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Revision 09-4; Effective December 1, 2009
This chapter contains processes for applications and redeterminations for all MEPD coverage groups.
See Chapter A, General Information and MEPD Groups, for descriptions.
Revision 09-4; Effective December 1, 2009
§358.505. Application Process Overview.
(a) The Texas Health and Human Services Commission (HHSC) gives anyone the opportunity to apply for a Medicaid-funded program for the elderly and people with disabilities (MEPD), in accordance with 42 CFR §435.906. A person can apply for MEPD by submitting:
(1) an application for assistance to HHSC; or
(2) an application for Supplemental Security Income (SSI) to the Social Security Administration.
(b) Under the application submittal process described in subsection (a)(1) of this section, a person must follow the requirements in §358.515 of this subchapter (relating to Application Requirements) to obtain an eligibility determination from HHSC.
(c) In accordance with 42 CFR §435.120 and §435.909(b)(1), an application for SSI as described in subsection (a)(2) of this section serves as an application for MEPD. A person receiving or deemed to be receiving SSI derives eligibility for MEPD from the person's SSI eligibility and does not require an eligibility determination from HHSC.
§358.510. Authorized Representative.
In accordance with 42 CFR §435.908, an authorized representative may accompany, assist, and represent an applicant or recipient in the application or eligibility redetermination process.
§358.515. Application Requirements.
(a) To apply for a Medicaid-funded program for the elderly and people with disabilities (MEPD) under the application submittal process described in §358.505(a)(1) and (b) of this subchapter (relating to Application Process Overview), and in accordance with 42 CFR §435.907, an applicant, authorized representative, or someone acting responsibly for the applicant (if the applicant is incompetent or incapacitated) must:
(1) use the application prescribed by the Texas Health and Human Services Commission (HHSC) and complete it according to HHSC instructions:
(A) in writing, using a paper application obtained via telephone, Internet request, or other means;
(B) online, using the application process available over the Internet;
(C) over the telephone, through the State's toll-free telephone number; or
(D) in person, by visiting an HHSC benefits office;
(2) provide all requested information according to HHSC instructions; and
(3) sign the application for assistance under penalty of perjury.
(b) If someone helps an applicant or authorized representative complete the application for assistance, the name of the person completing the form must appear as requested on the application.
(c) If HHSC sends an applicant or authorized representative a request for missing information or verification documents, or both, the applicant or authorized representative must provide the requested information to HHSC by the due date given in the request, or eligibility may be denied.
§358.520. Date of Application.
(a) The date of application is the date on which:
(1)the Texas Health and Human Services Commission receives an application for assistance in accordance with subsection (c) of this section; or
(2) an application for Supplemental Security Income is filed with the Social Security Administration.
(b) If an application for assistance is received after the close of business, the date of application is the next working day.
(c) For purposes of determining the date of application for an application for assistance received under subsection (a)(1) of this section:
(1) an application received via fax or mail must contain, at a minimum, the applicant's name, address, and valid signature; and
(2) an application received via telephone or the Internet:
(A) must contain, at a minimum, the applicant's name and address; and
(B) the applicant must provide a valid signature within 45 days after the date of application.
§358.525. Previously Completed Application for Assistance.
An application for assistance remains valid for 90 days after a date of denial, if the Texas Health and Human Services Commission denies eligibility. An applicant may use his or her previously completed application to reapply during the 90-day period, in accordance with HHSC instructions.
§358.530. Eligibility Determination.
(a) Time frame for determination. After an applicant or authorized representative provides all information and verification documents requested, the Texas Health and Human Services Commission (HHSC) makes an eligibility determination within the following time frames, in accordance with 42 CFR §435.911:
(1) by the 90th day after the date of application if the applicant is applying on the basis of a disability;
(2) by the 45th day after the date of application for all other applicants; or
(3) beyond the time frames established in paragraphs (1) and (2) of this subsection under unusual circumstances, such as those set forth in 42 CFR §435.911.
(b) Basis for determination. HHSC decides whether an applicant meets the eligibility criteria for a Medicaid-funded program for the elderly and people with disabilities based on:
(1) a complete, signed, and dated application for assistance;
(2) information obtained from an interview, if an interview occurred; and
(3) required verification documents.
§358.545. Eligibility Redetermination.
(a) In accordance with 42 CFR §435.916, the Texas Health and Human Services Commission (HHSC) redetermines a person's eligibility for a Medicaid-funded program for the elderly and people with disabilities (MEPD):
(1) at least every 12 months;
(2) after HHSC receives information about a change in the person's circumstances, such as living arrangement, income, or resources, that may affect MEPD eligibility; and
(3) at the appropriate time based on an anticipated change in the person's circumstances.
(b) If the result of an eligibility redetermination causes an adverse action, HHSC:
(1) gives timely and adequate notice of the proposed action to terminate, discontinue, or suspend MEPD eligibility;
(2) gives timely and adequate notice to reduce or discontinue MEPD services; and
(3) informs the person of the right to request a hearing to appeal the adverse action in accordance with 42 CFR Part 431, Subpart E and HHSC's fair hearing rules in Chapter 357 of this title (relating to Hearings).