A-830, Medicaid Coverage for the Months Prior to the Month of Application

Revision 13-2; Effective April 1, 2013

A—831 Three Months Prior Coverage

Revision 15-4; Effective October 1, 2015

Medical Programs except TP 40

Applicants may be eligible for Medicaid coverage during the three-month period before the month they apply for Medical Programs. Prior coverage may be continuous or there may be interrupted periods of eligibility involving all or some of the certified members.

TP 40

Medicaid for a pregnant woman does not begin before the first day of the month her pregnancy began, as explained in A-820, Regular Medicaid Coverage. 

A—831.1 How to Apply for Three Months Prior Coverage

Revision 15-4; Effective October 1, 2015

Medical Programs except TP 45

A person applies for three months prior Medicaid coverage by completing Form H1113, Application for Prior Medicaid Coverage. Advisors must give this form to applicants who indicate on an application or during the application interview that the family has unpaid medical bills incurred during the three months before the application month. Exception: For Children’s Medicaid, Form H1113 is not required if the family provides enough information to determine eligibility for prior months.

Related Policy

Continuous Medicaid Coverage, A-832
TP 45 Retroactive Coverage, A-833 

A—831.2 Eligibility for Three Months Prior Coverage

Revision 17-1; Effective January 1, 2017

Medical Programs except TP 40

Advisors certify the applicant for Medicaid only for the month(s) the individual meets all eligibility requirements and has:

  • unpaid medical bills for Title XIX-covered services; or
  • received Medicaid services from the Texas Department of State Health Services.

Advisors provide prior Medicaid coverage even if the:

  • family is not currently eligible for Medical Programs; or
  • person with unpaid medical bills is deceased.

TP 08

Certify a parent or caretaker relative for a prior month(s) if they are caring for a dependent child who meets all eligibility requirements in the prior month(s), but is not certified for Medicaid in the prior month(s) because the child does not have unpaid medical bills.

TP 40

Gaps do not apply to TP 40. Once eligibility is determined in one of the prior months, it continues even if there are no unpaid medical bills in a subsequent prior month. 

A—831.2.1 Reopening Three Months Prior Applications

Revision 21-3; Effective July 1, 2021

Medical Programs

Applications for prior Medicaid coverage may be reopened for one or more month(s) in the three-month prior period when:

  • the person requests the application be reopened within two years after the application file date; and
  • Medicaid eligibility (certification with or without spend down) for the person or month(s) of coverage requested was not previously established.

Verify a previous application was filed. Use any application filed by the household within the past two years as a basis for determining eligibility for prior Medicaid coverage, even if the application did not request ongoing Medicaid, prior months’ Medicaid coverage or claim unpaid medical bills. Medicaid eligibility can only be established within two years after the application file date whether or not the request was processed due to agency or applicant error.

Note: Do not reopen an application for prior Medicaid for a month that Medicaid eligibility (certification with or without spend down) was established, even if the spend down was closed by the Clearinghouse. 

A—831.3 Income Computation

Revision 15-4; Effective October 1, 2015

Medical Programs

Staff must determine eligibility for each month in which there are unpaid medical bills using the income and verification rules explained in A-1300, Income

The needs and income of people who would have been considered in the client’s MAGI household composition for each month the client’s MAGI household composition has unpaid medical bills are included. 

A—831.4 Determining the Appropriate Type Program for the Prior Month

Revision 15-4; Effective October 1, 2015

Medical Programs

Use the following chart to determine the type program to use for eligibility in the prior month:

If the type program is …

and the modified adjusted gross income for the prior month is …

then …

TP 08,

less than or equal to the FPIL amount for TP 08 and there is no gap in coverage,

certify the application for the prior month.

TP 08,

less than or equal to the FPIL amount for TP 08 and:

  • there is a gap in coverage, or
  • the individual is not currently eligible,

certify the application for the prior month(s).

TP 08,

more than the FPIL amount for TP 08,

do not certify the application for the prior month in this type program. Check eligibility for another type program.

TP 40, TP 43, TP 44, or TP 48,

less than or equal to the FPIL amount for that program,

certify the application for the prior month.

TP 40, TP 43, TP 44, or TP 48,

more than the FPIL amount for that program,

do not certify the application for the prior month in this type program. Check eligibility for TP 56.

TP 45,

not applicable,

these applicants are always eligible back to the date of birth.

TP 56,

more than the medically needy income limit (MNIL),

determine if the household has enough medical expenses to meet spend down for the prior month.

If yes, then certify the children or pregnant woman.

If no, then deny the application for prior coverage.

TA 31, TP 33, TP 34, TP 35, or TP 36,

less than or equal to the FPIL amount for that program,

certify the applicant for the prior month only for the dates of the emergency medical condition verified on Form H3038, Emergency Medical Services Certification, or Form H3038-P, CHIP Perinatal – Emergency Medical Services Certification.

TP 32

above the income limits as stated above (applies only to children [under age 19] and pregnant women),

determine if the household has enough medical expenses to meet spend down for the prior month.

If yes, then certify the child or pregnant woman.

If no, then deny the application for prior coverage.

Note: Applicants are considered for eligibility in Medicaid for Former Foster Care Children (TA 82) and Medicaid for Transitioning Foster Care Youth (TP 70) before TP 08. 

A—831.5 Medical Eligibility Date for Three Months Prior Coverage

Revision 13-2; Effective April 1, 2013

Medical Programs

The MED for a month of prior coverage begins the earliest day in the month the individual met all eligibility criteria. It is the first day of the month unless all eligibility criteria were not met.

Related Policy

Regular Medicaid Coverage, A-820 

A—831.6 Applications Based on Incapacity

Revision 15-4; Effective October 1, 2015

TP 08 and TA 31

If the applicant claiming incapacity meets the other eligibility requirements for prior Medicaid coverage, the advisor must document information according to A-1080, Disability Verification. 

A—832 Continuous Medicaid Coverage

Revision 24-2; Effective April 1, 2024

TP 40

Staff provide continuous Medicaid coverage without an application or an interview for a pregnant woman. This is through the second month after the pregnancy terminates regardless of income increases if she:

  • received Medicaid on a program other than TP 40 and was ineligible because of income;
  • provides verification that she was pregnant in the month she becomes ineligible for Medicaid; and
  • received Medicaid within 11 months before the application month.

Note: Accept the pregnant woman's, case name's or AR's verbal or written statement of pregnancy as verification. A statement must include the name of the woman who is pregnant, pregnancy start month, number of expected children, and anticipated date of delivery. The person may also provide Form H3037, Report of Pregnancy, or another document containing information specified on Form H3037.

Note: Staff provide continuous Medicaid coverage to a pregnant woman who was denied with an administrative denial reason such as failure to keep appointment and voluntary withdrawal, if her Medicaid would have been denied because of income if the income had been reported.

The continuous coverage policy applies to women who were receiving benefits from the following programs:

  • SSI or MEPD. Note: When an SSI Medicaid recipient is denied, TIERS sends Form H1296, Notice of SSI Medicaid Ending,
  • informing the recipient that she may be potentially eligible for other Medical Programs within HHSC.
  • A caretaker certified on TP 08 who is not eligible for TP 07 or TP 20.
  • A caretaker or child certified on TP 07 or TP 20.
  • A child certified on TP 44.

A child under 19 determined eligible and certified for TP 40 will receive a 12-month continuous eligibility (CE) period, regardless of when the child’s pregnancy ends.

If the child turns 19 before the end of their 12-month CE period, they will receive regular postpartum coverage through the second month following the month her pregnancy terminates. 

TP 43, TP 44 and TP 48

A child under 19 receives a 12-month certification period. The child is continuously eligible for Medicaid for 12 months or through the month of the child’s 19th birthday, whichever is earlier. 

The following are exceptions to continuous eligibility:

  • death;
  • moves out of state;
  • voluntary withdrawal;
    • certified in error:
  • confirmation that eligibility was granted in error at the most recent determination; or
  • renewal of eligibility due to agency error or fraud, abuse, or perjury attributed to the child or ARHHSC’s Office of Inspector General (OIG) has determined the person fraudulently received Medicaid and coverage should be denied; 
  • reaches 19;
  • if a household reports that a sibling has moved into the household; and 
  • requests Medicaid for the sibling, the sibling is added to the current case. 
  • the new Medicaid-eligible child’s certification period is aligned with the end of the existing child’s certification period; 
  • the household failed to report required information at application that causes the child’s ineligibility for Medicaid; or
  • child enters a secured juvenile facility. 

If the household is eligible in the application month, process month, or ongoing month, the child is eligible for a 12-month continuous coverage. This begins the first month the household meets the eligibility criteria. Note: This includes situations where the household is eligible in the application or process month, but not in an ongoing month.

If the household is eligible only in a month before the application, certify the child for a 12-month continuous eligibility. 

Note: Explore TP 56 for the child if the person indicates the child has unpaid bills in a month of ineligibility.

Related Policy

Medicaid Termination, A-825 
What to Report, B-621
 

A—833 TP 45 Retroactive Coverage

Revision 15-4; Effective October 1, 2015

TP 45

Advisors must provide retroactive TP 45 coverage for newborn children without requiring an application or an interview with the child's mother if all of the following conditions are met:

  • There are unpaid Title XIX bills for the newborn child.
  • The mother of the child is unwilling, unable or refuses to apply for current benefits for the child, or the child is not eligible for current benefits.
  • The advisor has verification of the following eligibility factors for the newborn child:

Eligibility Factor

Eligibility Requirement

Age

Coverage must be initiated within one year of the child's birth.

The child's coverage cannot continue after the child becomes 13 months old.

Residence

Child must be residing in Texas.

Natural mother's Medicaid coverage dates

Child's mother must be eligible for and receiving Medicaid on the day the child is born. The mother's eligibility can be determined retroactively. See A-820, Regular Medicaid Coverage.

The file date is the day the advisor is notified about the unpaid bills for the child.

TIERS will allow a:

  • file date as late as the month of the child's first birthday, and
  • medical effective date as early as the child's date of birth. 

A—834 Retroactive Medicaid Coverage for Abandoned Children

Revision 18-1; Effective January 1, 2018

Medical Programs

If a newborn or child is abandoned at an acute care hospital, or at a psychiatric hospital while receiving inpatient services, DFPS requests a court order for custody. Once the court order is obtained, DFPS provides Medicaid coverage from the day in which custody is granted. The MED is the date DFPS takes conservatorship. This may result in the newborn or child having unpaid medical bills if DFPS takes conservatorship after the date of birth or the date of admission to the hospital and the date DFPS takes conservatorship.

A designated DFPS representative completes Form H1113, Application for Prior Medicaid Coverage, requesting coverage on behalf of the abandoned child and forwards the request to a designated Texas Works advisor within Centralized Benefit Services (CBS) at cbs_ffche-mtfcy@hhsc.state.tx.us.

For children abandoned in a psychiatric hospital, DFPS will only submit applications to request retroactive Medicaid for a child receiving inpatient treatment.

CBS advisors provide retroactive Medicaid coverage only during the following situations:

  • A newborn is taken into foster care conservatorship after the date of birth but before the child is released from the hospital, creating a gap in coverage from the date of birth through the day before the foster care conservatorship date.
  • A child of any age is taken into foster care conservatorship while in the hospital, but after the admission date, creating a gap in coverage from the date of admission to the day before the foster care conservatorship date.

Note: The MED for a child (not a newborn) cannot precede the date of admission into the hospital.