Revision 21-3; Effective July 1, 2021
A woman is continuously eligible for 12 months beginning the first day of the month all eligibility criteria are met. There is no three months prior eligibility for the Healthy Texas Women (HTW) program.
Note: An HTW applicant can apply for and receive three months prior benefits under another Medicaid program (e.g. Medically Needy with Spend Down).
The medical effective date (MED) cannot precede the month of the woman's 15th birthday.
Follow applicable policy if the woman is confined in any public institution.
HTW is a fee-for-service program. Fee-for-service allows access to any health care provider and self-referral to specialists. The provider submits claims directly to the claims administrator for reimbursement of covered services.
If a household fails to report required information at the time of the application that causes the woman to be ineligible for HTW, deny the case.
HTW uses an administrative renewal process.
Note: Women are eligible to receive HTW during their Pay for Performance forfeit month(s).
W—911 Current Medicaid, Medicare (Part A or B) and Children's Health Insurance Program (CHIP) Recipients
Revision 22-3; Effective July 1, 2022
A woman is not eligible to receive HTW benefits if she is currently receiving another type of Medicaid, Medicare (Part A or B) or CHIP.
Note: HTW can briefly overlap full coverage Medicaid in the following situations:
- HTW and Medicaid for Pregnant Women (TP 40): If a woman certified for HTW reports her pregnancy, HTW and TP 40 coverage may overlap because HTW does not provide prenatal or pregnancy benefits. Terminate HTW coverage prospectively and certify TP 40 beginning the first of the month the woman meets all eligibility criteria.
- HTW and Medically Needy with Spend Down (TP 56): HTW and TP 56 coverage may overlap if the HTW woman has unpaid medical bills because HTW does not provide full coverage benefits. HTW coverage is sustained in this scenario.
- HTW and Medicaid for Breast and Cervical Cancer (MBCC): If a woman certified for HTW becomes eligible for MBCC, there may be an overlap in coverage for the month she applies for MBCC. MBCC eligibility begins the date an applicant meets all eligibility criteria and cannot precede the day after the diagnosis date. After the woman is determined eligible for MBCC, terminate HTW prospectively.
When determining HTW eligibility after a woman is determined ineligible for full Medicaid and CHIP, verify via State Online Query (SOLQ) that the applicant is not currently enrolled in Medicare (Part A or B).
If an HTW applicant is actively receiving Medicare (Part A or B) deny the application using the following disposition denial reason:
- English — You are ineligible to receive Healthy Texas Women services as you are currently receiving assistance under Medicare.
- Spanish — Usted no llena los requisitos para recibir los servicios del Healthy Texas Women ya que actualmente recibe ayuda de Medicare.
W—912 Pregnant Women
Revision 22-3; Effective July 1, 2022
Pregnant women cannot receive HTW benefits. If the applicant does not answer the question “Are you pregnant?”, pend the application and allow the applicant normal processing time frames to provide an answer to the pregnancy question. Accept the applicant’s statement as verification. Deny the application for failure to provide verification if the applicant does not provide an answer to the question “Are you pregnant?”.
If the woman reports a pregnancy on her application, determine if she meets eligibility requirements for Medicaid for Pregnant Women (TP 40) or CHIP-Perinatal (CHIP-P).
If the HTW recipient reports a pregnancy during her 12-month continuous coverage period, determine if she meets eligibility requirements for TP 40 or CHIP-P. Do not require the recipient to complete a new application. If the HTW recipient meets the eligibility requirements for TP 40, allow her to receive HTW and TP 40 in the same month since HTW does not provide full coverage benefits. TIERS will deny the HTW EDG prospectively once the recipient is certified for TP 40 coverage.
W—913 Third-Party Resource (TPR)
Revision 22-4; Effective Oct. 1, 2022
A woman cannot receive HTW benefits when she has creditable health coverage. Creditable health coverage is private health insurance that covers family planning services.
Private health insurance covers family planning services if it provides both:
- family planning-related physician office visits and procedures; and
- contraceptive drugs and devices.
In making this determination, only consider if the private health insurance provides coverage and do not consider other issues such as high deductibles or dollar limits on drug coverage.
Applications for medical programs ask the following questions:
- Does the health insurance cover family planning services?
- If yes: If we file a claim on your health insurance will it cause you physical, emotional, or other harm from your spouse, parents or other person?
- If yes: Tell us why filing a claim with your health insurance would cause you harm.
Note: A person applying for HTW with creditable health coverage is eligible to receive HTW benefits only if identifying and providing information to assist in pursuing third parties is against her best interest.
When determining HTW eligibility after the woman has been determined ineligible for full Medicaid and CHIP:
- Pend the person applying for HTW if she does not answer question 1, question 2 or both.
- Allow the person applying for HTW normal processing time frames to provide an answer. Verification is self-declared by the person applying for HTW.
- If the person applying for HTW does not self-declare the answer to question 1, question 2 or both by the deadline, deny the application for failure to provide.
Note: TPR questions must be addressed at application and renewal.
If the person applying for HTW states Yes to question 1 and question 2 but leaves question 3 blank, do not pend the person applying for HTW for an answer. Continue determining eligibility.
If the person applying for HTW states Yes to question 1 and No to question 2, deny the application using the following denial reason code and add the statement below to the comment section of Form TF0001, Notice of Case Action.
- English — On your application you told us you are covered by other health insurance. Women who are covered by other health insurance cannot receive Healthy Texas Women benefits.
- Spanish — En la solicitud, usted nos dijo que tiene cobertura de otro seguro médico. Las mujeres con cobertura de otro seguro médico no pueden recibir beneficios del programa Healthy Texas Women.
If the person receiving HTW reports having creditable health insurance during the 12-month continuous coverage period, record the change and take action on the TPR information at the next renewal.
W—914 Automatic Eligibility Determination for HTW
Revision 21-3; Effective July 1, 2021
HTW is part of the Modified Adjusted Gross Income (MAGI) cascade. Unless the woman opts out, all women are automatically tested for HTW eligibility when they are determined ineligible for other MAGI Medicaid programs and CHIP.
Women can opt out of the automatic HTW eligibility determination by indicating they want to waive HTW testing on their initial or renewal application.
When processing the following alerts, run the full MAGI cascade. If the cascade results in a denial of Medicaid and CHIP because the woman does not meet eligibility requirements, refer the woman to the Marketplace and test her for HTW eligibility.
- Alert 819, CHIP Child Aging Out Test MAGI
- Alert 823, MA Child Aging Out Test MAGI
- Alert 824, Pregnancy Ending Test MAGI
- Alert 825, Transitional MA Ending Test MAGI
- Alert 903, Test MAGI – Individual Aging out of TP 70 or TA 82
Note: Women receiving Medicaid for Pregnant Women (TP 40) are tested for HTW eligibility at the end of their TP 40 certification period even if they:
- voluntarily withdraw from Medicaid for Parents and Caretaker Relatives (TP 08), including before an eligibility determination is made; or
- are determined to be potentially eligible for Medicaid for Parents and Caretaker Relatives (TP 08) but fail to complete the interview.
When transitioning to HTW from another MAGI Medicaid program or CHIP, the effective date of the HTW EDG is the first day of the month following the end of the previous benefit’s certification period.
When a woman is determined eligible for HTW, TIERS generates:
- a TF0001, Notice of Case Action; and
- Form H1872, HTW Opting Out and Reporting Confidential Address.
Form H1872 provides the HTW recipient an opportunity to voluntarily withdraw (opt out) and report a confidential address. Form TF0001 and H1872 are addressed to the HTW recipient and mailed to the:
- confidential address; or
- case address if a confidential address has not been provided.