Revision 21-3; Effective July 1, 2021

 

W—910 General Policy

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).

Related Policy

Pay for Performance, A-2150
Medical Program Administrative Renewals, B-122.4
Termination of Medical Coverage for People Confined in a Public Institution, B-510
Eligibility Begin Dates, W-1920

 

W—911 Current Medicaid, Medicare (Part A or B) and Children's Health Insurance Program (CHIP) Recipients

Revision 21-3; Effective July 1, 2021

 

A woman is not eligible to receive Healthy Texas Women (HTW) benefits if she is currently receiving another type of Medicaid, Medicare (Part A or B) or CHIP.

When determining HTW eligibility after a woman is determined ineligible for full Medicaid and CHIP, verify via State Online Query (SOLQ) that an applicant is not currently enrolled in Medicare (Part A or B).

If an application is received for a woman who 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.

Related Policy

Eligibility Begin Dates, W-1920

 

W—912 Pregnant Women

Revision 21-3; Effective July 1, 2021

 

Women who are pregnant are ineligible to receive HTW benefits. If the question, “Are you pregnant?”, is not answered, pend the application for verification. Allow the applicant normal processing time frames to provide an answer to the pregnancy question. Verification is self-declared. Deny the application for failure to provide verification if the applicant or recipient does not provide the information.

If the woman reports that she is pregnant on her application, determine if she is eligible for Medicaid for Pregnant Women or CHIP-Perinatal (CHIP-P).

If the HTW recipient reports she is pregnant during her 12-month continuous coverage period, determine if she is eligible for Medicaid for Pregnant Women or CHIP-P. Do not require the recipient to complete a new application. TIERS will deny the HTW EDG once the recipient is certified to receive benefits for her pregnancy.

Related Policy

Processing Applications for Pregnant Women, A-128

 

W—913 Third-Party Resource (TPR)

Revision 21-3; Effective July 1, 2021

 

A woman is ineligible to receive HTW benefits if she has creditable health coverage (TPR). The applicant or recipient has creditable health coverage if her private health insurance covers family planning services.

An applicant or recipient's private health insurance is considered to cover 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 whether the private health insurance provides coverage and do not give consideration to other issues such as high deductibles or dollar limits on drug coverage.

Applications for medical programs ask the following questions:

  1. Do you have health insurance that covers family planning services? Yes  No
  2. If yes, will filing a claim on your health insurance cause physical, emotional or other harm to you from your spouse, parents or other person? Yes  No
  3. If yes, you must provide an explanation below of your situation.

An applicant 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 applicant if she does not answer question 1, question 2, or both. Allow the applicant normal processing time frames to provide an answer. Verification is self-declared by the applicant. If the applicant does not self-declare the answer to question 1, question 2, or both by the deadline, deny the application for failure to provide.

If the applicant states Yes to question 1 and question 2 but leaves question 3 blank, do not pend the applicant for an answer. Continue determining eligibility.

If the applicant 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 during the recipient's 12-month continuous coverage period she reports having creditable health insurance, 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.

Related Policy

Confidentiality, W-2400

 

W—920 Verification Requirements

Revision 17-2; Effective April 1, 2017

 

Accept self-declaration of pregnancy and TPR.

 

W—930 Documentation Requirements

Revision 07-0; Effective July 1, 2007

 

For TPR, staff must document in case comments:

  • the availability of TPR for family planning services;
  • if filing a claim would cause physical, emotional or other harm to the individual; and
  • why, if provided.