A-120, Office Procedures

A—121 Receipt of Application

Revision 23-3; Effective July 1, 2023

All Programs

Applications must be signed under or on the same page as the penalty of perjury statement before certification.

TANF

An application is valid if it has the applicant's name, the applicant’s address, and the signature of the:

• applicant; or
• applicant's designated authorized representative (AR).

SNAP

An application is valid if it has the applicant's name, the applicant’s address, and the signature of:

• the applicant;
• another responsible household member; or
• the applicant's designated AR.

Medical Programs

An application is valid if it has the applicant's name, the applicant’s address, and the signature of any of the following people:

• the adult or minor applicant;
• the applicant's designated AR; 
• an adult applying on behalf of a minor child; or 
• a person 19 or older who:
  • is included in the applicant’s MAGI household composition; or
  • has a tax relationship with the applicant.

Note: Applicants are not required to live at the same physical address to apply for each other. For example, a non-custodial parent may apply for Medicaid and CHIP on behalf of their child if the parent expects to claim the child as a tax dependent on their federal income tax return.

TP 43, TP 44 and TP 48

Do not require a new application when a household has an active Medicaid type program and requests to add Medicaid for another child who needs a new EDG. Add the child to the case per additions to the household policy. Exception: Do not add more children to a case where a Medicaid EDG was reinstated due to the child’s release from a juvenile facility. The household must submit an application for the other children. To identify these EDGs, view the Individual – Medicaid History page for the active child. If the Juvenile Placement History field indicates "Yes", the EDG has been reinstated.

This policy does not apply when there is no existing Children's Medicaid EDG. For example, do not add a child when the only other child is certified for Medicaid because the certified child receives SSI. A separate application is required to initiate coverage for the child being added.

Related Policy

Application Requests and Submissions, A-113
Filing the Application, A-122
Application Signature, A-122.1
Authorized Representatives (AR), A-170
Medical Programs, A-240
Children's Medicaid Redetermination Expectations, B-123.6
Denied EDGs, B-474.7
Additions to the Household, B-641

A—121.1 Receipt of Application from Residential Child Care Facility

Revision 24-1; Effective Jan. 1, 2024

Medical Programs

When a representative from a licensed residential child care facility applies for an independent child, accept and process the application.

A—121.2 Receipt of Duplicate Application

Revision 15-4; Effective October 1, 2015

All Programs

A duplicate application:

• is an application filed after another application has already been filed;
• does not include a request for programs different from programs requested on the initial application submitted;
• does not include a request for programs different from programs currently received by the applicant; and
• is not needed for a redetermination of any active program.

Example: If a household submits an application for SNAP on January 2 and later submits one or more additional applications for SNAP that are different from the one the household filed on January 2, and are not needed for a redetermination of any active program, the additional application submitted is considered a duplicate application.

Duplicate Application Received While Original Application Is Being Processed

If an office receives a duplicate application while staff are in the process of making an eligibility determination (an application or redetermination) based on the original application submitted, staff must:

• treat the duplicate application as a report of change; and
• assign the duplicate application as a change to the advisor currently processing the case.

The advisor processing the original application must:

• review the duplicate application for reported changes;
• document the duplicate application was reviewed for changes;
• document the type of changes, if changes were reported on the duplicate application; and
• use information provided by the household on both the original application and the duplicate application when determining eligibility for the household.

Duplicate Application Received After Original Application Is Processed

If an office receives a duplicate application and the applicant has already been certified for assistance based on another application previously submitted, staff must review the duplicate application to determine if the household is applying for programs other than what the household is currently receiving and if any redeterminations are due.

If the household is applying for different types of programs, the application is not a duplicate application and must be processed as a new application for assistance.

If the household is not applying for a different type of program and there are no redeterminations, office staff must:

• treat the duplicate application as a report of change; and
• assign the duplicate application as a change indicating "duplicate application."

Staff are not required to create a T number for TIERS cases and/or dispose of a duplicate application as "filed in error." If staff erroneously create a T number, staff must deny/dispose the T number as filed in error, in addition to other required actions listed above.

Note: If the office that receives the duplicate application does not normally process reported changes, staff may mark the application form as a duplicate application and route it to appropriate staff following local office procedures.

Advisors who process the duplicate application as a reported change must review the application to determine if any changes are indicated and take the following action. If no change is indicated on the duplicate application, the advisor must:

• document receipt of the duplicate application in TIERS Case Comments;
• route the duplicate application to be imaged as part of the electronic case record;
• sustain the benefits for each Texas Works program the household receives; and
• send an individual notice to the household that eligibility for benefits has not changed.

If a change is indicated on the duplicate application, staff must follow the procedures outlined in B600, Changes, when processing changes reported on the duplicate application.

A—121.3 Receipt of Identical Application

Revision 15-4; Effective October 1, 2015

All Programs

An identical application is one or more exact copy of an application previously filed by an applicant.

Example: If a household faxes in an application on January 2 and later submits an exact copy of the same application, which includes the same signature and date of the application the household previously submitted, the newly submitted application is considered an identical application.

Required Action on Identical Application Received

If an identical application is received, staff must write "Identical Application" on the front page of the application and route the application for imaging. The vendor will image the identical application and add it to the electronic case record. No other action is needed.

A—122 Filing the Application

Revision 20-4; Effective October 1, 2020

All Programs

Staff should encourage households to file an application the same day the household or its representative contacts the office in person, by telephone, fax, or mail, and expresses interest in obtaining assistance. Staff should explain how to file an application. Application forms are also available at YourTexasBenefits.com and can be downloaded, printed, and electronically submitted.

The file date is the day HHSC receives an application form containing the applicant's name, address, and appropriate signature. This is day zero in the application process. Staff use this as the file date to determine eligibility for the programs the household requests upon filing the application through the time of the interview.

For electronically filed applications, the file date is the date the applicant clicks the “Submit Application” button in YourTexasBenefits.com.

Exception: For all applications received outside of business hours when HHSC is closed, including weekends and holidays, the file date is the next business day.

The household must file another application form to apply for additional programs after the interview is held, even if the case was pended and is not completed at the time of the request for a new program. Exception: If the household requests three months prior Medicaid coverage according to policies in A-831.2, Eligibility for Three Months Prior Coverage, staff use a previously filed application with a file date that corresponds with the three-month prior period as a basis for determining eligibility.

Once an application is filed, staff must take the following actions:

• enter the file date in the appropriate section on the application form, if received as a paper document;
• for SNAP and TP 40, screen the application for expedited service eligibility;
• upon request, give the household Form H1800, Receipt for Application/Medicaid Report/Verification/Report of Change;
• register the application when required; and
• schedule an interview appointment for the applicant when required as soon as possible.

See special procedures in this section to determine the file date for TP 40, TP 40 Continuous Coverage and TP 45 Retroactive Coverage.

Related Policy
Application Requests and Submissions, A-113
Receipt of Application, A-121
Documentation Requirements, A-190

TP 40 Continuous Coverage

The file date is the date the advisor determines eligibility, if an application form is not used.

Related Policy
Continuous Medicaid Coverage, A-832

TP 45 Retroactive Coverage

The file date is the date the advisor is notified about the child's unpaid medical bills.

Related Policy
TP 45 Retroactive Coverage, A-833

TP 33, TP 34, TP 35, TP 43, TP 44 and TP 48

The file date is the date a contracted facility accepts the application. If the application is not forwarded to HHSC within three business days, the file date is the date the HHSC office receives the application.

The file date is the date an individual submits an application to any HHSC office. The application must be faxed or mailed to the correct office the same day it is returned.

For electronically filed applications, the file date is the date the applicant clicks the “Submit Application” button in YourTexasBenefits.com. For applications received outside of business hours when HHSC is closed, including weekends and holidays, the file date is the next business day.

A—122.1 Application Signature

Revision 23-3; Effective July 1, 2023

All Programs

The applicant must provide a signed application form before being certified. The signature can be captured anywhere  on the same page the penalty of perjury statement is captured.

If the agency receives an application with no required signature and the application is not date-stamped, the application is considered invalid. Return the application with a letter and a pre-paid envelope explaining that the application must be signed before the agency can establish a file date.

If the agency accepts an application without a required signature and the application is date-stamped, the date the application is received is considered a valid file date. Send Form H1020, Request for Information or Action, along with the signature page request a signature. If the applicant fails to provide a signed application by the final due date, deny the application for failure to provide information.

Eligibility Support Vendor Action on Unsigned Applications

If the eligibility support vendor receives an unsigned application, the application is considered invalid. Within one business day, return the application to the household with a letter and a pre-paid envelope explaining that the application must be signed before a file date can be established.

If the eligibility support vendor accepts an application without a signature and it is not identified as such before data entry or the data entry date is more than one business day after the receipt date of the application, the file date is the receipt date of the application. The missing signature is treated as missing information.

Electronically Filed Applications

All Programs

Applications submitted online through YourTexasBenefits.com by the applicant or authorized representative (AR), are considered electronically signed.

Exception: Do not consider the application electronically signed when a non-applicant or non-AR completes and submits the online application for the household. In this situation, a pre-populated application is mailed to the household requesting a written signature from the applicant.

Applications Filed by Phone

For certain programs, an applicant or AR may complete and sign an application by phone:

An applicant or AR who requests to apply for all programs by phone is informed that the option to complete and sign an application for all programs by phone is not available. The customer care representative directs the applicant or AR to submit an application online through YourTexasBenefits.com, by mail, by fax or at a local office.

TANF

The applicant or AR completes an application over the phone by providing their information to the customer care representative. However, the applicant or AR does not have the option to sign the application by phone. The customer care representative enters the information provided by the applicant or AR through YourTexasBenefits.com and a pre-populated application is mailed to the household requesting a written signature from the applicant or AR.

SNAP

The applicant or AR does not have the option to complete or sign the application by phone.

Medical Programs

The applicant or AR may complete and sign an application over the phone by:

• providing their information over the phone to the customer care representative; and
• signing the application over the phone by stating their name and agreeing to a penalty of perjury statement read by the customer care representative.

The customer care representative enters and submits the information provided by the applicant or AR through YourTexasBenefits.com.

Note: Staff cannot accept telephonic signatures.

Applications signed and submitted over the phone by the applicant or AR are considered signed by phone except when:

• the applicant or AR declines to sign the application by phone; or
• a non-applicant or non-AR completes and signs the application by phone for the household.

Correspondence is sent based on the following actions taken by the applicant or AR:

Notes:

• People who sign a renewal by phone receive the same correspondence, Form H1031, Telephonic Signatures Cover Letter, as people who sign an application by phone.
• People who decline to sign a renewal by phone receive the following correspondence:
  • Form H1032, Cover Letter for Unsigned Your Texas Benefits Renewal Form, which notifies the person a signature is needed to complete the renewal process; and
  • Form H2020-YTB, Your Texas Benefits Renewal Form, the unsigned renewal populated with information provided over the phone.

Related Policy
Application Requests and Submissions, A-113
Authorized Representatives (AR), A-170

Signatures Elsewhere

All Programs

Accept the applicant’s signature on the first or last page of Form H1010, Texas Works Application for Assistance - Your Texas Benefits, to establish a file date if the application meets all other application receipt requirements.

Note: If the applicant only provides a signed last page of Form H1010, do not require an additional signature for the first page of Form H1010.

Medical Programs

If an applicant signs and returns only Form H1010-MR, MAGI Renewal Addendum, with no corresponding application, the application is considered invalid. Attempt to contact the applicant by phone and advise them to file an application. No action is taken on Form H1010-MR without a corresponding application.

If the applicant returns a signed application without Form H1010-MR, consider the application incomplete. Send Form H1020, Request for Information or Action, with Form H1010-MR requesting the necessary information to make a determination based on Modified Adjusted Gross Income (MAGI) rules. If the applicant fails to provide a completed Form H1010-MR by the final due date, deny the request for failure to provide information.

Related Policy

Application Requests and Submissions, A-113
Receipt of Application, A-121

A—122.2 Scheduling Appointments

Revision 22-4; Effective Oct. 1, 2022

SNAP, TANF, TP 08 and TA 31

An interview is required at application and redetermination for SNAP, TANF and Medicaid for Parents and Caretaker Relatives. Complete an interview even if the application only contains the applicant’s name, address, and signature. Attempt to interview the applicant as a lobby walk-in or by making a cold call. If the cold call is unsuccessful, mail the applicant Form H1830-FA, Application/Review/Expiration/Appointment Notice that provides the applicant information about how to call the agency for a flexible appointment interview.

TP 33, TP 34, TP 35, TP 36, TP 40, TP 43, TP 44, TP 45 and TP 48

An interview is not required for Children's Medicaid or Medicaid for Pregnant Women. Process the application unless the applicant requests an interview.

Exceptions:

• If the applicant was previously denied for failure to provide Form H1024, Subject: Self-Declaration Notice, or for missing an appointment related to a Health Care Orientation (HCO) or Texas Health Steps noncompliance, schedule a phone appointment and deliver the HCO or remind the applicant about the importance of the Texas Health Steps  checkup at that time.
• Staff conduct an interview for an initial application or redetermination when HHSC receives conflicting information related to household composition or income that affects eligibility and the information cannot be verified through other means, such as an associated EDG.

Related Policy

Interviews, A-131
Explanation of Benefits, A-1531.4

A—122.3 Registering an Application

Revision 22-3; Effective July 1, 2022

All Programs

Perform Application Registration (App Reg) within one workday after the file date when application registration is required.

To prevent overpayments or incorrectly providing benefits, take the following action before registering an application:

• screen each application filed; and
• associate the old case number in File Clearance when appropriate.

Perform inquiry on all household members applying for benefits listed on the application for assistance. Use Social Security numbers (SSNs), case name search and available case or EDG numbers to determine case status.

A—123 Withdrawal of an Application

Revision 15-4; Effective October 1, 2015

All Programs

The individual may voluntarily withdraw an application any time before certification.

SNAP

If someone other than the head of household, spouse, a responsible household member, or an AR requests a withdrawal, staff should contact the household to confirm the withdrawal.

Related Policy

The Texas Works Message, A-1527

A—124 Processing Presumptive Eligibility Applications

Revision 15-3; Effective July 1, 2015

TA 66, TA 74, TA 75, TA 76, TA 83, TA 86 and TP 42

Presumptive eligibility (PE) provides short-term medical coverage to pregnant women, MBCC applicants, children under age 19, parents and caretaker relatives of dependent children under age 19, and former foster care children. PE provides full fee-for-service Medicaid with the exception of pregnant women. Pregnant women receive ambulatory prenatal care only.

Qualified hospitals (QHs) determine PE for all groups except MBCC.

Qualified entities (QEs) determine PE for pregnant women and MBCC applicants. For MBCC applicants, only QEs that are also Texas Department of State Health Services (DSHS) Breast and Cervical Cancer Services contractors may make MBCC PE determinations, following the process outlined in X100, Application Processing.

A—124.1 Eligible Groups

Revision 15-3; Effective July 1, 2015

The following groups can receive presumptive eligibility coverage:

• Children:
  • MA-Children Under 1 Presumptive — TA 74
  • MA-Children 1–5 Presumptive — TA 75
  • MA-Children 6–18 Presumptive — TA 76
• Former Foster Care Children (MA-FFCC Presumptive — TA 83)
• Pregnant Women (MA-Pregnant Women Presumptive — TP 42)
• Parents and Other Caretaker Relatives (MA-Parents and Caretaker Relatives Presumptive — TA 86)

A—124.2 File Clearance

Revision 15-3; Effective July 1, 2015

TIERS performs automated file clearance for each individual determined presumptively eligible if the individual has a 100 percent match in TIERS or if there is no match for the individual in TIERS. For individuals for whom TIERS cannot perform automated file clearance, TIERS triggers an alert to create a TLM task for staff to manually do file clearance for the individual. TIERS routes manual file clearance tasks to the Out-stationed Worker Program (OWP) queue for assignment and processing.

A—124.3 Task List Manager

Revision 15-3; Effective July 1, 2015

When TIERS cannot automatically perform file clearance for an individual whom a QH/QE has determined to be presumptively eligible, an OWP advisor needs to take action. TIERS creates the task "Process a File Clearance Failure for Presumptive Eligibility" and sends it to an OWP advisor based on the applicant's ZIP code.

To complete the task, the advisor:

1. Selects the Work icon.
2. Selects the individual who needs file clearance from the Presumptive Eligibility Individual — Summary page.
3. Matches the PE individual to the TIERS individual on the PE File Clearance — Results page.
4. Selects Auto Process PE on the File Clearance — Results page to complete the task once the advisor has performed file clearance for all individuals on the case.  

The advisor can also manually clear the task. When an advisor searches for an application on the Self Service Application Search page, the SS Application Search Results section displays a Determine PE link if a PE individual on the case requires manual file clearance. TIERS displays the Presumptive Eligibility Individual — Summary page when the advisor clicks the link.

Once the advisor completes file clearance, TIERS notifies TLM to close the QH/QE PE task.

A—124.4 Application Processing

Revision 15-3; Effective July 1, 2015

The TLM routes applications for regular Medicaid from individuals whom a QH/QE has determined to be presumptively eligible for Medicaid to an OWP advisor for processing. If the QH has an OWP advisor, the TLM assigns the application to that advisor for processing. If the QH does not have an OWP advisor or a QE submits the application, the TLM routes the application to the regional OWP queue.

Process the applications using current policy and application processing time frames. See B112, Deadlines. If both a PE task for file clearance and a regular Medicaid application exist for the same person, clear the PE task first.

A—124.5 Verifications

Revision 15-3; Effective July 1, 2015

Use standard verification requirements when processing an application for regular Medicaid from an individual determined presumptively eligible. See C900, Verification and Documentation.

Related Policy

Verifications, C1113.4

A—124.6 Medical Effective Date

Revision 15-4; Effective October 1, 2015

The medical effective date for PE is the date that the QH or QE determines the individual is presumptively eligible for Medicaid. 

Note: An individual is not eligible for PE coverage if the individual is currently certified for Medicaid, CHIP or CHIP perinatal.  

If the individual does not apply for regular Medicaid, PE coverage ends the last day of the month after the month of the PE determination (see scenario 1 below).

If the individual submits Form H1205, Texas Streamlined Application, or Form H1010, Texas Works Application for Assistance — Your Texas Benefits, HHSC determines whether the individual is eligible for regular Medicaid. If the person is not eligible for regular Medicaid, the individual's PE coverage ends the date that HHSC determines the individual is ineligible (see scenario 2 below). If the person is eligible for regular Medicaid, the person’s PE coverage ends when HHSC makes the Medicaid eligibility determination, following cutoff rules. 

If an individual is Medicaid-eligible during the application month, the individual receives Medicaid from the first of that month through the PE MED. Regular Medicaid coverage for the ongoing period starts once the PE period ends (see scenarios 3 and 4 below). Exception: Since PE for pregnant women provides only limited prenatal services, ongoing Medicaid coverage overlays the PE coverage (see scenario 5 below).

Examples:

A—124.7 Periods of Presumptive Eligibility

Revision 15-3; Effective July 1, 2015

Pregnant women are allowed one PE period per pregnancy.

For all other PE groups, an individual is allowed no more than one period of PE per two calendar years. Example: An individual receives PE for children ages 6–18 in June 2015. He cannot receive another period of PE until January 2017.

A—124.8 Fair Hearings

Revision 15-3; Effective July 1, 2015

Appeals and fair hearings do not apply to PE.

A—124.9 Questions About the Presumptive Eligibility Process

Revision 20-4; Effective October 1, 2020

Refer hospitals and entities that are interested in becoming qualified to make PE decisions to the PE website.

Refer a person with questions about their PE coverage dates to the QH/QE that made the PE determination. For questions about services covered by Medicaid, tell the person to call the Medicaid help line at 800-335-8957.

A—124.10 Presumptive Eligibility Forms

Revision 15-3; Effective July 1, 2015

Qualified hospital/qualified entity staff use the following forms in the presumptive eligibility process: 

• Form H1265, Presumptive Eligibility (PE) Worksheet — Completed by the QH/QE and used to determine if an applicant is presumptively eligible.    
• Form H1266, Short-term Medicaid Notice: Approved — Completed by the QH/QE and given to an individual determined presumptively eligible. This form notifies the individual about PE coverage and lists the eligibility start and end dates. If an individual takes this form to a local eligibility determination office and requests a temporary Medicaid identification card, give the person Form H1027-A, Medicaid Eligibility Verification.
• Form H1267, Short-term Medicaid Notice: Not Approved — Completed by the QH/QE and given to an individual determined ineligible for PE coverage. This form explains the reason for ineligibility and how to apply for regular Medicaid.

Related Policy

Qualified Hospital/Qualified Entity Policy and Procedures for Presumptive Eligibility Determinations, C1113

A—125 TP 45 Provider Referral Process

Revision 16-3; Effective July 1, 2016

TP 45

State Office Data Integrity (SODI) uses the Provider Referral Process when a hospital, birthing center, or Federally Qualified Health Center (FQHC) submits a referral directly to SODI for a newborn whose mother is Medicaid eligible. The provider does not submit a claim for payment to the claims administrator for the child at this time.

SODI researches eligibility files. After verifying the mother's Medicaid coverage, which can be retroactive, SODI creates a TP 45 EDG for the newborn.

Coverage for the child begins with the child's date of birth (DOB). The last month of coverage is the month the child turns age one, unless one of the following situations occurs.

• The hospital notifies SODI using Texas Department of State Health Services Form 7484, Hospital Report (Newborn Child or Children), that the child's mother relinquishes her parental rights.
  • If Form 7484 indicates a relinquishment but the new caretaker’s information is incomplete or is not provided, SODI provides newborn Medicaid coverage from the child's DOB through the end of the month the child is relinquished.
  • If Form 7484 indicates a relinquishment and the new caretaker’s name and address are provided, SODI completes two case actions. The first action is to process an open and close newborn Medicaid EDG with the birth mother as the case name. The coverage begins with the child’s DOB and continues through the end of the month the child was relinquished. The second action is to open a newborn Medicaid case/EDG with the new caretaker as the case name. The coverage begins the first of the month after the original newborn Medicaid coverage ended and continues through the month of the child’s first birthday.
• The child's mother received TP 42 Pregnant Women Presumptive coverage at the time of the child's birth and the mother's application for regular Medicaid coverage is denied. SODI certifies the child through the birth month.

The computer generates and sends the following documents for each EDG:

• A notice of the newborn's individual number to the referring provider and other providers, if identified on the provider's referral;
• Your Texas Benefits Medicaid card to the newborn's mother; and
• A notice informing the newborn's mother/caretaker:
  • that the child is eligible to receive medical coverage through the month the child turns age one, as long as the Texas residence requirement is met, and to report any changes concerning these eligibility requirements;
  • to report if information on Form H1027-A, Medicaid Eligibility Verification, is incorrect;
  • to report if the newborn's siblings receive TANF; and
  • if the mother's Medicaid end date changes because the child was not born in the anticipated month.

A—125.1 Advisor Action in Provider Referral Process

Revision 15-4; Effective October 1, 2015

TP 45

A task is created when a TP 45 EDG is established and the TIERS case contains an active SNAP or TANF EDG. The advisor must take the following actions once the advisor claims the newborn alert task.

A—125.2 Suspended Claim Process

Revision 15-4; Effective October 1, 2015

TP 45

The Medicaid provider sends a claim for a newborn child with the child's mother's claim to the claims administrator. If the claims administrator cannot find the child on HHSC's eligibility files, the claims administrator suspends the child's claim and sends an exception notice to State Office Data Integrity (SODI). SODI checks the child's mother's Medicaid eligibility. If the mother received Medicaid at the time of the child's birth, including a retroactive determination, SODI follows procedures in the Provider Referral Process to provide Medicaid coverage for the child.

A—125.3 Mandated TIERS Inquiry

Revision 15-4; Effective October 1, 2015

TP 45

Field staff must perform TIERS inquiry before providing coverage for a newborn when there is no evidence of SODI TP 45. Staff should inquire by the newborn's mother's individual number and look for a process date that is after the child's DOB.

A—126 Processing Children’s Insurance Applications

Revision 15-4; Effective October 1, 2015

See A-113, Application Requests and Submissions, for how to apply for Medical programs for children.  

A—126.1 Front Desk Process

Revision 15-4; Effective October 1, 2015

CHIP and TP 43, TP 44 and TP 48

When individuals come to a local eligibility office to inquire about health insurance for their child(ren), the front desk clerk must:

• explain the ways to submit an application as outlined in A-113, Application Requests and Submissions; and
• explain that the Medicaid application process provides that if a child is found ineligible for Medicaid based on income, HHSC will test the child for CHIP and, if eligible, the Enrollment Broker will send an enrollment packet to the household.

A—126.2 Inquiry

Revision 15-4; Effective October 1, 2015

CHIP and TP 43, TP 44 and TP 48

Before certifying a child for any type of Medicaid program, advisors must perform an inquiry to determine whether the child applying for Medicaid is already enrolled or pending enrollment in Medicaid, CHIP, or CHIP perinatal.

A—126.3 Advisor Action for Determining Eligibility for Children

Revision 16-2; Effective April 1, 2016

CHIP and TP 43, TP 44 and TP 48

When taking action on an application, the following procedures must be applied:

After determining a child is ineligible for Medicaid, TIERS will test eligibility for CHIP.

When the head of household does not provide their date of birth (DOB) and/or Social Security number (SSN), the following steps are taken to obtain the information:

• Call the household to try to obtain the correct DOB and/or SSN. Let the household know this information is voluntary and is not required to make an eligibility determination for the child; however, it will help expedite the process.
• If unable to obtain the DOB and/or SSN by telephone, continue to process the child's application for Medicaid.
• Select a random DOB for the caretaker/second parent, with a year between 1965 and 1975. Using randomly selected DOBs reduces or eliminates the problem of duplicate individual numbers.
• The SSN field is left blank if the correct number is not available.
• Staff ensure that all other demographic information is correct and include the individual's middle name, when available.

A—126.3.1 Neonatal Intensive Care Unit (NICU) Newborn Process

Revision 15-4; Effective October 1, 2015

CHIP Perinatal, TP 36, TP 43 and TP 45

Income Above the Limit for Medicaid for Pregnant Women (TP 40)

When a CHIP perinatal mother whose household income is above the income limit for TP 40 applies for Medicaid for her newborn and HHSC hospital-based staff have information from the applicant or the hospital that the newborn is medically fragile and that the newborn is admitted into the NICU, HHSC hospital-based staff must certify the newborn using the following process:

• Upon receipt of an application for a Medicaid NICU newborn, HHSC hospital-based staff must perform inquiry to determine if the mother is on CHIP perinatal or whether the newborn has been assigned a TIERS individual identification (ID) number and is active on Medicaid.
• If the newborn is not active on Medicaid, staff must deny the CHIP perinatal and certify the eligible newborn for TP 43, if eligible, following existing policy.
• If not eligible, test the newborn for TP 56 and do not deny the newborn’s CHIP perinatal coverage.
• If eligible, the newborn may receive TP 56 and CHIP perinatal coverage.

Income at or Below the Limit for Medicaid for Pregnant Women (TP 40)

When HHSC hospital-based staff have information from the applicant or the hospital that a newborn born to a CHIP perinatal mother whose household income is at or below the income limit for TP 40 is medically fragile and that the newborn is admitted into the NICU, HHSC hospital-based staff must certify the eligible mother for Emergency Medicaid and the newborn for TP 45, effective on the newborn's date of birth. The CHIP perinatal mother must submit Form H3038-P, CHIP Perinatal — Emergency Medical Services Certification, to the hospital. HHSC hospital-based staff must process Form H3038-P.

Upon receipt of Form H3038-P, HHSC hospital-based staff must:

• perform inquiry on the Newborn Perinatal Match Interface (Interfaces – TIERS Left Navigation) to verify the CHIP perinatal household's FPIL;
• use the date Form H3038-P is provided as the file date for both the Emergency Medicaid and Medicaid for the newborn child;
• certify the CHIP perinatal mother for Emergency Medicaid and deny the CHIP perinatal Eligibility Determination Group (EDG); and
• certify the eligible newborn for TP 45, effective on the newborn's date of birth.

Related Policy

Adding a New Child, D1433.1

A—126.4 CHIP Good Cause

Revision 15-4; Effective October 1, 2015

CHIP good cause is explained in D1723.6, Good Cause Exemptions for Children Subject to the 90-day Waiting Period.

A—126.4.1 Claiming Good Cause

Revision 15-4; Effective October 1, 2015

CHIP good cause is explained in D1723.6, Good Cause Exemptions for Children Subject to the 90-day Waiting Period.

A—127 Prior Medicaid Coverage

Revision 15-4; Effective October 1, 2015

Children's Medicaid and TP 33, TP 34 and TP 35

Staff use any valid application or renewal form to determine three months prior coverage for Children's Medicaid. Do not require Form H1113, Application for Prior Medicaid Coverage, if the family provides enough information to determine eligibility for prior months. If the family does not provide enough information and cannot be reached by telephone, staff sends Form H1113 with Form H1020, Request for Information or Action, to request verification. Note: Three months prior coverage does not apply to CHIP. See D1723.5, Coverage Start Dates, to determine when CHIP coverage begins.

Staff must not delay certification of ongoing eligibility to determine if any child is eligible for prior coverage.

Related Policy

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

A—128 Processing Applications for Pregnant Women

Revision 15-4; Effective October 1, 2015

CHIP Perinatal, TP 40 and TP 36

A pregnant woman may apply for health care coverage using applications and ways to submit an application explained in A- 113, Application Requests and Submissions.

When a pregnant woman applies for health care coverage, she will first be tested for TP 40 coverage. If ineligible for TP 40, TIERS will determine whether the woman is eligible for CHIP or CHIP perinatal.

CHIP perinatal coverage provides services to unborn children of pregnant women, regardless of age, who are at or below the program income limit and are ineligible for:

• Medicaid because of immigration status or income; or
• CHIP because of age or immigration status.

CHIP perinatal households are exempt from the:

• 90-day waiting period;
• cost-sharing (enrollment fees and co-payments); and
• six-month income check.

A—128.1 Inquiry for Pregnant Women

Revision 15-4; Effective October 1, 2015

CHIP Perinatal, TP 40 and TP 36

Before certifying a pregnant woman for any type of health care coverage, advisors must perform inquiry to determine whether the pregnant woman is already certified for Medicaid or enrolled or pending enrollment in CHIP or CHIP perinatal.

Searching by the woman's last name and date of birth may increase the possibility for a match.

A—128.2 Staff Action for Determining Eligibility for Pregnant Women

Revision 21-2; Effective April 1, 2021

TA 85 (CHIP-P), TP 40 and TP 36

When taking action on an application, apply the following procedures.

* When a woman enrolled in CHIP perinatal submits a new application, they must be tested for Medicaid coverage. When processing a change for a woman certified for CHIP perinatal, TIERS will automatically test for Medicaid eligibility. A new application is not required.

A—128.3 CHIP Perinatal Application Process

Revision 21-2; Effective April 1, 2021

TA 85 (CHIP-P), TP 36 and TP 45

CHIP perinatal (TA 85) covers labor with delivery charges for households with income above the income limit for Medicaid for Pregnant Women (TP40), but not for households that qualify for Emergency Medicaid coverage (women who do not meet citizenship requirements, and whose household income is at or below the income limit for TP40). These Medicaid-eligible households must submit Form H3038-P, CHIP Perinatal — Emergency Medical Services Certification, to apply for Emergency Medicaid to pay for these charges.  A woman certified for TA 85 with household income above the TP40 income limit cannot be certified for Emergency Medicaid to cover the labor with delivery charges.

A child born to a CHIP perinatal mother whose household income is at or below the income limit for TP40 and who receives Emergency Medicaid to cover labor with delivery charges is enrolled in Medicaid instead of CHIP perinatal.  

Thirty days before the expected due date, TIERS generates and sends Form H3038-P with Form H1061, Birth Outcome Letter, to the household. If the household has not reported the child’s birth by 30 days after the expected due date, TIERS sends a Form H1062 , Birth Outcome Reminder Letter, and a second Form H3038-P with instructions for getting Form H3038-P completed and signed by the medical practitioner, along with a self-addressed postage-paid envelope. The household must return Form H3038-P to HHSC.

Upon receipt of Form H3038-P:

• the form is linked to the mother's case; and
• a task is created for Customer Care Center (CCC) staff to certify the mother for Emergency Medicaid and the newborn for TP 45.

Staff must not certify the mother for Emergency Medicaid or the newborn for TP 45 if the household has not returned Form H3038-P within 60 days from the date of the expected pregnancy due date. Reopen three-month prior applications for people who return Form H3038-P after 60 days from the expected pregnancy due date.

Note: For newborns admitted to the Neonatal Intensive Care Unit (NICU), process both the Emergency Medicaid coverage for the mother and the TP 45 for the newborn.

CCC Staff Process

CCC is assigned a task to process Form H3038-P. Staff must:

• determine whether mother and newborn are already active on Medicaid;
• if mother and newborn are not active on Medicaid, use all TP 40 eligibility policies and procedures to determine Emergency Medicaid eligibility, except when verifying income and citizenship/alien status;
• use the verified income provided to determine CHIP perinatal eligibility to determine Emergency Medicaid eligibility. Note: TIERS will not run financial rules when certifying a recipient for Emergency Medicaid and will instead use the verified income used to determine the woman’s CHIP Perinatal eligibility; 
• verify all non-financial eligibility points prior to certification using: 
  • identity verification sources; and
  • residence verification sources;
• use the date Form H3038-P is received as the file date for the Emergency Medicaid and TP 45; and
• process Form H3038-P by the 45th date after the file date.

The file date for the TP 45 is usually the date Form H3038-P is received if it includes the newborn's information. Birth outcome information can also be received via the newborn interface or from the person by phone or in writing. When birth outcome information is received after Form H3038-P has already been submitted to the HHSC, a second task is assigned to CCC to process TP 45 coverage for the newborn.

When CCC staff receive a task that includes Form H3038-P dated more than 60 days after the pregnancy due date, CCC must stamp "Received (Date) CCC" on Form H3038-P, to indicate the form was provided after the 60 days from the pregnancy due date. CCC staff must return Form H3038-P along with an application and a letter informing the person that they must apply for Medicaid. The person is instructed to complete the application and return it to the nearest HHSC office or appropriate out-stationed worker, if an out-stationed worker is housed at the hospital where the delivery took place.

Out-Stationed and HHSC Eligibility Office Staff Process

The chart below explains procedures staff must follow to determine appropriate action.

Notes:

• Fax the bar-coded Form H3038-P to 877-447-2839. If Form H3038-P is not bar-coded, write the mother's case and CHIP perinatal EDG number on the top of the form.
• If the applicant requests the fax number for Form H3038-P, instruct the applicant to fax the form to 877-447-2839.

Related Policy

Receipt of Duplicate Application, A-121.2
Receipt of Identical Application, A-121.3
Neonatal Intensive Care Unit (NICU) Process, A-126.3.1
Verification Sources, A-621
Verification Sources, A-761
Reopening Three Months Prior Applications, A-831.2.1
Deadlines, B-112

A—129 Data Broker Requirements

Revision 15-4; Effective October 1, 2015

All Programs

Staff must request Data Broker reports as required in C-820, Data Broker.

Related Policy

Permissible Purpose, C-824