A-240, Medical Programs

Body

Revision 16-4; Effective October 1, 2016

Medical Programs

The following individuals may be certified for medical coverage if they meet all eligibility criteria:

  • children under age 19;
  • other-related children under age 19;
  • independent children under age 19;
  • pregnant women;
  • legal parent(s);
  • caretaker relatives; or
  • spouse of caretaker relatives.

MAGI rules are used to determine financial eligibility for certain Medical Programs. MAGI rules are based on Internal Revenue Service tax rules.

The following criteria are considered when determining the MAGI household composition for Medical Programs:

  • tax status;
  • tax relationships;
  • living arrangements; and
  • family relationships.

Tax Status

An individual’s tax status must be designated before their MAGI household composition can be determined.

Tax status is based on the individual’s self-declaration for what he or she plans to report on his or her federal income tax return for the taxable year in which eligibility for Medical Programs is requested.

Individuals must be designated as one of the following:

  • A taxpayer – an individual who plans to file a federal income tax return for the taxable year in which eligibility for Medical Programs is requested and who is not claimed by another taxpayer. Spouses who plan to file a joint or separate federal income tax return are both considered taxpayers.

Note: For MAGI household composition purposes, an unmarried individual who intends to file a joint tax return is considered a taxpayer filing separately. An individual who is unmarried is not considered a taxpayer filing jointly.

  • A tax dependent – an individual who plans to be claimed as a tax dependent by a taxpayer.

Note: An individual who is both a taxpayer and tax dependent is considered a tax dependent. Example: A college student who plans to file his or her own federal income tax return and expects to be claimed by his or her parents will be considered a tax dependent.

  • A non-taxpayer/non-tax dependent – an individual who does not plan to file a federal income tax return in the taxable year in which eligibility for Medical Programs is requested and does not plan to be claimed by a taxpayer. 

Tax Relationships

Individuals have a tax relationship to one another if they:

  • plan to file a joint federal income tax return;
  • are the taxpayer that plans to claim specific tax dependent(s); or
  • are a tax dependent of a specific taxpayer.

Individuals do not have a tax relationship to anyone if they:

  • do not plan to file a federal income tax return;
  • are not the taxpayer planning to claim the specified tax dependent(s); or
  • are not a tax dependent of a specified taxpayer.

Living Arrangements

Individuals are not required to live at the same physical address in order to apply for each other if they have a tax relationship, as explained in A-121, Receipt of Application.

Domicile requirements explained in A-900, Domicile, apply to TP 08, Parents and Caretaker Relatives Medicaid. A parent/caretaker relative must reside with a dependent child to receive TP 08 benefits.

A child entering a state hospital may qualify as an independent child. The child may qualify even if ordered by the court into a state hospital. A child is considered an independent child if court ordered into a state hospital because the parent/caretaker relative no longer has care and control. If the parent/caretaker relative admitted the child voluntarily into a state hospital, verification of whether the parent/caretaker relative still has care and control to determine independent child status is required.

An inquiry should be performed prior to certifying an independent child. The child is certified as an independent child if all eligibility criteria are met. The coverage continues for 12 months, even if the child is released from the state hospital. If a child is released from the facility prior to the end of the 12-month period, the address change is processed and coverage is continued.

Determining Custodial Parent

A custodial parent is established based on physical custody and who has legal authority to claim a child as a tax dependent specified in a court order, binding separation agreement, divorce agreement, or custody agreement.

  • If there is no order or agreement, or in the event of a shared custody agreement without specifications for filing federal income tax returns, the custodial parent is the parent with whom the child spends most nights. In the event that the child spends an equal amount of nights with both parents, the advisor must make a prudent person decision regarding which parent should be considered the custodial parent.
  • If both a custodial parent and a non-custodial parent declare that they plan to claim the same child as a tax dependent on their federal income tax return, the advisor should build the child’s MAGI household composition as a tax dependent of the custodial parent. 

Family Relationships

Family relationships that impact household composition include:

  • marriage;
  • parents of children under age 19; and
  • siblings under age 19 or a child under age 19.

The tax status of the individual impacts how the family relationship is used in determining MAGI household composition.

Notes:

  • For MAGI only applications and renewals, a relationship and tax status of unmarried and intending to file jointly is not an indication that the individual is currently married or that there is a discrepancy in the individual's marital status.
  • For integrated applications and renewals that include SNAP or TANF, a relationship and tax status of unmarried and intending to file jointly should be treated as a case clue if marital status is questionable.
  • For all applications and renewals, if the client provides a tax document with an indication of marital status that is inconsistent with the marital status that was reported on an application, the discrepancy in the marital status must be resolved.

A household cannot choose to exclude a child from the budget group when determining eligibility for Medical Programs. 

The policy in A-241, Budget Group, and A-242, Certified Group, is used to determine whom to include in the budget and certified group.

Related Policy

Children Admitted into State Hospitals, A-922
Verification Requirements, A-940
Documentation Requirements, A-950
Applications for Babies Born to Women in Prison, A-116.3
Eligibility Requirements, A-521

 

A—241 Budget Group

Revision 12-1; Effective January 1, 2012

 

 

A—241.1 Who Is Included

Revision 15-4; Effective October 1, 2015

 

 

A—241.1.1 Taxpayer’s MAGI Household Composition

Revision 15-4; Effective October 1, 2015

Medical Programs

The following individuals are included in the taxpayer’s MAGI household composition:

  • The taxpayer;
  • The taxpayer’s spouse, if the taxpayer and the spouse live together;
  • The taxpayer’s spouse, if the taxpayer and spouse file a joint federal income tax return; and
  • Any individual the taxpayer plans to claim as a tax dependent.

 

A—241.1.2 Tax Dependent Exceptions

Revision 19-1; Effective January 1, 2019

Medical Programs

If a tax dependent meets any one of the following exceptions, staff must use the non-taxpayer/non-tax dependent rules explained in A-241.1.4, Non-Taxpayer/Non-Tax Dependent’s or Tax Dependent with an Exception MAGI Household Composition, (not the tax dependent rules) to build the tax dependent’s MAGI household composition:

  • The tax dependent is not the taxpayer’s spouse or the taxpayer’s child (natural, adopted or step) regardless of age;
  • The tax dependent is a child under age 19 who lives with both parents who do not plan to file a joint federal income tax return and the child was claimed by one parent; or
  • The tax dependent is a child under age 19 who is claimed as a tax dependent only by a non-custodial parent.

For a child claimed as a tax dependent by both parents who are filing jointly, with one parent living outside the home, the child does not meet the third tax dependent exception. Staff must build the child’s MAGI household composition using the tax dependent rules explained in A-241.1.3, Tax Dependent’s MAGI Household Composition.

 

A—241.1.3 Tax Dependent’s MAGI Household Composition

Revision 15-4; Effective October 1, 2015

Medical Programs

If an individual is a tax dependent and does not meet a tax dependent exception previously listed, the following individuals must be included in the tax dependent’s MAGI household composition:

  • The tax dependent;
  • The individuals in the MAGI household composition of the taxpayer who is planning to claim the tax dependent; and
  • The tax dependent’s spouse, if the tax dependent and the spouse live together.

 

A—241.1.4 Non-Taxpayer/Non-Tax Dependent’s or Tax Dependent with an Exception MAGI Household Composition

Revision 15-4; Effective October 1, 2015

Medical Programs

If an individual does not plan to file a tax return nor plans to be claimed as a tax dependent, the individual is considered a non-taxpayer/non-tax dependent. All tax dependents who meet an exception – Tax Dependent Exceptions­ – will build his or her MAGI household composition using the non-taxpayer/non-tax dependent rules.

The following individuals must be included in the non-taxpayer/non-tax dependent’s or tax dependent with exception’s MAGI household composition if living together

  • The individual,
  • The individual’s spouse,
  • The individual’s children under age 19, and
  • If the individual is a child under age 19:
    • The individual’s parents, and
    • The individual’s siblings under age 19.

 

A—241.1.5 Inclusion of the Unborn

Revision 16-4; Effective October 1, 2016

Medical Programs

The expected number of unborn children are included in the MAGI household composition of:

  • a pregnant woman; and
  • any individual whose MAGI household composition includes a pregnant woman.

Note: When including the expected number of unborn children in the MAGI household composition, the pregnant woman is not required to be certified on a medical program.

Related Policy

General Policy, A-910
Income Limits and Eligibility Tests, A-1341
Who Is Included, D-321
Who Is Not Included, D-322

 

A—241.2 Who Is Not Included

Revision 15-4; Effective October 1, 2015

Advisors must use the MAGI household composition policy explained in A-241.1, Who Is Included, when determining eligibility for Medical Programs. 

 

A—241.3 Household Composition Situations (Minor Parents, Independent Children, Etc.)

Revision 15-4; Effective October 1, 2015

Advisors must use MAGI household composition policy explained in A-241.1, Who Is Included, when determining eligibility for Medical Programs.

 

A—241.3.1 Children's Living Arrangements

Revision 18-1; Effective January 1, 2018

Medical Programs

A child is considered institutionalized if the child is residing in a facility:

  • that is an organizational part of a governmental entity, such as a county holding facility for juveniles; or
  • over which a government unit exercises final administrative control.

A child is not considered institutionalized if the child is residing in a facility that is a:

  • publicly operated community residence that serves no more than 16 residents, such as a county emergency shelter;
  • non-public facility, such as a group or foster home or a general residential operations facility;
  • state hospital; or
  • halfway house operated by the Texas Juvenile Justice Department or Juvenile Probation Department that meets the following federally required criteria:
    • the halfway house must operate in such a way that individuals living there have freedom of movement and association according to the following tenets;
    • residents are not precluded from working outside the facility in employment available to individuals who are not under justice system supervision;
    • residents can use community resources at will; and
    • residents can seek health care treatment in the community to the same or similar extent as other Medicaid enrollees.

Related Policy

Children Placed in a Non-Secure Facility, B-474.1.2.1.1

 

A—241.4 Family Violence Exemption

Revision 15-4; Effective October 1, 2015

Medical Programs

Individuals may not be able to or may not want to provide information about a member of their MAGI household composition because they fear physical or emotional harm by that person. Individuals who are pended for missing information about a MAGI household composition member who may be a family violence offender can contact HHSC to request the family violence exemption by calling 2-1-1 or visiting a local office.  

Advisors must ask the individual requesting the family violence exemption, at the time the exemption is requested, if they want to be designated as the head of household for the case. Advisors must also confirm the address that should be used for agency correspondence and offer to set up an alternate address if needed. Individuals experiencing family violence must be allowed to provide an address for agency correspondence other than the address on the case with the offender.

If the individual wants to pursue the family violence exemption, advisors must determine whether the individual has existing approved Office of the Attorney General (OAG) good cause for TANF or TP 08 as explained in A-1130, Explanation of Good Cause. 

  • If the individual has existing OAG good cause, no further action is required for the individual. The advisor must select “OAG Good Cause” as the verification source in TIERS.
  • If the individual does not have existing OAG good cause, the advisor must make a referral to a family violence specialist at a nearby family violence service provider, following the process explained in A-241.4.1, Referral to a Family Violence Specialist. 

 

A—241.4.1 Referral to a Family Violence Specialist

Revision 15-4; Effective October 1, 2015

Advisors must send the contact information for the nearest family violence shelter to the individual pursuing the family violence exemption using Form H1071, Family Violence Exemption for Medicaid and CHIP. Form H1071 informs the individual how they can claim the family violence exemption and is sent along with Form H1020, Request for Information or Action. 

The individual must contact the family violence specialist and explain the need to claim the family violence exemption. After the family violence specialist makes the recommendation, the family violence specialist completes Form H1706, Good Cause Recommendation and Family Violence Exemption, and may mail or fax the form to HHSC, or send the form back with the individual to HHSC. Only a family violence specialist can recommend the exemption using Form H1706. Form H1706 is due 10 days from the date Form H1020 was sent (or 30 days from the file date, whichever is later).

  • If the family violence specialist recommends the family violence exemption, the exemption is granted and will affect all MAGI EDGs on the case by removing the offender from their MAGI household composition. 
  • If the family violence specialist does not recommend the family violence exemption, the exemption is denied. The advisor must re-pend the MAGI EDGs to give the individual additional time to provide the information that was originally requested for the MAGI household member.
  • If Form H1706 is not returned by the due date, the exemption is denied. All pending MAGI EDGs are denied for failure to provide information that was originally requested for the MAGI household member.
  • If the client withdraws the request for the family violence exemption, the client must provide the information that was originally requested for the MAGI household member by the due date, or the pending MAGI EDGs are denied.

Once the family violence exemption has been established by a family violence specialist, advisors do not need to re-evaluate the exemption. If the individual contacts HHSC to indicate that they no longer wish to receive the family violence exemption, advisors should update the page by indicating that the exemption has been withdrawn by the client.

The individual continues to receive the family violence exemption until there is a break in eligibility for all MAGI EDGs on the case. If an individual wants to pursue the family violence exemption again after a break in eligibility, advisors must follow the referral process explained in this section.

 

A—242 Certified Group

Revision 17-1; Effective January 1, 2017

Medical Programs

Each EDG will have one individual in the certified group.

TP 08

Parents and caretaker relatives caring for a dependent child who receives Medicaid.

TA 31, TP 32, TP 33, TP 34, TP 35 and TP 36

Pregnant women, children under age 19, and parents and caretaker relatives who are ineligible for ongoing Medicaid because they are non-immigrants, undocumented aliens, or certain legal permanent resident aliens who do not meet the citizenship eligibility requirement but meet all other eligibility requirements. Only a person with an emergency medical condition is certified.

TP 40

Minor or adult pregnant woman unless disqualified from Medical Programs for not complying with TPR or SSN requirements.

TP 43

Children under age 1.

If the child is hospitalized on the child’s first birthday, eligibility is continued through the month the hospitalization ends. See A-825, Medicaid Termination, for additional information.

TP 44

Children age 6 to 18. Children are eligible through the month of their 19th birthday.

Note: A child should be certified for TP 48 rather than TP 44 the month of the child’s sixth birthday.

If the child is hospitalized on his 19th birthday, eligibility is continued through the month the hospitalization ends. See A-825, Medicaid Termination, for additional information.

TP 45

Children under 12 months old whose mother was eligible for and receiving Medicaid at the time of the child's birth. The mother's eligibility for the child's birth month can be determined retroactively.

TP 48

Children age 1 to 5. Children are eligible through the month of their sixth birthday.

Note: A child should be certified for TP 45 (or 43) rather than TP 48 the month of the child’s first birthday.

If the child is hospitalized on the child’s sixth birthday, eligibility continues through the month the hospitalization ends. See A-825, Medicaid Termination, for additional information.

TP 56

The following individuals should be certified for TP 56 if they meet all other eligibility criteria:

  1. A pregnant woman with household income that exceeds the income limits for TP 40 unless disqualified from Medical Programs for not complying with:
    • TPR requirements; or
    • SSN requirements.
  2. Children under age 19 with household income that exceeds the income limits for TP 43, TP 44 and TP 48 unless disqualified from Medical Programs for not complying with:
    • TPR requirements; or
    • SSN requirements.