X-930, Creditable Coverage

X—931 General Overview

Revision 17-2; Effective April 1, 2017

A woman is ineligible to receive MBCC if she has creditable coverage. Deny an MBCC application if her plan covers breast or cervical cancer treatment.

Creditable coverage is defined as:

  • group health insurance;
  • health insurance coverage;
  • Medicare (Part A or B);
  • Medicaid;
  • CHIP;
  • armed forces insurance; or
  • a state health risk pool.

Do not consider a plan with a limited scope of coverage such as dental, vision, long-term care, etc., or for only a specific illness/disease, such as drug/substance abuse, as creditable coverage. Note: Healthy Texas Women (TA 41) is not considered creditable coverage.

Consider a woman as having creditable coverage even if it has limits on benefits, such as limited drug coverage or limits on the number of outpatient visits, or high deductibles. A woman is considered to no longer have creditable coverage if she:

  • is in a period of exclusion (such as pre-existing condition exclusions or a health maintenance organization [HMO] affiliation period) for treatment of breast or cervical cancer; or
  • exhausts her lifetime limit on all benefits under the plan or coverage or her yearly benefits for breast or cervical cancer treatment. When the new plan year begins, determine if the woman has creditable coverage.

Note: Set a special review if it is known that the exclusion period of the creditable coverage will expire (pre-existing period has expired) or the woman’s yearly benefits for breast or cervical cancer treatment will be reinstated before the next periodic review. See X-1930, Setting Special Reviews.

Women screened under BCCS are not subject to a waiting period if they had prior creditable coverage.

As long as the termination of the creditable coverage occurs before disposition, a woman is eligible to receive benefits under the MBCC program.

A woman is required to report when she has obtained creditable coverage.

If an MBCC applicant indicates she has health insurance but does not know whether it provides coverage for breast or cervical cancer, certify the woman for MBCC-Presumptive. Contact the insurance provider to verify whether the policy provides coverage for breast or cervical cancer.

X—932 Other Medical Assistance

Revision 17-2; Effective April 1, 2017

An MBCC applicant is not eligible to receive benefits if she is currently receiving Medicaid, Medicare Part A or B, or coverage through CHIP. If an application is received for a woman who receives Medicaid, Medicare (Part A or B) or CHIP, or if a Medicaid or CHIP application is certified before the MBCC application, deny the MBCC application.

Staff must verify via TIERS, the State Online Query (SOLQ) or the Wire Third-Party Query (WTPY) system that an applicant is not currently enrolled in Medicaid, Medicare Part A or B, CHIP, or Healthy Texas Women (HTW) before disposition. If a woman is eligible for MBCC and is currently receiving HTW, the HTW EDG must be denied.

X—932.1 Currently Receiving MBCC and Applies for Other Benefits

Revision 16-3; Effective July 1, 2016

A woman receiving MBCC-Presumptive or MBCC who is found eligible for another type of Medicaid program is ineligible to continue to receive MBCC-Presumptive or MBCC. The MBCC advisor receives a task to prospectively deny the MBCC-Presumptive/MBCC EDG so that the advisor processing the application can certify the woman for the other type of Medicaid. The MED for the other Medicaid type begins the first of the month following the MBCC-Presumptive/MBCC EDG denial.

When the other Medicaid type of assistance is denied, the woman may be eligible for MBCC if she continues to be in need of active treatment for breast or cervical cancer and she meets all other eligibility criteria. When the other type of Medicaid is denied (unless the denial is due to death, unable to locate or a move out of state), TIERS generates a reapplication packet if  the woman is under age 65 and less than 12 months has passed since her diagnosis date or the date her active treatment was last verified, whichever is later.  The reapplication packet contains:

  • Form H1833, Cover Letter — Other Medicaid Ending or Form H1834, Cover Letter — Other Medicaid Denied;
  • Form H2340, Medicaid for Breast and Cervical Cancer Renewal;
  • Form H1551, Treatment Verification;
  • a self-addressed envelope; and
  • Form H0025, HHSC Application for Voter Registration.

The woman must return the completed Form H2340 and Form H1551 for her eligibility for MBCC to be reconsidered.

If more than 12 months have passed since the woman's diagnosis date or her active treatment was last verified, the woman must be screened and reapply for MBCC through a Breast or Cervical Cancer Services (BCCS) contractor using Form H1034, Medicaid for Breast and Cervical Cancer.  TIERS generates either Form H1833-L, Other Medicaid Ending, or Form H1834-L, Other Medicaid Denied, informing the woman how to reapply for MBCC and provides the web address (www.healthytexaswomen.org/healthcare-programs/breast-cervical-cancer-services/bccs-how-apply) where the woman can locate a BCCS contractor in her area.