Revision 22-3; Effective July 1, 2022
Regular Medicaid eligibility begins the day a person meets all eligibility criteria. It is usually the first day of the application month if all eligibility criteria are met on that date.
The medical effective date (MED) may not be the first day of the application month in the following situations.
The MED cannot precede:
- A newborn's date of birth.
- The date a child enters the home.
Note: Assign the date of birth as the MED for a child born to a woman incarcerated in the Texas Department of Corrections at Gatesville when contacted by HHSC staff housed at the University of Texas Medical Branch (UTMB) Hospital. Document this contact in Case Comments.
- For the parent or caretaker relative’s Medicaid application, the newborn’s date of birth or the date a child enters the home when the newborn or entering child is the only eligible child.
TP 08 Exception: TIERS assigns an earlier MED if the parent or caretaker relative has unpaid medical bills and would have been eligible for Medicaid as a pregnant woman from the first day of her infant's birth month.
- The start date of the emergency condition for aliens eligible for Emergency Medicaid.
- The date a disqualified parent or caretaker relative complies.
- The month at least one eligible dependent child is certified for Medicaid.
If the only child of a parent or caretaker relative eligible for TP 08 dies before certification, process an application for Medicaid for a deceased person. Certify coverage for the child through the date of death and for the parent or caretaker relative through the remainder of that month.
Medicaid for a pregnant woman does not begin before the first day of the month her pregnancy begins. The applicant’s (pregnant woman's, case name's, or authorized representative's [AR's]) verbal or written statement is an acceptable source of verification for the start month, the number of expected children, and the anticipated date of delivery.
If the applicant’s (pregnant woman's, case name's or AR's) statement is not available, use one of the verification requirements to obtain the pregnancy start date and anticipated date of delivery.
If information is requested but not returned by the 15th business day from the file date, deny the application. Reopen the application if the person provides verification by the 60th day from the file date.
Exception: Do not request verification of pregnancy if the:
- application is processed after the pregnancy terminates; and
- applicant provides proof of the newborn child's birth.
A pregnant woman remains eligible through the second month following the month her pregnancy terminates if all other eligibility requirements are met and countable income is below the income limits in:
- the application month; or
- one of the three months prior to the application month if in the prior month she:
- had unpaid Medicaid-reimbursable bills; or
- received services from the Texas Department of State Health Services (DSHS).
Example: A pregnant woman applies for Medicaid in May 2020. Her expected delivery date is December 2020. She has unpaid medical bills in February 2020 and meets all other eligibility requirements. She does not have any unpaid medical bills in March or April 2020. Certify her for Medicaid from February 2020 through February 2020.
After determining a pregnant woman is eligible for TP 40, the woman remains eligible even if the budget group's income increases above the income limit.
Note: If a woman certified for Healthy Texas Women (HTW) reports her pregnancy, the HTW and Medicaid for Pregnant Women (TP 40) coverage may overlap because HTW does not provide prenatal or pregnancy benefits. In this situation, HTW is denied prospectively, and the woman is enrolled in TP 40 beginning the first of the month when she meets all eligibility criteria.
If a woman who was certified for expedited benefits provides postponed verifications that prove she does not meet eligibility requirements, provide advance notice of adverse action, and deny her coverage.
Before providing initial TP 45 coverage for a newborn child, verify that the:
- mother was:
- eligible for and received Medicaid in Texas on the day the child was born; or
- retroactively eligible for Medicaid for the day the child was born;
- child resides in Texas; and
- mother was continuously eligible for Medicaid (or would have been eligible if pregnant) during the child's birth month.
Note: A newborn child born to a mother who received Emergency Medicaid coverage at the time of the child's birth is eligible to receive TP 45 coverage from the date of birth through the end of the month of the child's first birthday.
The MED for the initial certification is always the child's date of birth.
Before resuming coverage for a newborn who has been denied TP 45, verify that the child resides in Texas.
Medicaid coverage for children or pregnant women with spend down begins the first day the household meets spend down.
Note: A woman certified for HTW may have overlapping coverage with TP 56 if she has unpaid medical bills related to her pregnancy because HTW does not provide full coverage benefits.
The applicant meets spend down by submitting or having a provider submit medical bills to the Clearinghouse.
- determines when the person meets spend down; and
- notifies Texas Integrated Eligibility Redesign System (TIERS) via an interface. TIERS sets the MED for the certified members.
Note: The Clearinghouse may discover a discrepancy while processing a spend down EDG. Processing is put on hold and the EDG is referred to State Office Data Integrity (SODI) to research. SODI sends a memo to field staff asking for information to clear the discrepancy. Respond quickly to these requests so that the Clearinghouse can complete the spend down process.
Medicaid eligibility begins on the start date of the emergency medical condition verified by the attending practitioner on Form H3038, Emergency Medical Services Certification, or Form H3038-P, CHIP Perinatal – Emergency Medical Services Certification.
Provider Referral Process, A-125
Medicaid Termination, A-825
Verification Requirements, A-870
How to Determine Spend Down, A-1359
Spend Down EDGs, A-1532.1
Reuse of an Application Form After Denial, B-111
Medicaid Reinstatement, B-530
Current Medicaid, Medicare (Part A or B) and Children's Health Insurance Program (CHIP) recipients, W-911
Pregnant Women, W-912
A—821 Types of Coverage
Revision 15-4; Effective October 1, 2015
The type of coverage determines how recipients access Medicaid services. There are two types of coverage: fee-for-service and managed care.
Revision 15-4; Effective October 1, 2015
Fee-for-service, also known as Traditional Medicaid, allows access to any Medicaid provider and self-referral to specialists. The provider submits claims directly to the claims administrator for reimbursement of Medicaid-covered services.
A—821.2 Managed Care
Revision 21-1; Effective January 1, 2021
Medical Programs except TA 31, TP 32, TP 33, TP 34, TP 35, TP 36, and TP 56
Medicaid managed care is health care provided through a network of doctors, hospitals or other health care providers who contract with a managed care organizations (MCO). The state pays the MCO a capitated rate for each member enrolled, rather than paying for each unit of service. The providers submit claims directly to the MCO for reimbursement of Medicaid-covered services.
Medicaid managed care programs include:
- STAR (State of Texas Access Reform). STAR provides acute care services (like doctor visits, hospital visits and prescriptions), and each member is enrolled in an MCO and assigned a main doctor to coordinate care. People who are dually eligible for Medicare and Medicaid are excluded from this program.
- STAR Health. STAR Health provides comprehensive, coordinated health care services for children in foster care and kinship care. Each member is enrolled with a single MCO, Superior HealthPlan, and is assigned a main doctor to coordinate care. People who are dually eligible are excluded from this program.
- STAR+PLUS. STAR+PLUS provides acute care and long-term services and supports (LTSS). A key feature of this program is service coordination, or specialized care management. Each member is enrolled with an MCO, and Medicaid-only members are assigned a main doctor. STAR+PLUS serves Medicaid-only and dually eligible people, including most nursing facility residents. It is a statewide program.
- STAR Kids. STAR Kids provides acute care services and LTSS. Additionally, people eligible for Medically Dependent Children’s Program (MDCP) waiver services receive these services through STAR Kids. A key feature of this program is service coordination. Each member is enrolled with an MCO and assigned a main doctor to coordinate care. STAR Kids serves children and young adults age 20 or younger with disabilities.
- Children's Medicaid Dental Services. Children's Medicaid Dental Services provide primary and preventive dental services through managed care. Each member is enrolled in a dental maintenance organization (DMO) and has a main dental home. Most children, birth through age 20, who receive Medicaid, are eligible for dental services.
Medicaid managed care is available statewide. Information concerning the medical and dental managed care plans with contact information for each plan is located at hhs.texas.gov/services/health/medicaid-chip/provider-information/managed-care-organization-dental-maintenance-organization-provider-services-contact-information.
Texas Works Medicaid recipients must enroll in managed care. Exceptions (not comprehensive):
- STAR exceptions:
- people who are dually eligible for Medicaid and Medicare;
- children enrolled in the DSHS Children with Special Health Care Needs (CSHCN) Program;
- children and adults residing in institutions (nursing facilities, Intermediate Care Facilities, and State Supported Living Centers);
- medically-needy program participants;
- children in foster care or kinship care;
- adults that receive SSI; and
- children and adults that are in a 1915(c) waiver program.
- STAR Health exceptions:
- youth adjudicated in Texas Juvenile Justice Department (TJJD) facilities;
- youth from other states placed in Texas, or Texas youth placed in other states; and
- youth residing in Medicaid-paid facilities.
- STAR+PLUS exceptions:
- a person 20 or younger who is not in the Medicaid for Breast and Cervical Cancer (MBCC) program;
- people over the age of 21 in Former Foster Care in Higher Education (FFCHE); and
- people over 21 who are in a 1915(c) waiver program or who reside in community home for people with Intellectual Developmental Disabilities and are dually eligible for Medicare and Medicaid.
- STAR Kids: A person over the age of 21 and a person 20 or younger without disabilities.
- Children's Medicaid Dental Services exceptions:
- people 20 or younger who reside in an institution;
- people in STAR Health;
- youth placed in other states; and
- adults 21 and older.
- Contracts with the state to enroll recipients into Medicaid managed care.
- Mails enrollment packets that include information about the plan choices available in their county of residence to newly certified recipients.
If a recipient does not choose a plan or a main doctor by the deadline provided in the enrollment packet, MAXIMUS assigns a plan and a main doctor. They then mail the information to the recipient.
Members of federally recognized Indian tribes are exempt from mandatory enrollment in Medicaid managed care but may choose to participate voluntarily.
At all Medicaid applications and redeterminations, identify and determine if the person qualifies for this exemption. If this information is not available, do not designate the person as exempt. Do not pend the application or delay the eligibility determination for this information.
TIERS refers newly certified recipients to MAXIMUS to initiate their enrollment into managed care. MAXIMUS staff is available in some local eligibility determination offices. A recipient can call the MAXIMUS Helpline at 800-964-2777 to initiate enrollment, to request a plan change, or to disenroll from managed care if they are exempt from mandatory enrollment in Medicaid managed care.
If a recipient has difficulty accessing medical services in a managed care plan, refer the person to the Medicaid Managed Care Helpline at 866-566-8989. The Medicaid Managed Care Helpline advocates for managed care recipients who are having trouble accessing the medical and dental care they need.
A—822 Medicaid Coverage for New State Residents
Revision 15-4; Effective October 1, 2015
Advisors must determine the correct MED for applicants who:
- move to Texas from another state during the application month or the three months prior to the application month, and
- are Medicaid recipients in the losing state in the month they move.
|1||If the losing state denied the recipient's Medicaid the last day of the month the recipient moved from the state or later, then go to Step 2.
If the losing state denied the recipient's Medicaid the day the recipient moved from the state, then assign an MED = date the applicant became a Texas resident.
|2||Did any member of the certified group incur Medicaid-reimbursable bills after they moved to Texas?
If yes, then verify the effective date of denial in the losing state. Go to Step 3.
If no, then verify the effective date of denial in the losing state. Assign an MED = first day of the month after the month the losing state denied the recipient's Medicaid.
|3||Will the losing state pay for the bills incurred in Texas after the day the person became a Texas resident?
If yes, then assign an MED = first day of the month after the month the losing state denied the recipient's Medicaid.
If no, then assign an MED = date the applicant became a Texas resident.
Note: If the applicant is unable to provide a contact person in the losing state, the advisor must contact the appropriate state Medicaid director's office. See C-1111, State Medicaid Agencies, for telephone numbers.
When a Texas Medicaid recipient moves to another state, staff from the gaining state may contact the local office about effective dates of denial and coverage of bills incurred in the gaining state. Texas Medicaid pays for Medicaid-reimbursable services provided out-of-state if the:
- recipient needs services because of a medical emergency documented by the attending physician or other provider;
- recipient's health could be jeopardized by not obtaining services; and
- provider enrolls in the Texas Medicaid Program. Out-of-state providers can obtain enrollment information by calling the claims administrator at 1-800-925-9126.
A—823 Lock-In Status
Revision 15-4; Effective October 1, 2015
HHSC identifies fee-for-service and managed care individuals who:
- received duplicative, excessive, contraindicated or conflicting health services, including drugs; or
- abused, misused or committed fraudulent actions related to Medicaid benefits and services.
These clients may choose one pharmacy and/or one main doctor to be their designated provider for Medicaid services.
The duration periods of lock-in status are as follows:
- The initial period is 36 months.
- The second period is an additional 60 months.
- The third period is for the duration of eligibility and all subsequent periods of eligibility.
- The period of lock-in status for individuals arrested, indicted or convicted of, or admitting to, a crime related to Medicaid fraud differs from the time period listed for initial, second and third periods of lock-in. These individuals will be assigned lock-in status for 60 months or the duration of eligibility and subsequent periods of eligibility up to or equal to 60 months.
For individuals with enrollment lock-in status, HHSC issues a Your Texas Benefits Medicaid card printed with "Lock-in Doctor" and/or "Lock-in Drug Store" on the front of the card, along with the name of the doctor and/or drug store. If an individual with lock-in status prints a Medicaid card from the YourTexasBenefits.com, the same information is displayed.
Staff must verify current lock-in status when issuing Form H1027-A, Medicaid Eligibility Verification. To verify an individual’s lock-in status, the advisor may access the individual’s Lock-In Enrollment page from the Individual – Summary page’s hover menu. If an individual is in lock-in status, the Lock-In Enrollment page will display the provider name and begin date of the status.
Individuals are removed from lock-in status at the end of the specified period if their use of medical services no longer meets the criteria for lock-in status.
Advisors refer individuals with questions regarding their lock-in status to the HHSC Office of Inspector General (OIG) at 1-800-436-6184.
A—824 Issuance of Form H1027-A, Medicaid Eligibility Verification
Revision 15-4; Effective October 1, 2015
Advisors must issue Form H1027-A, Medicaid Eligibility Verification, to an eligible Medicaid individual only if the individual:
- needs his eligibility verified to receive medical services;
- does not have access to a Your Texas Benefits Medicaid card; and
- is unable to reprint the Medicaid card from YourTexasBenefits.com.
The individual may not have a Your Texas Benefits Medicaid card if the individual:
- is newly certified and has not received it,
- lost or accidentally destroyed the card, or
- is temporarily separated from other eligible family members who have their card.
Before issuing Form H1027-A, staff must verify the individual's current eligibility, enrollment lock-in status and managed care enrollment by accessing the Individual – Summary and Individual – Medicaid History pages. If inquiry is unavailable, advisors must follow regional procedures.
Medicaid with No Enrollment Lock-in or Managed Care Coverage
Issue Form H1027-A for current eligibility if the most recent medical coverage period on the Individual – Summary and Individual – Medicaid History pages:
- is open (no close date shown), and
- reflects regular Medicaid coverage.
If an individual is in enrollment lock-in status, "Yes" will display after Lock-In on the Individual – Summary page. Advisors select Lock-In Enrollment from the hover menu over the individual's client number. The Individual – Lock-In Enrollment page provides information regarding the provider(s) to which the individual is currently or was once locked in.
If an individual is currently in lock-in, advisors issue a separate Form H1027-A for the individual and print LIMITED and the name(s) of the provider(s) to which the individual is locked in. Form H1027-A generated in TIERS is printed with "LIMITED" in the "Type of Coverage" field.
Managed Care Coverage
If an individual is in a managed care service area, "Yes" will display after Managed Care on the Individual – Summary page. Select Managed Care from the hover menu over the individual's client number. Advisors select the Individual – Managed Care page to view the individual's plan to which the individual is enrolled.
Advisors must issue Form H1027-A for everyone on the case in the same managed care plan by printing the appropriate managed care program name (e.g., STAR, STAR Health, STAR+PLUS) and the name and telephone number of the plan. This information is in C-1116, Managed Care Plans.
After staff verify eligibility, enrollment lock-in status and managed care enrollment, advisors complete, sign and date Form H1027-A. The unit supervisor or other second party must approve the form indicating he verified eligibility and lock-in status.
Form H1027-A is not used if the most recent medical period:
- is closed, or
- shows institutional coverage.
Form H1027-A instructions include detailed information for completing the form.
TA 74, TA 75, TA 76, TA 83, TA 86 and TP 42
The advisor must issue Form H1027-A if the person has a completed Form H1266, Short-term Medicaid Notice: Approved, showing the date the person is approved for coverage.
Form H1027-A instructions include detailed information for completing the form.
State Paid Medicaid
State Paid Medicaid coverage shows in the Medicaid History screen when the individual was not eligible for Medicaid and staff have issued Form H1027-A in error. State Paid Medicaid is 100 percent state-funded.
A—825 Medicaid Termination
Revision 22-2; Effective April 1, 2022
If an application is not received by the last day of the month, an EDG is automatically denied effective the last day of the last benefit month.
Denial at Redetermination, A-2342
Eligibility for Emergency Medicaid ends the date the person's medical condition is stabilized as verified by the attending practitioner or other practitioner familiar with the patient's condition. Verification is done on Form H3038, Emergency Medical Services Certification, or Form H3038-P, CHIP Perinatal – Emergency Medical Services Certification.
A woman certified for Medicaid for Pregnant Women – Emergency (TP 36) on the day her pregnancy ends is eligible to receive TP 36 in the two-month postpartum period if she has another medical emergency.
Regular Medicaid Coverage, A-820
Medicaid eligibility for a pregnant woman ends on the last day of the second month following the month the pregnancy terminates.
If the pregnancy terminates early because of molar pregnancy, abortion or premature delivery, deny the coverage effective the last day of the second month following the month the pregnancy terminated. If the pregnancy ends in a month later than expected, change the end date to reflect the new termination date.
A woman whose Medicaid for Pregnant Women coverage ends is automatically tested for other types of assistance using current case information without requiring a new application, if the EDG was not denied for the following reasons:
- voluntary withdrawal;
- move out of Texas;
- receipt of benefits in another group; or
- failure to provide postponed verification.
TIERS automatically determines eligibility for another type of assistance. If eligible, the woman receives a new certification period which begins after the TP 40 EDG ends.
TP32, TP36, TP40, and TP56
A woman certified for Medicaid (TP 32, TP 36, TP 40, TP 56) on the day her pregnancy ends, is eligible to receive the same type of Medicaid (TP 32, TP 36, TP 40, TP 56) for two months after her pregnancy ends.
Medicaid for Pregnant Women– Emergency (TP 36) and Medically Needy with Spend Down (TP 32 and TP 56) are only provided in the two-month postpartum period if the woman meets the additional eligibility requirements for these type programs. The original budget used to certify the Medicaid coverage on the day the woman’s pregnancy ends, is the same budget used in the two-month postpartum period.
TP 43, TP 44 and TP 48
A child is continuously eligible for the first six months of the 12-month certification period. If a household fails to report required information at application that causes a child to be ineligible for Medicaid, deny the EDG and send a fraud referral to the Office of the Inspector General (OIG). This does not apply if the household provides verification required by policy. For example, the household applies for Medicaid for a child, provides one pay stub, and is determined eligible. If providing more income verification would result in the child being ineligible, do not deny the Medicaid EDG. The child remains continuously eligible for the first six-months of the 12-month certification period, because policy requires only one pay stub to verify income for a child's Medicaid EDG.
EDGs with end dates do not require staff action to close the EDG when the household does not return a renewal form. These will close effective the last day of the last benefit month of the certification period.
Note: Independent children residing in state hospitals are continuously eligible for the first six months of the 12-month certification period, even if the child is released from the state hospital. If a child is released from the facility prior to the end of the six-month period, process the address change and continue coverage.
A child is eligible through the last day of the month of the child’s:
- first birthday for TP 43;
- sixth birthday for TP 48; and
- 19th birthday for TP 44.
When a child ages out of the current type of assistance during the continuous eligibility period, TIERS:
- Denies the TP 43 or TP 48 EDG through mass update and opens a new EDG for the next type of assistance for the remainder of the continuous eligibility period if the child is eligible for the next type of assistance.
- Sustains the TP 43 or TP 48 EDG if the child is not eligible for the next type of assistance.
When a child ages out of the current type of assistance during the non-continuous eligibility period, TIERS denies the TP 43 or TP 48 EDG and opens a new EDG for the next type of assistance if the modified adjusted gross income (MAGI) is equal to or below the corresponding Federal Poverty Level (FPL).
If the MAGI is more than the FPL for the next type program, the child’s eligibility for CHIP is tested. If ineligible for CHIP, the child is referred to the Federally Facilitated Marketplace (FFM).
Exception: Children aging out of TP 44 are eligible through the last day of the month of their 19th birthday.
If a child is ineligible for the next type of assistance or turns 19, the child may continue to receive Medicaid if the child:
- is hospitalized on the child's 19th birthday;
- remains hospitalized (there is not a time limit); and
- meets all eligibility requirements except age.
Verify the child’s hospitalization and update the child’s living arrangement to “hospital” to prevent TIERS from denying the child’s coverage.
Verify the hospitalization each month and update the child’s living arrangement when the hospitalization ends.
A child's eligibility terminates the last day of the month of the child's first birthday. Deny the TP 45 EDG before the child's first birthday if the:
- child's mother was presumptively eligible and received TP 42 at the time of the child’s birth but was not eligible for regular Medicaid at the time of the child’s birth. The child is eligible for TP 45 through the end of the birth month; or
- child no longer resides in Texas. The child is eligible for TP 45 through the month the change occurs.
- If the child's mother met spend down and received TP 56 or TP 32 to cover the child's birth, the child is eligible for TP 45 from the date of birth until the end of the month the child turns one.
- State Office Data Integrity (SODI) terminates the newborn's coverage before the child's first birthday in situations in which the child's mother relinquishes her parental rights and information about the child's current residency and new caretaker is unknown.
A-825.1 Recipients of TANF and TP 08
Revision 17-2; Effective April 1, 2017
Recipients of TANF must comply with the Personal Responsibility Agreement (PRA), including cooperating with child support requirements and participating in the Choices program, unless exempt. TP 08 coverage is terminated if an individual receiving both TP 08 and TANF is sanctioned for failure to comply with the Choices PRA requirements.
Individuals certified for TP 08, but not TANF, must cooperate with medical support requirements. Failure to cooperate with the requirements result in the termination of the individual's TP 08 coverage.
- TANF sanctions due to noncooperation with other PRA requirements do not result in termination of TP 08 coverage.
- Individuals receiving TP 08 who are not receiving TANF are not required to comply with the TANF PRA.
- The noncooperating adult may reapply for Medicaid and qualify after the identified forfeit months, with the exception of those who non-comply with child support. These individuals must comply before becoming eligible for Medicaid.
A—826 Reserved for Future Use
Revision 20-4; Effective October 1, 2020
A—827 Your Texas Benefits Medicaid Card
Revision 19-4; Effective October 1, 2019
When a person is certified for ongoing Medicaid benefits, a Your Texas Benefits Medicaid card is mailed, which should:
- be carried and protected like a driver's license or credit card; and
- used when visiting a Medicaid provider (i.e., doctor, dentist or pharmacy).
The Your Texas Benefits Medicaid card is plastic, like a credit card, and includes the following information printed on the front:
- person’s name and Medicaid ID number;
- managed care program name (if STAR Health);
- date the card was issued; and
- billing information for pharmacies.
The back of the card includes the statewide toll-free phone number where people can get more information about the Your Texas Benefits Medicaid card.
Each person certified for Medicaid in a household receives one Your Texas Benefits Medicaid card. It is intended to be the person’s permanent card.
If a person loses:
- Medicaid coverage but later regains coverage, the person can use the same Your Texas Benefits Medicaid card.
- Their Your Texas Benefits Medicaid card, they can request a replacement by:
- logging on to their YourTexasBenefits.com account;
- calling 2-1-1 (after selecting language, select Option 2, and then Option 1); or
- calling 855-827-3748.
If a person forgets their Your Texas Benefits Medicaid card, a provider (i.e., doctor, dentist or pharmacy) can verify Medicaid coverage by:
- calling the TMHP Contact Center at 800-925-9126; or
- visiting the Texas Medicaid and Healthcare Partnership’s (TMHP's) TexMedConnect website using the person’s Medicaid ID number or one of the following combinations for the person:
- Social Security Number (SSN) and last name;
- SSN and date of birth (DOB); or
- last name, first name, and DOB.
If a person needs quick proof of eligibility, they can;
- log in to their www.YourTexasBenefits.com account to print a temporary card; or
- go to a local benefits office to request a card. HHSC staff in the office will:
- assist the person accessing and printing a Medicaid card from the person’s www.YourTexasBenefits.com account from the office’s lobby computer; or
- generate a temporary Form H1027-A, Medicaid Eligibility Verification via TIERS if the person prefers not to or has trouble accessing their Medicaid card online.