Appendix XVI, Medicaid Program Actions

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3-2017

When a Medicaid for the Elderly and People with Disabilities (MEPD) Texas Integrated Eligibility Redesign System (TIERS) action is needed, complete Form H1746-A, MEPD Referral Cover Sheet.

Use the following chart to determine whether or not a new Form H1200, Application for Assistance – Your Texas Benefits, must be attached to the coversheet. If a type program does not appear in this table, submit Form H1746-A and the application, if needed.

Supplemental Security Income (SSI) Adding Any HHSC Program

TIERS Type of Assistance	Program Name in TIERS	MEPD Action	Case Worker Action
TA08	ME – SSI State Group Home	No worker intervention	No application needed No Form H1746-A needed
TP12	ME – Temp Manual SSI	No worker intervention	No application needed No Form H1746-A needed
TP13	ME – SSI	No worker intervention	No application needed No Form H1746-A needed
TP38	ME – SSI Nursing Facility	No worker intervention	No application needed No Form H1746-A needed
TP39	ME – SSI State Hospital	No worker intervention	No application needed No Form H1746-A needed
TA02	ME – SSI Waivers	No worker intervention	No application needed No Form H1746-A needed

SSI Denial to Medicaid Waiver

TIERS Type of Assistance	Program Name in TIERS	MEPD Action	Case Worker Action
TA02	ME – SSI Waivers	Add MEPD Eligibility Determination Group (EDG)	Submit Form H1200 Submit Form H1746-A

SSI Denials to Community Attendant Services (CAS)

TIERS Type of Assistance	Program Name in TIERS	MEPD Action	Case Worker Action
TA08	ME – SSI State Group Home	Add ME – Community Attendant EDG	Submit Form H1200 Submit Form H1746-A
TP12	ME – Temp Manual SSI	Add ME – Community Attendant EDG	Submit Form H1200 Submit Form H1746-A
TP13	ME – SSI	Add ME – Community Attendant EDG	Submit Form H1200 Submit Form H1746-A
TP38	ME – SSI Nursing Facility	Add ME – Community Attendant EDG	Submit Form H1200 Submit Form H1746-A
TP39	ME – SSI State Hospital	Add ME – Community Attendant EDG	Submit Form H1200 Submit Form H1746-A
TP46	ME – SSI State Supported Living Center	Add ME – Community Attendant EDG	Submit Form H1200 Submit Form H1746-A
TA02	ME – SSI Waivers	Add ME – Community Attendant EDG	Submit Form H1200 Submit Form H1746-A

SSI Denials to State Supported Living Center

TIERS Type of Assistance	Program Name in TIERS	MEPD Action	Case Worker Action
TA08	ME – SSI State Group Home	Add ME – State Supported Living Center EDG	Submit Form H1200-PFS, Medicaid Application for Assistance (for Residents of State Facilities) Property and Financial Statement Submit Form H1746-A and Form H0090-I, Notice of Admission, Departure, Readmission or Death of an Applicant/Recipient of Supplemental Security Income and/or Assistance Only in a State Institution
TP12	ME – Temporary Manual SSI	Add ME – State Supported Living Center EDG	Submit Form H1200-PFS, Medicaid Application for Assistance (for Residents of State Facilities) Property and Financial Statement Submit Form H1746-A and Form H0090-I, Notice of Admission, Departure, Readmission or Death of an Applicant/Recipient of Supplemental Security Income and/or Assistance Only in a State Institution
TP13	ME – SSI	Add ME – State Supported Living Center EDG	Submit Form H1200-PFS, Medicaid Application for Assistance (for Residents of State Facilities) Property and Financial Statement Submit Form H1746-A and Form H0090-I, Notice of Admission, Departure, Readmission or Death of an Applicant/Recipient of Supplemental Security Income and/or Assistance Only in a State Institution
TP38	ME – SSI Nursing Facility	Add ME – State Supported Living Center EDG	Submit Form H1200-PFS, Medicaid Application for Assistance (for Residents of State Facilities) Property and Financial Statement Submit Form H1746-A and Form H0090-I, Notice of Admission, Departure, Readmission or Death of an Applicant/Recipient of Supplemental Security Income and/or Assistance Only in a State Institution
TP39	ME – SSI State Hospital	Add ME – State Supported Living Center EDG	Submit Form H1200-PFS, Medicaid Application for Assistance (for Residents of State Facilities) Property and Financial Statement Submit Form H1746-A and Form H0090-I, Notice of Admission, Departure, Readmission or Death of an Applicant/Recipient of Supplemental Security Income and/or Assistance Only in a State Institution
TA02	ME – SSI Waivers	Add ME – State Supported Living Center EDG	Submit Form H1200-PFS, Medicaid Application for Assistance (for Residents of State Facilities) Property and Financial Statement Submit Form H1746-A and Form H0090-I, Notice of Admission, Departure, Readmission or Death of an Applicant/Recipient of Supplemental Security Income and/or Assistance Only in a State Institution

Qualified Medicare Beneficiaries (QMB)/Specified Low-Income Medicare Beneficiaries (SLMB) to CAS

TIERS Type of Assistance	Program Name in TIERS	MEPD Action	Case Worker Action
TP23	MC – SLMB	Add MEPD – Community Attendant EDG	No application needed Submit Form H1746-A
TP24	MC – QMB	Add MEPD – Community Attendant EDG	No application needed Submit Form H1746-A

QMB/SLMB to Waiver

TIERS Type of Assistance	Program Name in TIERS	MEPD Action	Case Worker Action
TP23	MC – SLMB	Add MEPD EDG Explore the impact of transfer of assets, home equity and spousal impoverishment	Submit Form H1200 Submit Form H1746-A
TP24	MC – QMB	Add MEPD EDG Explore the impact of transfer of assets, home equity and spousal impoverishment	Submit Form H1200 Submit Form H1746-A

QMB/SLMB to State Supported Living Center

TIERS Type of Assistance	Program Name in TIERS	MEPD Action	Case Worker Action
TP23	MC – SLMB	Add MEPD – State Supported Living Center EDG Explore the impact of transfer of assets, home equity and spousal impoverishment	Submit Form H1200-PFS Submit Form H1746-A and Form H0090-I
TP24	MC – QMB	Add MEPD – State Supported Living Center EDG Explore the impact of transfer of assets, home equity and spousal impoverishment	Submit Form H1200-PFS Submit Form H1746-A and Form H0090-I

Qualifying Individuals (QI-1) to CAS

TIERS Type of Assistance	Program Name in TIERS	MEPD Action	Case Worker Action
TP26	MC – QI-1	Add MEPD – Community Attendant EDG and end MC- QI-1 EDG	No application needed Submit Form H1746-A Include a statement that the individual is willing to give up QI-1 to obtain CAS

QI-1 to Waiver

TIERS Type of Assistance	Program Name in TIERS	MEPD Action	Case Worker Action
TP26	MC – QI-1	Add MEPD EDG and end MC-QI-1 EDG Explore the impact of transfer of assets, home equity and spousal impoverishment	Submit Form H1200 Submit Form H1746-A Include a statement that the individual is willing to give up QI-1 to obtain waiver

CAS to Waiver

TIERS Type of Assistance	Program Name in TIERS	MEPD Action	Case Worker Action
TP14	ME – Community Attendant	Add MEPD EDG and end MEPD – Community Attendant EDG Determine the impact of any transfer of assets and impact of home equity and spousal impoverishment on waiver eligibility	Submit Form H1200 Submit Form H1746-A

Nursing Facility to Waiver

TIERS Type of Assistance	Program Name in TIERS	MEPD Action	Case Worker Action
TP17	ME – Nursing Facility	End MEPD – Nursing Facility EDG and add MEPD EDG Determine the impact of any transfer of assets and impact of home equity on waiver eligibility	No application needed Submit Form H1746-A
TP41	ME – Skilled Nursing Care	End MEPD – Nursing Facility EDG and add MEPD EDG Determine the impact of any transfer of assets and impact of home equity on waiver eligibility	No application needed Submit Form H1746-A

Intermediate Care Facility for Individuals with an Intellectual Disability or Related Condition (ICF/IID) to Waiver

TIERS Type of Assistance	Program Name in TIERS	MEPD Action	Case Worker Action
TA12	ME – State Group Home	End appropriate ICF/IID EDG and add ME EDG Determine the impact of any transfer of assets and impact of home equity on waiver eligibility.	No application needed Submit Form H1746-A
TA26	ME – SSI Non-State Group Home	End appropriate ICF/IID EDG and add ME EDG Determine the impact of any transfer of assets and impact of home equity on waiver eligibility.	No application needed Submit Form H1746-A
TP10	ME – State Supported Living Center	End appropriate ICF/IID EDG and add ME EDG Determine the impact of any transfer of assets and impact of home equity on waiver eligibility.	No application needed Submit Form H1746-A
TP15	ME – Non-State Group Home	End appropriate ICF/IID EDG and add ME EDG Determine the impact of any transfer of assets and impact of home equity on waiver eligibility.	No application needed Submit Form H1746-A
TP16	ME – State Hospital	End appropriate ICF/IID EDG and add ME EDG Determine the impact of any transfer of assets and impact of home equity on waiver eligibility.	No application needed Submit Form H1746-A

ICF/IID to State Supported Living Center

TIERS Type of Assistance	Program Name in TIERS	MEPD Action	Case Worker Action
TA12	ME – State Group Home	End appropriate ICF/IID EDG and add ME – State Supported Living Center EDG	No application needed Submit Form H1746-A and Form H0090-I
TA26	ME – SSI Non-State Group Home	End appropriate ICF/IID EDG and add ME – State Supported Living Center EDG	No application needed Submit Form H1746-A and Form H0090-I
TP10	ME – State Supported Living Center	End appropriate ICF/IID EDG and add ME – State Supported Living Center EDG	No application needed Submit Form H1746-A and Form H0090-I
TP15	ME – Non-State Group Home	End appropriate ICF/IID EDG and add ME – State Supported Living Center EDG	No application needed Submit Form H1746-A and Form H0090-I
TP16	ME – State Hospital	End appropriate ICF/IID EDG and add ME – State Supported Living Center EDG	No application needed Submit Form H1746-A and Form H0090-I

Community Medical Assistance Only (MAO) to Waiver

TIERS Type of Assistance	Program Name in TIERS	MEPD Action	Case Worker Action
TA10	ME – Waivers	No change to EDG	No application needed No Form H1746-A needed
TA18	ME – Grandfathered LTC	No change to EDG	No application needed No Form H1746-A needed
TP03	ME – Pickle	No change to EDG	No application needed No Form H1746-A needed
TP18	ME – Disabled Adult Child	No change to EDG	No application needed No Form H1746-A needed
TP21	ME – Disabled Widow(er)	No change to EDG	No application needed No Form H1746-A needed
TP22	ME – Early Aged Widow(er)	No change to EDG	No application needed No Form H1746-A needed
TP87	ME – Medicaid Buy In (MBI)	No change to EDG	No application needed No Form H1746-A needed

Community MAO to State Supported Living Center

TIERS Type of Assistance	Program Name in TIERS	MEPD Action	Case Worker Action
TA10	ME – Waivers	End ME EDG and add ME – State Supported Living Center EDG Explore the impact of transfer of assets, home equity and spousal impoverishment	Submit Form H1200-PFS Submit Form H1746-A and Form H0090-I
TA18	ME – Grandfathered LTC	End ME EDG and add ME – State Supported Living Center EDG Explore the impact of transfer of assets, home equity and spousal impoverishment	Submit Form H1200-PFS Submit Form H1746-A and Form H0090-I
TP03	ME – Pickle	End ME EDG and add ME – State Supported Living Center EDG Explore the impact of transfer of assets, home equity and spousal impoverishment	Submit Form H1200-PFS Submit Form H1746-A and Form H0090-I
TP14	ME – Community Attendant	End ME EDG and add ME – State Supported Living Center EDG Explore the impact of transfer of assets, home equity and spousal impoverishment	Submit Form H1200-PFS Submit Form H1746-A and Form H0090-I
TP18	ME – Disabled Adult Child	End ME EDG and add ME – State Supported Living Center EDG Explore the impact of transfer of assets, home equity and spousal impoverishment	Submit Form H1200-PFS Submit Form H1746-A and Form H0090-I
TP21	ME – Disabled Widow(er)	End ME EDG and add ME – State Supported Living Center EDG Explore the impact of transfer of assets, home equity and spousal impoverishment	Submit Form H1200-PFS Submit Form H1746-A and Form H0090-I
TP22	ME – Early Aged Widow(er)	End ME EDG and add ME – State Supported Living Center EDG Explore the impact of transfer of assets, home equity and spousal impoverishment	Submit Form H1200-PFS Submit Form H1746-A and Form H0090-I
TP87	ME – Medicaid Buy-In	End ME EDG and add ME – State Supported Living Center EDG Explore the impact of transfer of assets, home equity and spousal impoverishment	Submit Form H1200-PFS Submit Form H1746-A and Form H0090-I

Texas Works-Related Medicaid to Waiver

TIERS Type of Assistance	Program Name in TIERS	MEPD Action	Case Worker Action
TA31	MA – Parents and Caretaker Relatives – Emergency	No change to EDG.	No application or Form H1746-A needed
TP02	MA – Refugee Medical Assistance (RMA)	No change to EDG.	No application or Form H1746-A needed
TP07	MA – Earnings Transitional	No change to EDG.	No application or Form H1746-A needed
TP08	MA – Parents and Caretaker Relatives	No change to EDG.	No application or Form H1746-A needed
TP20	MA – Spousal Support Transitional	No change to EDG.	No application or Form H1746-A needed
TP40	MA – Pregnant Women	No change to EDG.	No application or Form H1746-A needed
TP43	MA – Children Under One Year	No change to EDG.	No application or Form H1746-A needed
TP44	MA – Children Six to 18 Years	No change to EDG.	No application or Form H1746-A needed
TP45	MA – Newborn Children	No change to EDG.	No application or Form H1746-A needed
TP48	MA – Children One to Five Years	No change to EDG.	No application or Form H1746-A needed
TP70	Medicaid for the Transitioning Foster Care Youth (MTFCY)	No change to EDG.	No application or Form H1746-A needed
TP92	Adoption Assistance - Federal Match - With Cash	No change to EDG.	No application or Form H1746-A needed
TP93	Foster Care - Federal Match - No Cash	No change to EDG.	No application or Form H1746-A needed
TP94	Foster Care - Federal Match - With Cash	No change to EDG.	No application or Form H1746-A needed
TP95	Adoption Assistance - No Federal Assistance - No Cash	No change to EDG.	No application or Form H1746-A needed
TP96	Adoption Assistance - No Federal Assistance - With Cash	No change to EDG.	No application or Form H1746-A needed
TP97	Foster Care - No Federal Match - With Cash	No change to EDG.	No application or Form H1746-A needed
TP98	Foster Care - No Federal Match - With Cash	No change to EDG.	No application or Form H1746-A needed
TP99	MA - Non-AFDC Foster Care	No change to EDG.	No application or Form H1746-A needed

CAS to QI-1

TIERS Type of Assistance	Program Name in TIERS	MEPD Action	Case Worker Action
TP14	ME – Community Attendant	End MEPD – Community Attendant EDG and add MC -QI-1 EDG	No application needed Submit Form H1746-A Include a statement that the individual is willing to give up CAS to obtain QI-1

Waiver to QI-1

TIERS Type of Assistance	Program Name in TIERS	MEPD Action	Case Worker Action
TA10	ME – Waivers	End MEPD – Waiver EDG and add MC – QI-1 EDG	No application needed Submit Form H1746-A Include a statement that the individual is willing to give up waiver to obtain QI-1

Waiver to CAS

TIERS Type of Assistance	Program Name in TIERS	MEPD Action	Case Worker Action
TA10	ME – Waivers	End MEPD – Waiver EDG and add MEPD – Community Attendant EDG	No application needed Submit Form H1746-A

Waiver to Nursing Facility

TIERS Type of Assistance	Program Name in TIERS	MEPD Action	Case Worker Action
TA10	ME – Waivers	End MEPD – Waiver EDG and add MEPD – Nursing Facility EDG	No application needed No Form H1746-A needed

Waiver to ICF/IID

TIERS Type of Assistance	Program Name in TIERS	MEPD Action	Case Worker Action
TA10	ME – Waivers	End MEPD – Waiver EDG and add MEPD EDG for the ICF/IID	No application needed No Form H1746-A needed

Waiver to State Supported Living Center

TIERS Type of Assistance	Program Name in TIERS	MEPD Action	Case Worker Action
TA10	ME – Waivers	End MEPD – Waiver EDG and add MEPD – State Supported Living Center EDG	No application needed Submit Form H1746-A and Form H0090-I

Medicaid Buy-In for Children to Waiver

TIERS Type of Assistance	Program Name in TIERS	MEPD Action	Case Worker Action
TP88	ME – Medicaid Buy-In for Children	End MEPD-Medicaid Buy-In for Children EDG and add MEPD EDG Explore the impact of transfer of assets, home equity and spousal impoverishment	Submit Form H1200 Submit Form H1746-A

Medicaid Buy-In to State Supported Living Center

TIERS Type of Assistance	Program Name in TIERS	MEPD Action	Case Worker Action
TP87	ME – Medicaid Buy-In	End MEPD EDG and add MEPD – State Supported Living Center EDG Explore the impact of transfer of assets, home equity and spousal impoverishment	Submit Form H1200-PFS Submit Form H1746-A and Form H0090-I
TP88	ME – Medicaid Buy-In for Children	End MEPD EDG and add MEPD – State Supported Living Center EDG Explore the impact of transfer of assets, home equity and spousal impoverishment	Submit Form H1200-PFS Submit Form H1746-A and Form H0090-I

Texas Women's Health Program to Waiver

TIERS Type of Assistance	Program Name in TIERS	MEPD Action	Case Worker Action
TP41	Health Care – Texas Women's Health Program (TWHP)	Add MEPD EDG Coordinate efforts with Texas Works Do not discuss the TWHP with anyone other than the certified TWHP member.	Submit Form H1200 Submit Form H1746-A Do not discuss the TWHP with anyone other than the certified TWHP member.

Texas Women's Health Program to CAS

TIERS Type of Assistance	Program Name in TIERS	MEPD Action	Case Worker Action
TP41	Health Care – Texas Women's Health Program (TWHP)	Add MEPD EDG Do not discuss the TWHP with anyone other than the certified TWHP member.	Submit Form H1200 Submit Form H1746-A Do not discuss the TWHP with anyone other than the certified TWHP member.

One Type Waiver to Another Type Waiver

TIERS Type of Assistance	Program Name in TIERS	MEPD Action	Case Worker Action
TA10	ME – Waivers	Update Long-term Services and Supports Summary Screen and Medicaid Waivers/Community Attendant Screen	No application needed Submit Form H1746-A

Foster Care to State Supported Living Center

TIERS Type of Assistance	Program Name in TIERS	MEPD Action	Case Worker Action
TP52	MA – State Foster Care – A	Coordinate efforts with the Texas Department of Family and Protective Services (DFPS)	Submit Form H1200-PFS Submit Form H1746-A
TP53	MA – State Foster Care – B	Coordinate efforts with the Texas Department of Family and Protective Services (DFPS)	Submit Form H1200-PFS Submit Form H1746-A
TP54	MA – State Foster Care – 32	Coordinate efforts with the Texas Department of Family and Protective Services (DFPS)	Submit Form H1200-PFS Submit Form H1746-A
TP57	MA – State Foster Care – D	Coordinate efforts with the Texas Department of Family and Protective Services (DFPS)	Submit Form H1200-PFS Submit Form H1746-A
TP58	MA – State Foster Care – JPC	Coordinate efforts with the Texas Department of Family and Protective Services (DFPS)	Submit Form H1200-PFS Submit Form H1746-A
TP88	MA – Non-AFDC Foster Care – JPC	Coordinate efforts with the Texas Department of Family and Protective Services (DFPS)	Submit Form H1200-PFS Submit Form H1746-A
TP90	MA – State Foster Care	Coordinate efforts with the Texas Department of Family and Protective Services (DFPS)	Submit Form H1200-PFS Submit Form H1746-A
TP93	Foster Care – Federal Match – No Cash	Coordinate efforts with the Texas Department of Family and Protective Services (DFPS)	Submit Form H1200-PFS Submit Form H1746-A
TP94	Foster Care – Federal Match – With Cash	Coordinate efforts with the Texas Department of Family and Protective Services (DFPS)	Submit Form H1200-PFS Submit Form H1746-A
TP97	Foster Care – No Federal Match – No Cash	Coordinate efforts with the Texas Department of Family and Protective Services (DFPS)	Submit Form H1200-PFS Submit Form H1746-A
TP98	Foster Care – No Federal Match – With Cash	Coordinate efforts with the Texas Department of Family and Protective Services (DFPS)	Submit Form H1200-PFS Submit Form H1746-A
TP99	MA – Non-AFDC Foster Care	Coordinate efforts with the Texas Department of Family and Protective Services (DFPS)	Submit Form H1200-PFS Submit Form H1746-A

Adoption Assistance to State Supported Living Center

TIERS Type of Assistance	Program Name in TIERS	MEPD Action	Case Worker Action
TP91	Adoption Assistance – Federal Match – No Cash	Coordinate efforts with DFPS	Submit Form H1200-PFS Submit Form H1746-A and Form H0090-I
TP92	Adoption Assistance -Federal Match – With Cash	Coordinate efforts with DFPS	Submit Form H1200-PFS Submit Form H1746-A and Form H0090-I
TP95	Adoption Assistance – No Federal Assistance – No Cash	Coordinate efforts with DFPS	Submit Form H1200-PFS Submit Form H1746-A and Form H0090-I
TP96	Adoption Assistance – No Federal Assistance – With Cash	Coordinate efforts with DFPS	Submit Form H1200-PFS Submit Form H1746-A and Form H0090-I

Appears In

Community Care Services Eligibility Handbook
STAR Kids Program Support Unit Operational Procedures Handbook
STAR+PLUS Program Support Unit Operational Procedures Handbook