SSI recipient, the person must apply for:
- SSI if the monthly income is less than the SSI income limit; or
- another Medicaid program under the Texas Medicaid program, such as an MEPD program.
See Section B-4000, Date of Application, for more information about the file date of an application and accepting an application.
The financial Medicaid eligibility component for the Texas Home Living (TxHmL) Program is not completed using the special income limit. More specifically, to be eligible for the TxHmL Program, the person must already be receiving Medicaid. HHSC will not certify a person for Medicaid as a condition of the TxHmL Program.
Under the financial Medicaid eligibility component criteria when determining eligibility for waivers using special income limit, a person:
- must meet nonfinancial criteria outlined in Chapter D, Non-Financial;
- must meet resource criteria outlined in Chapter F, Resources, with specific consideration given to:
- must meet income criteria outlined in Chapter E, General Income, with the understanding that:
- deeming procedures are not used; and
- support and maintenance is not counted as income; and
- must meet financial eligibility and payment plan budget requirements outlined in Chapter G, Eligibility Budgets, with specific consideration given to:
A medical effective date can be established when all the criteria are met for both the:
- waiver eligibility component; and
- financial eligibility component.
See Section R-1200, Medical Effective Date. For waiver eligibility, the medical effective date is one of the following:
- The first day of the month of entry into a nursing facility, ICF/IID or state supported living center if the applicant filed a Medicaid application during that month, then requested a program transfer before being certified and met all eligibility criteria.
- The first day of the month if the applicant met all waiver eligibility component and financial Medicaid eligibility component criteria.
- The day after the effective date of SSI denial, for recipients transferred from SSI assistance to an MEPD program (excluding any Medicare Savings Program).
- Consider potential three months prior to the date of application if the person entered a nursing facility, ICF/IID or state supported living center and then transitioned into a waiver setting before being certified. See O-5000, Waiver Programs and 30 Consecutive Days.
- Consider potential three months prior to the date of application if the person received waiver services in the prior months period and lost waiver eligibility due to failure to return a redetermination application. See R-1200, Medical Effective Date, for examples of these situations.
- The TxHmL Program requires that the person already be eligible for Medicaid before placement in the TxHmL Program. Persons cannot be determined eligible for this waiver under the special income limit.
In addition, to comply with the federally approved waiver, co-payment must be considered for waiver recipients whose eligibility is determined under the special income limit. See Appendix XXII, Home and Community-Based Services Waiver Program Co-Payment Worksheets, for the sequence in which deductions are allowed. Allow deductions indicated on the appropriate co-pay worksheet. For many waiver recipients, the co-payment will be $0. Notify HHSC of the co-payment amount using the Medicaid Eligibility to HHSC automated communication tool.
When the person is married and applying for waiver eligibility, use spousal impoverishment policy for consideration of resources. See Chapter J, Spousal Impoverishment. Spousal impoverishment policy is not used in the TxHmL Program.
Denied SSI Due to Earned Income Impact on Waiver Eligibility
Sometimes an SSI denial is short term and an SSI recipient is reinstated. There might be a gap in SSI and Medicaid coverage. This might happen when the eligibility is based on earned weekly income, normally with four paychecks. When five paychecks are received in one month, income ineligibility might occur whether based on a recipient’s earnings or deemed income that includes weekly earnings. Even though Medicaid eligibility might be established retroactively using the special income limit to cover the gap month, Medicaid waiver services may be interrupted during the gap month.
When notified that a person receiving Medicaid waiver services is being denied SSI due to income ineligibility from the receipt of an extra paycheck, send an application to the Medicaid waiver person.
Once the application is obtained, determine eligibility for the Medicaid waiver person using the special income limit. If all eligibility criteria are met, certify the Medicaid waiver person under ME-Waivers.
After receipt of the first application, it may be used for up to 12 months. A new application must be obtained yearly and processed as a redetermination.