Revision 09-4; Effective December 1, 2009

§358.211. Aged, Blind, or Disabled.

(a) To be eligible for a Medicaid-funded program for the elderly and people with disabilities (MEPD), a person must be aged, blind, or disabled, according to the following criteria:

(1) Aged. A person must be 65 years of age or older to be considered aged, in accordance with 42 U.S.C. §1382c(a)(1)(A).

(2) Blind.

(A) To be considered blind for eligibility purposes, a person must meet the criteria in 42 U.S.C. §1382c(a)(2).

(B) There is no minimum age requirement for a person who is blind.

(C) A person must have a medical determination of blindness before the Texas Health and Human Services Commission (HHSC) can determine eligibility.

(3) Disabled.

(A) To be considered disabled for eligibility purposes, a person must meet the criteria in 42 U.S.C. §1382c(a)(3).

(B) There is no minimum age requirement for a person who is disabled, unless the person lives in an institution for mental diseases as described in §358.213 of this subchapter (relating to Resident of an Institution for Mental Diseases).

(C) A person must have a medical determination of a disability before HHSC can determine eligibility.

(b) A person under 65 years of age who has applied for Supplemental Security Income, and subsequently applies for retroactive coverage, must have a medical determination of blindness or a disability effective during any month of coverage that the person was under 65 years of age.

Revision 09-4; Effective December 1, 2009

In determining age for aged, blind, or disabled individuals, the age is reached the day before the anniversary of birth. This affects the month a disability determination is required for persons born on the first day of the month. Example: The person turns 65 on Jan. 1, and is eligible for Medicare Dec. 1, before the person’s 65th birthday in January. If the person meets all other eligibility criteria, the person can be certified for benefits for December without a disability decision.

Determine a person's age by the person’s statement on the application. Compare the reported information with Social Security Administration records using systems in place to exchange or request data. Other acceptable evidence includes such readily available sources as:

• insurance policies;
• family Bible;
• marriage record;
• child's birth certificate;
• hospital admission record;
• driver's license;
• hunting license;
• fishing license; or
• voter registration card.

 

D-1210 Definition of a Child

Revision 09-4; Effective December 1, 2009

A child is neither married nor a head of a household and is either:

• under age 18; or
• under age 22 and a student regularly attending school, college or training that is designed to prepare him/her for a paying job.

Child status ceases effective with the month after the month of attainment of age 22 (age 18, if not a student) or the month after the month the person last meets the definition of child.

SSI policy defines full-time student as an individual attending at least:

• 12 hours per week if in high school or under;
• 12 hours per week if in a technical or vocational school (shop practice is not included in the course);
• 15 hours per week if in a technical or vocational school (shop practice is included in the course); or
• eight hours per week per semester if in a college or university.

A student is deemed to be in regular school attendance during normal vacation periods if he attends regularly during the month immediately following the vacation period. A person may be considered a full-time student without attending the required number of hours per week, if the person is disabled and physically unable to attend full-time, has difficulty obtaining transportation or is taking all that is needed to complete the person's education.

The age requirements involved in identifying a child apply only to a person who is otherwise eligible. A blind or disabled applicant who meets these age requirements, however, can become eligible for Medicaid, even though the person does not meet the definition of a child.

Revision 09-4; Effective December 1, 2009

In determining blindness for aged, blind or disabled individuals, blindness is met if a person is considered “legally blind” as defined by the Social Security Administration. Based on a medical determination of blindness, a person is considered blind if the visual acuity in the person's better eye is 20/200 or less with corrective lenses, or if the person has tunnel vision that limits the field of vision to 20 degrees or less.

Revision 09-4; Effective December 1, 2009

In determining disability for aged, blind or disabled individuals, disability is met if the person is considered disabled as defined by the Social Security Administration. Based on a medical determination of disability, a person is considered disabled if the person is unable to engage in any substantial, gainful activity because of a medically determinable physical or mental impairment that can be expected to result in death or has continued or can be expected to continue for at least 12 months. A child who is not engaged in substantial, gainful activity is considered disabled if the child suffers from any medically determinable physical or mental impairment of comparable severity to that which would preclude an adult from engaging in substantial, gainful activity.

Note: A person who lives in an institution for mental diseases (IMD) must be 65 years of age or older to be eligible for an MEPD program. Do not establish a medical determination for blindness or disability for a person who lives in an IMD who is less than 65 years old.

Revision 12-4; Effective December 1, 2012

Receipt of Medicare is an indication that the person is either:

• age 65 or older; or
• has been determined blind or disabled based on the Social Security Administration (SSA) criteria for RSDI Title II or SSI Title XVI disability.

A medical determination is not required to establish blindness or disability if the person has Medicare. The receipt of the Medicare is satisfactory verification that the person has been determined to meet the SSA's criteria for aged, blind or disabled. This includes a person determined blind or disabled by SSA in the 24-month period before receiving Medicare. Upon verification of the receipt of a disability benefit, a medical determination is not required to establish blindness or disability if a person is currently receiving disability benefits from:

• SSI;
• RSDI; or
• Railroad Retirement.

For an eligibility determination during the retroactive coverage months, a medical determination is not required to establish blindness or disability during that retroactive coverage period if a person:

• has unpaid or reimbursable covered Medicaid expenses during the retroactive coverage months prior to the application;
• has a date of onset for RSDI Title II blindness or disability based on SSA query records; and
• the date of onset for the RSDI Title II blindness or disability covers the retroactive coverage months prior to the application.

Note: Do not use the Title XVI "Dsblty Onset Date" on the SSI Entitlement screen as the basis to establish blindness or disability for:

• retroactive coverage;
• current coverage; or
• future coverage.

A medical determination is not required to establish blindness or disability if a person:

• applies with HHSC for SSI-related medical assistance only (MAO);
• is under age 65; and
• lost SSI for reasons other than a decision that the disability or blindness has stopped.

Revision 16-4; Effective December 1, 2016

When an individual does not have Medicare or is not receiving a disability benefit from SSI, RSDI, or Railroad Retirement (See E-4200, Railroad Retirement Benefits), a medical determination, including date of onset, of either disability or blindness is required. The date of onset can affect the start date of Medicaid.

The following must not be used to establish disability for MEPD programs:

• a Civil Service disability  determination;
• a medical certification an individual submits to an Achieving a Better Life Experience (ABLE) program or to the Internal Revenue Service as proof of meeting ABLE program requirements.

An individuals under age 65 who lives in an institutional setting and who would, except for income, be eligible for SSI if they lived outside the facility, must meet the SSA's definition of disability or blindness. These individuals may or may not have applied for SSI cash benefits.

If a medical decision for determining blindness or disability is required, request a decision from the Disability Determination Unit (DDU). See Section D-2300, Requesting a Decision from the Disability Determination Unit (DDU).

Do not request a decision from the DDU in the following circumstances.

If an individual …	then …
resides in a state supported living center or the Rio Grande State Center,	the staff at these facilities, and not HHSC staff, is responsible for ensuring the completion of the forms for a disability determination.
requests an eligibility determination during a retroactive period and the individual: has unpaid or reimbursable covered Medicaid expenses during the retroactive coverage months prior to the application; has a date of onset for RSDI Title II blindness or disability based on SSA query records; and the date of onset for the RSDI Title II blindness or disability does not cover any of the retroactive coverage months prior to the application,	the DDU cannot establish an earlier date of onset for RSDI Title II blindness or disability because federal regulations prevent a state's disability determination to conflict with the RSDI Title II date of onset.

A medical determination of disability or blindness is required when RSDI Title II blindness or disability is not established and an individual is:

• under age 65;
• either under or over age 65 and applying for the Medicaid Buy-In (MBI) program; or
• either under or over age 65 and presumed to be a child with a disability to meet exception to transfer penalty.

To determine whether  RSDI Title II blindness or disability is established, query the SSA records available.

Do not use the SSI Title XVI "Dsblty Onset Date" as the basis to establish blindness or disability.

Revision 14-4; Effective December 1, 2014

When a medical decision for determining blindness or disability is necessary, a decision must be requested from DDU. Complete and submit these forms for imaging, along with the medical records, to the Texas Health and Human Services Commission, P.O. Box 149027, Austin, TX 78714-9971:

• Form H3034, Disability Determination Socio-Economic Report
• Form H3035, Medical Information Release/Disability Determination

In addition to these forms, submit the following when available:

• Minimum Data Set information (physician's signature page)
• Medical treatment records for a waiver applicant
• Medical records for an applicant for primary home care services through Community Attendant Services (CAS)

DDU may request more complete medical documentation.

On receipt of Form H3034, Form H3035 or other medical records, DDU uses this information to determine whether the person meets SSA's definition of disability or blindness and makes the final decision about disability or blindness.

DDU will consider the date of onset for the retroactive period, if needed. Specify the retroactive months needed on Form H3034. DDU's date of onset, however, cannot precede the RSDI Title II disability onset date indicated on the SSA query.

Revision 11-4; Effective December 1, 2011

When the application is for a person who is younger than age 65 and has never had a disability determination, an override for the application due date default of 45 days is needed. The application due date will be 90 days from the file date. Follow the steps in the system procedure instructions for this override.

Sometimes an application cannot be certified within 90 days because a disability determination is pending past the initial 90 days. In these cases, send Form H1247, Notice of Delay in Certification, to the applicant and the facility administrator, if applicable.

Applications for which delay-in-certification procedures have been followed are excluded from the delinquent count in timeliness reports. These applications are excluded for 180 days (90 days + 90-day extension); however, if the application is still pending on the 181st day, it will be counted as delinquent. Applications that cannot be certified within the normal 90-day limit, plus the 90-day extension, must be denied. A new application will be necessary to reconsider eligibility.

Revision 14-4; Effective December 1, 2014

An applicant for Social Security disability benefits is evaluated for both SSI Title XVI and RSDI Title II disability eligibility. HHSC determines Medicaid eligibility for retroactive coverage for up to:

• three months before the date of SSI application for a person who has been denied SSI; or
• two months before the month in which an SSI recipient's Medicaid coverage automatically begins.

In these cases, the medical records; Form H3034, Disability Determination Socio-Economic Report; and Form H3035, Medical Information Release/Disability Determination, should be imaged in the Texas Integrated Eligibility Redesign System (TIERS). DDU uses this information to make the final decision (disability or blindness) for the retroactive coverage months. DDU enters the disability determination in case comments and in the Disability Determination — DDU page in TIERS, which indicates the decision, including the date of onset of the disability or blindness.

Federal regulations prevent a state's disability determination to conflict with the RSDI Title II date of onset, and DDU cannot establish an earlier date of onset for RSDI Title II blindness or disability. As a result, deny an application based on the person not meeting blind (Not Blind) or disabled (Not Disabled) criteria when a person applies for Medicaid and the person:

• has unpaid or reimbursable covered Medicaid expenses during the retroactive coverage months prior to the application;
• has a date of onset for RSDI Title II blindness or disability based on Social Security Administration (SSA) query records; and
• the date of onset for RSDI Title II blindness or disability does not cover any of the retroactive coverage months prior to the application.

Note: Do not use the SSI Title XVI "Dsblty Onset Date" on the SSI Entitlement screen as the basis to establish blindness or disability for retroactive coverage.

Federal regulations prohibit a state from making a disability decision that conflicts with an SSA decision. DDU cannot make an independent decision until all appeals to SSA regarding the date of disability onset for both RSDI Title II and SSI Title XVI are settled.

Request medical records covering the period for which eligibility is being tested when:

• there is no date of onset for RSDI Title II disability; or
• 90 days have elapsed since the SSI/RSDI file date and SSA has not completed a disability determination.

Submit the following items for imaging to the Texas Health and Human Services Commission, P.O. Box 149027, Austin, TX 78714-9971:

• Medical records
• Form H3034
• Form H3035

Occasionally, Form 4116, Authorization for Expenditures, is required to provide payment to medical providers for submitting medical records. If Form 4116 is required, submit this form for imaging with the medical records, Form H3034 and Form H3035.

Revision 13-2; Effective June 1, 2013

DDU will enter the disability determination in TIERS case comments and in the Disability Determination – DDU page. This determination will include notification about the decision, including the date of onset of the disability or blindness and if the individual is permanently excused from any further medical review.

• Do not make a final eligibility decision until DDU has completed the Disability Determination – DDU page in TIERS and documented the decision in case comments.
• Medicaid cannot begin and the medical effective date cannot precede or be earlier than the first day of the month in which the onset of the disability or blindness occurred.
• Medicaid begin and end date for ME – A&D Emergency is date-specific. Medicaid does not occur in full month increments for this program.
• Before certifying a person under age 65 for Medicaid, the eligibility specialist must review case comments and the Disability Determination – DDU page to see if the individual has had a previous disability determination and/or is permanently excused. If documentation does not indicate that the individual is permanently excused, the eligibility specialist may contact DDU. The specialist must document in case comments concerning any previous disability determination decision.

Revision 13-2; Effective June 1, 2013

Some applicants for Medicaid in an institutional setting are former recipients of Medicaid.

If a person was certified for Medicaid in an institutional setting based on the medical decision for either disability or blindness reflected in TIERS case comments and documented on the Disability Determination – DDU page, continue to use the existing record to reinstate the Medicaid in an institutional setting, unless case comments indicates a review of the disability or blindness is needed.

In addition, if TIERS case comments and the Disability Determination – DDU page indicates the applicant is permanently excused from further medical review, staff can continue to use this decision for future ME-A and D-Emergency requests or applications.

Do not use the existing Disability Determination – DDU page to process an application in any other situations, except those mentioned above.

Revision 23-4; Effective Dec. 1, 2023

At each annual redetermination, review case comments or the “DDU” tab in the Texas Integrated Eligibility Redesign System (TIERS) Disability Determination logical unit of work (LUW). Determine if the disability or blindness decision is current or if the recipient is permanently excused from further medical review. If the determination is not current and the recipient is not excused from further review, complete a new Form H3034, Disability Determination Socio-Economic Report. Submit to the Disability Determination Unit (DDU) with Form H3035, Medical Information Release/Disability Determination, and current medical records before the required date of review.

Revision 09-4; Effective December 1, 2009

§358.207. Residence.

To be eligible for a Medicaid-funded program for the elderly and people with disabilities, a person must be a resident of the United States (U.S.) and the state of Texas.

(1) U.S. residence. The Texas Health and Human Services Commission (HHSC) follows 20 CFR §416.1603 in determining a person's U.S. residence.

(A) The U.S. residence requirement does not apply to:

(i) a child who is a citizen and is living with a parent who is a member of the U.S. Armed Forces assigned to permanent duty ashore outside the U.S.; or

(ii) to certain persons temporarily abroad for study.

(B) Once eligible for benefits, a person must maintain a presence in the U.S. in accordance with 42 U.S.C. §1382(f)(1). If a person has been outside the U.S. for 30 consecutive days, the person is not eligible for benefits until the person has been in the U.S. for 30 consecutive days.

(2) Texas residence. HHSC follows 42 CFR §435.403 in determining a person's state residence.

§358.215. Inmates of Public Institutions.

An inmate of a public institution, including a jail, prison, reformatory, or other correctional or holding facility, as defined in 42 CFR §435.1009 and §435.1010, is not eligible for Medicaid payment for Medicaid-covered services received while residing in the public institution.

§358.213. Resident of an Institution for Mental Diseases.

A person who lives in an institution for mental diseases must be 65 years of age or older to be eligible for a Medicaid-funded program for the elderly and people with disabilities.

Revision 09-4; Effective December 1, 2009

To be eligible for Medicaid, a person must be a resident of the U.S.

To be eligible for an MEPD program under Texas Medicaid, a person must be a resident of the state of Texas. The person must have established residence in Texas and must intend to remain in Texas.

Consider a person a resident of the U.S. and Texas if the person has:

• established an actual dwelling place within the geographical limits of the U.S. and Texas; and
• the intent to continue to live in the U.S. and Texas.

Accept the person's statement on the application or redetermination form regarding Texas residency.

Further evidence of Texas residency is required only if Texas residency is questionable. A person can prove residency by providing document(s) that indicate a Texas address. For example, sources of evidence could be from the following:

• Property, income or other tax forms or receipts
• Utility bills, leases or rent payment records

Revision 18-1; Effective March 1, 2018

A Medicaid recipient is not eligible for Medicaid for any month during all of which the person is outside of the U.S. If a person is outside of the U.S. for 30 or more days in a row, they are not considered to be back in the U.S. until they are back for 30 days in a row. A person may again be eligible for Medicaid in the month in which the 30 days end if they continue to meet all other eligibility requirements.

Note: The U.S. is considered the 50 States, the District of Columbia and the Northern Mariana Islands.

The period of absence begins with the day after the person's departure from the U.S. The period of absence ends for eligibility purposes:

• the day before the person's return to the U.S., if the time outside the U.S. is less than 30 consecutive days; or
• 30 consecutive days after return to the U.S., including a person newly arrived in the U.S. (that is, for the very first time), if the time outside the U.S. is 30 consecutive days or more.

Develop continuous presence in the U.S. if there is reason to believe the person has been outside the U.S. for 30 consecutive days or a full month.

If otherwise eligible, a person whose eligibility has been denied because of absence from the U.S. can be recertified effective with the day:

• following the 30th day of continuous presence in the U.S. after the person's return, if the time outside the U.S. was 30 consecutive days or more; or
• the person returned to the U.S., if the time outside the U.S. was a full calendar month, but less than 30 consecutive days (calendar month of February only).

 

D-3310 Exceptions to U.S. Presence

Revision 09-4; Effective December 1, 2009

The U.S. residence requirement does not apply to:

• a child who is a citizen and is living with a parent who is a member of the U.S. Armed Forces assigned to permanent duty ashore outside the U.S.; or
• to certain persons temporarily abroad for study.

Revision 12-3; Effective September 1, 2012

When a recipient moves, the recipient is required to report this change within 10 days to HHSC. A permanent change of address or residence is important for the following reasons:

• It is very important to receive and maintain current address and residence information on the recipient's record to ensure proper receipt of Medicaid. Processing a change of address (COA) or residence request promptly will help alleviate any problems affecting the recipient's Medicaid eligibility.
• A COA or residence request may indicate that a change in circumstances has occurred which may affect continuing Medicaid eligibility. For example, there may be changes in living arrangements, marital status, in-kind support and maintenance, and resources (for example, home ownership).

When a recipient wishes to visit another address within the state for more than a month, the recipient is required to report this change within 10 days to HHSC. If this COA is temporary, a temporary COA does not impact eligibility if the visit is for no longer than three months.

See Section F-3121, Intent to Return Policy.

Revision 09-4; Effective December 1, 2009

To be eligible for Texas Medicaid, a person must be a resident of the state of Texas; that is, the person must have established residence in Texas and must intend to remain in Texas.

 

D-3510 Intent to Return

Revision 11-4; Effective December 1, 2011

A visit to another state does not terminate Texas residence if the person intends to return when the purpose of the visit is completed.

If a Texas resident visits out of the state (but remains in the United States) with subsequent returns or expressions of intent to return, the person’s Texas residence is not interrupted. A recipient is responsible for requesting a temporary change of address because of an absence from the state. The recipient is also responsible for informing HHSC about the purpose, plans, date of departure and date of planned return.

If the recipient does not contact HHSC before departure, but HHSC learns about the recipient’s absence from some other source, treat this information as a reported change. Attempt to get the recipient’s out-of-state address. After receiving the out-of-state address, contact the recipient to determine whether the absence from the state is temporary, why the recipient left and when the recipient plans to return to Texas.

The length of out-of-state visits is not limited. Review the recipient’s situation every three months to determine where the recipient intends to live permanently.

If the recipient’s absence from the state is temporary and an annual review is scheduled, mail the redetermination packet directly to the recipient at the out-of-state address. If the nature of the recipient’s visit is questionable, additionally request the recipient to:

• restate the purpose of the absence; and
• indicate the recipient’s official permanent residence.

Review the recipient’s response on the redetermination packet as to residency and intent to remain a Texas resident. Redetermine eligibility based on the recipient’s usual living arrangement unless the recipient no longer indicates Texas residency with the intent to remain a Texas resident.

Reference: Chapter F, Resources, for treatment of a home and out-of-state property.

 

D-3520 No Intent to Return

Revision 09-4; Effective December 1, 2009

A recipient leaving the state with no declared intent to return, and without any evidence that would indicate plans to return, is considered to have moved from the state and Medicaid is denied immediately. If the recipient subsequently returns to the state and declares the intent to remain, Medicaid may be resumed if the recipient meets all other eligibility requirements.

D-3610 Interstate Requests for Assistance

Revision 09-4; Effective December 1, 2009

If a recipient is eligible for Medicaid in another state and receives Medicaid in that state, the person is not eligible for Medicaid from the state of Texas.

If a person is placed in an institution located in Texas by an agency of another state, the person remains a resident of the state that made the placement.

 

D-3620 Out-of-State Medicaid and Texas Medicaid Recipients

Revision 09-4; Effective December 1, 2009

Under certain conditions, HHSC makes vendor payment to out-of-state providers on behalf of Texas Medicaid recipients. An out-of-state provider must be contracted with Texas as a Medicaid provider in its own state to provide care or services to Medicaid recipients and the recipients must be eligible for Texas Medicaid for the time involved. No payment commitment can be made until all necessary forms have been completed.

An out-of-state provider can contact Texas' contracted Medicaid claims administrator, currently the Texas Medicaid and Healthcare Partnership (TMHP). TMHP's website for the Texas Medicaid Program is www.tmhp.com.

The provider should furnish as much information as possible about the recipient, including the recipient's full name, Texas Medicaid number, Social Security number, date of birth, date of admission and date of discharge.

Note: If the person receives SSI and intends to live in the other state, inform the person to notify the Social Security Administration immediately about the move.

 

D-3630 Texas Applicant Outside the State of Texas

Revision 09-4; Effective December 1, 2009

If a person from Texas wishes to apply for Medicaid while outside the state, the person should contact the other state's Medicaid agency. The other state's Medicaid agency determines whether:

• the person plans to live or visit in that state; and
• that state's Medicaid is available to the person.

If the other state's Medicaid agency determines that the person is not eligible for that state's Medicaid, the other state's Medicaid agency contacts HHSC.

HHSC sends the person an application to apply for Texas Medicaid.

When the completed application is returned, use the person's Texas address as the residence address and the out-of-state address as the mailing address. Consider the person as a resident of Texas for the month of application and for the retroactive coverage period if appropriate.

After eligibility is determined, a copy of the decision is sent to the other state's Medicaid agency.

 

D-3640 Applicant from Another State

Revision 09-4; Effective December 1, 2009

A person from another state may ask to apply for Medicaid in Texas. Although the opportunity to apply for Medicaid cannot be denied to another, ask the following questions to assist the person in determining whether an application in Texas is appropriate:

• Is the person visiting or does the person intend to live in Texas?
• Is the person receiving Medicaid from another state?
• Does the person want to receive Medicaid from Texas or from the other state?
• Has the person declared intent to live in Texas with the full knowledge that if the person is eligible for Medicaid in Texas, the person is not eligible to receive Medicaid from the other state?
• Is the person aware that if the person declares the intent to live in Texas and is certified for Medicaid in Texas, HHSC notifies the other state?

In some instances, a person might tentatively declare intent to live in Texas but is found to be ineligible for Medicaid in Texas. Be careful to avoid action that might jeopardize a person's continued eligibility for Medicaid from another state. Although a person might at first declare intent to live in Texas, the person might decide to continue receiving Medicaid from the other state (if the person learns of ineligibility for Medicaid in Texas). Consequently, the person might revoke the declaration of intent to live in Texas and keep the person's residence in the other state.

 

D-3650 Out-of-State Recipient Visiting Texas

Revision 09-4; Effective December 1, 2009

If a recipient who receives a money grant (TANF, general assistance, state supplementary payments to SSI) or Medicaid, including Medicare Savings Program benefits, from another state and applies for Medicaid in Texas, determine whether:

• the recipient intends to continue receiving the money grant or Medicaid from the other state; and
• Medicaid benefits are available to the recipient from that state.

Declaration to continue living in the other state — If the recipient declares the intent to continue living in the other state, the recipient is not eligible for Medicaid in Texas. Contact the out-of-state Medicaid agency to determine which services are covered and how providers file claims. Have the recipient inform any Texas Medicaid provider to send any claim to the out-of-state Medicaid agency in the recipient's state of residence.

Declaration to live in Texas — If a recipient who receives a money grant from another state (TANF, general assistance, state supplementary payments to SSI) makes a declaration of intent to live in Texas, this declaration does not automatically establish eligibility. Determine eligibility according to the requirements of the Texas Medicaid Program.

Impact on the medical effective date — If the intent to live in Texas is made by the recipient and the recipient meets Texas MEPD requirements, contact the out-of-state Medicaid agency of the recipient's former state of residence to determine the last day Medicaid claims will be paid by that state. The denial effective date is the last day for which the recipient 's former state of residence will pay Medicaid claims. This is not necessarily the denial effective date on the former state's computer system. The medical effective date for the recipient in Texas is no earlier than the day following the date the recipient 's former state of residence will pay Medicaid claims.

 

D-3660 SSI Recipient Visiting in Texas

Revision 16-3; Effective September 1, 2016

If an out-of-state SSI recipient indicates an intent to live in Texas, refer the recipient to a Social Security Administration (SSA) office. SSA makes the SSI residence determination. SSA will modify the SSI file indicating the new address. The change in the SSI file will trigger a change in the new address for the Medicaid file.

If the SSI recipient indicates a need for medical care during the month of the move to Texas, give the recipient Form H1300, Declaration of Texas Residency, and refer the recipient to an SSA office for verification of SSI status. SSA accepts Form H1300 via fax.

When the completed Form H1300 is returned, process under ME – Nursing Facility, to begin Medicaid coverage in Texas effective the day after the last date claims will be paid in the former state. Once the application has been disposed, Form H1027-A, Medicaid Eligibility Verification, covering the recipient's residence in Texas can be issued, if needed.

Example: An SSI recipient moves to Texas on Aug. 10 and needs medical care. After receipt of confirmation of SSI status for the month of August and verification from the former state that it will pay no Medicaid claims after Aug. 9, the eligibility specialist processes the application using ME – Nursing Facility for 8/10/YYYY through 8/31/YYYY and issues Form H1027 for those dates, if needed.

Note: Remember that Medicaid coverage in Texas may begin no earlier than the day after the last date claims will be paid by the former state.

If the request for coverage of medical care received in the month of the recipient's move to Texas is made during a subsequent month (or received in the month of the move, but the application is not disposed until the following month), the procedure is the same as above except that the application is processed using ME-SSI Prior for the month of move to Texas. In this instance, the medical effective date would be the first day of the month of move and the denial date would be the last day of that month. Do not issue Form H1027 for a past month. Instead, inform the recipient that Your Texas Benefits Medicaid ID card will be sent so that receipt is within seven to 14 days. The recipient must notify all providers of the added coverage for purposes of timely claims filing.

Example: An SSI recipient moves to Texas on May 24 and receives medical care on May 26. On June 15, the recipient requests assistance for that expense. After receipt of confirmation of SSI status for the month of May and verification from the former state that it will pay no Medicaid claims after May 23, the eligibility specialist processes the application using ME-SSI Prior for 5/1/YYYY through 5/31/YYYY. Inform the recipient that Your Texas Benefits Medicaid ID card will be sent so that receipt is within seven to 14 days, which the recipient must then use to notify provider(s) of Medicaid eligibility.

TIERS Procedures

Process as a manual SSI during the month of move. The medical effective date will be the first of the month.

Note: Even though the medical effective date precedes the actual date the recipient moves into the state, Texas medical claims would not have been incurred prior to the move date.

Revision 09-4; Effective December 1, 2009

In the following situations, the state in which the person resides is influenced by several factors.

• Under age 21 and not in an institutional setting. A person under age 21 who is not residing in an institutional setting is a Texas resident if the person is:
  • living in Texas more than temporarily;
  • living in another state when Texas has legal custody of the person; or
  • living in Texas, meets the blindness or disability criteria, and is MEPD eligible.
• Under age 21 and in an institutional setting.
  • If the parent(s) or legal guardian lives outside of Texas, the residence of an institutionalized person under age 21 is the state in which the parent or legal guardian states the institutionalized person is present, and intends to stay.
  • If the parents have abandoned the person and no legal guardian has been appointed, the person's residence is the state in which the institution is, if the authorized representative acting on behalf of the person in making an application for MEPD lives in that same state.
  • If the person is married, the person's residence is the institution's state.
• Age 21 or over and in an institutional setting.
  • The residence of an institutionalized person age 21 or over is the state in which the person is residing with the intent to remain.
  • If the person is incapable of indicating intent, the person's residence is determined in the same way as the residence of an institutionalized person under age 21.

Interstate institutional setting issue — If a person, regardless of his/her age, is placed in an institution located in Texas by an agency of another state, the person remains a resident of the state that made the placement.

Reminder: A person who lives in an institution for mental diseases must be age 65 or older to be eligible for an MEPD program.

Revision 21-4; Effective December 1, 2021

A person confined in a public institution, including a jail, prison, reformatory or other correctional or holding facility, is not eligible for Medicaid.;

Permanent Release

A person who enters a Medicaid certified long-term care facility, skilled nursing facility, nursing facility or intermediate care facility for people with an intellectual disability or related condition after a permanent release from a correctional facility is not considered to be in a public institution.

Related Policy

People Confined in a County Jail in Texas, D-3810

D-3810 People Confined in a County Jail in Texas

Revision 22-2; Effective June 1, 2022

When a Texas county jail reports a Medicaid recipient is confined for more than 30 days, suspend or terminate benefits.

If notified of the person’s confinement from a source other than a county jail in Texas, terminate the person’s Medicaid.

Suspension

Suspend Medicaid within two business days of receiving a report of confinement from a county jail for the following types of assistance (TOAs):

• TA 10, ME – Waivers
• TA 88, ME – Medicaid Buy-In for Children
• TP 03, ME – Pickle
• TP 14, ME – Community Attendant Services
• TP 18, ME – Disabled Adult Child
• TP 21, ME – Disabled Widow(er)
• TP 22, ME – Early Aged Widow(er)
• TP 23, MC – SLMB
• TP 24, MC – QMB
• TP 26, MC – QI-1

The suspension is effective the day after the report of confinement is received.

Provide a new reasonable opportunity period to submit documentation of citizenship or alien status if a person’s original reasonable opportunity period expires during the suspension period. The new reasonable opportunity period is the earlier of:

• 95 days from the date the reinstatement is disposed; or
• the last day of their current certification period.

Keep the original reasonable opportunity period if the person’s Medicaid coverage is reinstated before the reasonable opportunity period end date.

The TF0001, Notice of Case Action, generated at reinstatement will include the reasonable opportunity information to remind the person to submit documentation of citizenship or alien status.

Note: For couple cases, suspend Medicaid for the incarcerated person only. The spouse may continue to receive benefits, if eligible.

Reinstatement

Reinstate Medicaid that was suspended due to incarceration in a county jail within two business days of receiving notification from any source that a person has been released from a Texas county jail. To reinstate Medicaid:

• Perform individual inquiry. Determine if the person has suspended Medicaid.
• If Medicaid is suspended, perform a County Jail Release - Search. Determine if:
  • the person’s Medicaid was suspended due to confinement; and
  • there are months remaining in their original certification period.
• If yes, create a Process a County Jail Confinement/Release task for all active cases where the person was included before suspension. Enter the release information into TIERS on the County Jail Release - Details page.

Medicaid coverage is reinstated effective the date of the person’s release from the county jail for the remaining months of the original certification period. Form TF0001 is generated to notify the person of the reinstatement.

Consider the report of release as a change report for all other types of assistance. Determine if the person needs to be added to the other types of assistance.

If the person’s health care coverage terminated at confinement or the original certification period has ended, the person is not eligible for reinstatement. Send a Medicaid application to the person’s last known address.

Termination

Terminate Medicaid within two business days of receiving a report of confinement for the following TOAs:

• TA 12, ME – State Group Home
• TP 10, ME – State Supported Living Center
• TP 15, ME – Non-State Group Home
• TP 16, ME – State Hospital
• TP 17, ME – Nursing Facility
• TP 25, MC – QDWI
• TP 87, ME – Medicaid Buy In

Medicaid is terminated effective the day after HHSC receives the notification.

Related Policy

People confined in a Public Institution, D-3800
Reasonable Opportunity to Provide Verification of Alien Immigration Status, D-8841

Revision 09-4; Effective December 1, 2009

§358.327. Transactions Involving Agents.

(a) An action by a fiduciary agent is the same as an action by the person for whom the fiduciary agent acts.

(1) An asset held by a fiduciary agent for another person is not a countable asset to the fiduciary agent.

(2) An asset held by a fiduciary agent for another person is a countable asset to the person for whom the fiduciary agent acts, unless otherwise excludable.

(b) A person's resources are available if the resources are being managed by a legal guardian, representative payee, power of attorney, or fiduciary agent. If, however, a court denies a guardian or fiduciary agent access to the person's resources, the resources are not considered available to the person.

(1) If a person's guardianship papers do not show that a legal guardian is prohibited access, and if the court has not subsequently ruled a prohibition, the resources are considered available.

(2) A guardian's routine need to petition the court for permission to dispose of a person's resources is not a prohibition.

(3) When the court rules on a petition to dispose of a person's resources, resources are considered available only to the extent to which the court has made the resources available for the person's benefit.

 

D-4120 Transactions Involving Agents

Revision 15-4; Effective December 1, 2015

Agents act on the person's behalf to sign applications and redetermination packets. When a guardianship exists, only that person can act on the person's behalf to sign applications and redetermination forms.

Guardian of the estate. Under Section 1151.101 and 1151.151 of the Texas Estates Code, it is the duty of the guardian of the estate to take care of and manage the estate as a prudent person would manage the person's own property. The guardian of the estate collects all debts, rentals or claims due to the ward, enforces all obligations in favor of the ward, and brings and defends suits by or against the ward. Only the guardian of the estate can deal with resources.

Guardian of the person. Under Section 1151.051 of the Texas Estates Code, the guardian of the person has the:

• right to have physical possession of the ward;
• right to establish the ward's legal domicile;
• duty of care, control and protection of the ward;
• duty to provide the ward with clothing, food, medical care and shelter; and
• power to consent to medical, psychiatric and surgical treatment other than the in-patient psychiatric commitment of the ward.

For HHSC purposes, the guardian of the person can sign documents, represent the person at hearings, and deal with small amounts of money. The guardian of the person is like other authorized representatives in that they have the authority to protect the interests of the ward.

Under Section 1151.004 of the Texas Estates Code, a court may appoint the same person to be both guardian of the estate and guardian of the person. If there are two guardians, one of the estate and one of the person, then the eligibility specialist must examine the court orders establishing the guardianships to decide which is the most appropriate to represent the person with HHSC.

A person's resources are available to him if they are being managed by a legal guardian, representative payee, power of attorney or fiduciary agent. If, however, a court denies a guardian or agent access to the resources, HHSC does not consider the resources available to the person.

If a person's guardianship papers do not show that the legal guardian is prohibited access, and if a court has not subsequently ruled a prohibition, the person's resources are considered available. A guardian's routine need to petition the court for permission to dispose of a person's resources is not a prohibition. When the court rules on a petition to dispose of a person's resources, resources are considered available only to the extent to which the court has made them available for the person's benefit.

If a legal guardian exists, obtain a copy of the guardianship or power of attorney document. Identify a fiduciary relationship by the way in which a resource is styled. A bank account established in two names connected by "for" or "by" indicates a fiduciary relationship. Another indication is an account established in two names with the designation of "representative payee" next to one of the names, or an account with the designation "special."

 

D-4121 Examples

Revision 15-4; Effective December 1, 2015

• A person has resources valued at $1,300, which are being managed by his son. The son claims that as the power-of-attorney, he is the only one who has access to the funds.
  
  Because a power-of-attorney is given voluntarily, and management of the resources is with the person's consent and for his benefit, this person's resources are available to him.
• Another person's parents used their own funds to purchase a certificate of deposit (CD) for him. The CD was issued as "Person's Name, by Parents' Names, Joint Representative Payees."
  
  The CD is an available resource to this person, because the designation indicates that the parents are acting in a fiduciary capacity in controlling funds belonging to him, regardless of the fact that the parents paid the purchase price.
• A third person recently left the hospital and entered a long-term care facility. She is in a coma, and there are no known living relatives or friends. After the person had a stroke, her landlady looked through the person's papers and found a $600 term life insurance policy and a checkbook showing a balance of $3,840.65. The eligibility specialist verified the bank balance.
  
  Although court action to appoint a guardian would be necessary to allow disposal of the person's excess funds, the resources are available to her. Until a court judges the person to be incompetent and unable to handle her affairs, the eligibility specialist cannot assume that the court will prohibit an appointed guardian from disposing of any of the funds in the checking account. This person is ineligible because of excess resources.

Revision 09-4; Effective December 1, 2009

Whether or not a person is married or has children has some bearing on the treatment of income and resources in determining Medicaid eligibility, both in a community setting or an institutional setting.

If the living arrangement is in a community setting, deeming of income and resources affects the budget.

When the living arrangement is in an institutional setting, spousal impoverishment and dependant allowances may have a bearing on the budget. This chapter focuses on the community setting. Chapter J covers spousal impoverishment policy for institutional settings.

 

D-4210 Deeming

Revision 09-4; Effective December 1, 2009

When neither a person's spouse nor child is in an institutional setting, deeming from spouse-to-spouse or parent-to-child applies in household situations. Only those residing in the household are considered part of the household for deeming purposes.

Exceptions to deeming:

• A person is in an institutional setting, including receiving services through a Home and Community-Based Services waiver program.
• Spouse-to-spouse and parent-to-child deeming do not apply in situations where a family does not have a residence. For example, if a family lives in a car because they cannot afford shelter, neither spouse-to-spouse nor parent-to-child deeming would apply.
• A person is not a member of the household if he/she is absent from home for a period that is not a temporary absence (for example, confinement in a public institution). Consider absences due to active duty military assignments as temporary.
• If a child is born in an institution (for example, a hospital), the child is not a member of the household until the month after the month the child goes home.
• Deeming does not apply when either an eligible person or an ineligible spouse is in an institutional setting, even when sharing a room.

Deeming does apply in noninstitutional care situations (for example, adult foster care), if the eligible person is living with an ineligible spouse.

 

D-4211 Spouse

Revision 15-4; Effective December 1, 2015

For Medicaid purposes, whether two people are married governs whether:

• couple computation rules apply;
• spousal or parental deeming applies; and/or
• spousal impoverishment rules apply.

Note: Someone who is married cannot be a child for Medicaid purposes.

Accept a person's allegation that he or she is married unless:

• the person would otherwise be considered a child for Medicaid purposes;
• there is evidence to the contrary; or
• the allegation could be self-serving.

Normally, for Medicaid purposes, two people are married as of the first moment of the month. If a marital relationship ends by death, divorce or annulment in the same month it began, treat the marriage as if it had never existed. Otherwise, the termination of marriage is effective the month after the month of death, divorce or annulment.

In Texas, there are three ways to terminate a marriage:

• Void marriages — A determination that the marriage could not have existed because of one of the following legal impediments: the parties married within a prohibited degree of consanguinity (for example, nephew or niece), or at least one party has a previous marriage that has not been resolved. Void marriages do not require a lawsuit, and the marriage may be declared void in a collateral action (for example, contest of will). A legal marriage between parties never existed.
• Annulments — Also called voidable marriages. Grounds for annulment include, but are not limited to, marrying under the influence of drugs/alcohol, at least one party being incapacitated or the marriage being coerced. Annulments require court action, but under common law, an annulment is retroactive to the date of marriage.
• Divorce — Requires court action, and the marriage is dissolved effective the date of the divorce decree.

Persons with void marriages or who have obtained a court annulment of their marriages are treated as though they were always individuals. In the instance of a divorce, persons are considered married through the end of the calendar month in which the divorce is issued.

For spouse-to-spouse deeming purposes, consider the following in the budget:

• the eligible individual; and
• the spouse; or
• any of the couple's children (or children of either member of the couple).

 

D-4212 Child

Revision 09-4; Effective December 1, 2009

A child is someone who is neither married nor the head of a household, and is:

• under age 18; or
• under age 22 and a student.

Eligible child for deeming purposes. For deeming purposes, an eligible child is a natural or adopted child under age 18 who lives in a household with one or both parents, is not married and is eligible for Medicaid.

Deeming to such an eligible child no longer applies beginning the month following the month the child attains age 18.

A person attains a particular age on the day preceding the anniversary of his/her birth. Deeming applies in the month of attainment of age 18 regardless of whether an application filed that month is filed before or after the day of attainment.

Ineligible child for deeming purposes. For deeming purposes, an ineligible child must:

• be either a natural or adopted child of:
  • an eligible person or the eligible person's spouse; or
  • an ineligible parent or the ineligible parent's spouse;
• live in the same household with an eligible person;
• not be married; and
• be either:
  • under age 18; or
  • under age 22 and a student.

Verification and Documentation Guidelines

• Verify an eligible child's date of birth and document the file. Accept the allegation of an ineligible child's age, absent evidence to the contrary.
• Accept a person's statement that a parent-child relationship exists.
• If a child under age 18 alleges to have no earnings, accept the allegation of student status. If an eligible or ineligible child under age 18 (or a student child age 18 to 22) alleges student status and earnings, verify school attendance and document.
• Document an eligible child's income and verify when necessary following general income rules for an eligible person.
• If any ineligible children in the household have income, and the ineligible spouse or parent has income that is subject to deeming, verify and document the ineligible child's income. However, if the alleged income exceeds the amount of the ineligible child allocation (that is, no ineligible child allocation applies for that ineligible child), document the allegation, but do not verify the income unless the income would be subject to the student child earned income exclusion. Accept an allegation when any ineligible child living in the household has no income.

 

D-4213 Parent

Revision 09-4; Effective December 1, 2009

A parent whose income and resources are subject to deeming is one who lives in the same household with an eligible child and is:

• a natural or adoptive parent of the child; or
• the spouse of the natural or adoptive parent (“stepparent”) who lives in the same household as the natural or adoptive parent.

Deeming applies from a parent to a child when they live together in the same household, except in a Home and Community-Based Services waiver situation. Deem a parent's income and resources to an eligible child beginning the month:

• after the month the child comes home to live with the parent(s) (for example, the month following the month the child comes home from the hospital);
• of birth if a child is born in the parent's home;
• after the month of adoption (the month of adoption is the month the adoption becomes final); or
• after the month of a parent’s marriage (that is, when a natural or adoptive parent marries) or the month after the month a parent begins living in a “holding out” relationship.

Generally, the same deeming rules that apply to a parent also apply to the spouse of a parent (a stepparent).

Exceptions: Do not deem the income or resources of a stepparent living with an eligible child if the natural or adoptive parent:

• is deceased;
• is divorced from the stepparent; or
• has permanently left the household.

Treat any absence by a natural or adoptive parent as permanent unless it is considered a temporary absence, such as military duty.

For parent-to-child deeming purposes, consider the following in the budget:

• the eligible child;
• the eligible child's parent(s); and
• other children of the parents.

Note: A person whose parental rights have been terminated due to adoption no longer meets the definition of “parent” for Medicaid purposes. This remains true even if the adopted child later lives in the same household with the former parent.

Refer cases involving adopted Native American children who return to the household of a former parent to your regional attorney. The parent-child relationship in these cases is governed by tribal law and likely requires further legal interpretation.

Revision 09-4; Effective December 1, 2009

§358.203. Citizenship and Qualified Alien Status.

(a) In accordance with 42 CFR §435.406, to be eligible for a Medicaid-funded program for the elderly and people with disabilities (MEPD), a person must be:

(1) a citizen or national of the United States (U.S.);

(2) an alien who entered the U.S. before August 22, 1996, who has lived in the U.S. continuously since entry, and who meets the definition of a qualified alien at 8 U.S.C. §1641; or

(3) an alien who entered the U.S. on or after August 22, 1996, who has lived in the U.S. continuously since entry, and who meets the definition of a qualified alien at 8 U.S.C. §1641 with the eligibility limitations in 8 U.S.C. §1612 and §1613.

(b) A person must provide proof of eligibility under subsection (a) of this section that establishes both identity and citizenship or alien status, unless the person:

(1) receives Supplemental Security Income (SSI) or has ever received SSI and was not denied due to citizenship;

(2) is entitled to or enrolled in any part of Medicare, as determined by the Social Security Administration (SSA); or

(3) is entitled to federal disability benefits based on SSA disability criteria.

Revision 09-4; Effective December 1, 2009

An individual may become a U.S. citizen by birth or naturalization.

For Medicaid eligibility purposes, a person meets the citizenship requirement if he/she:

• was born in one of the 50 states, the District of Columbia, Puerto Rico, Guam, Virgin Islands of the U.S., American Samoa, Swains Island or the Northern Mariana Islands;
• was born to a U.S. citizen living abroad; or
• is a naturalized U.S. citizen.

The Immigration and Nationality Act of 1952 provides that a child of unknown parentage found in the U.S. while the child is under five years old is a citizen of the U.S. unless it is shown (before the child is 21) that the child was not born in the U.S.

Note: While all U.S. citizens are U.S. nationals, persons born in American Samoa or Swains Island are technically considered non-citizen U.S. nationals. For purposes of Medicaid eligibility, "citizenship" includes these non-citizen nationals when discussed in this section. A person born in the Independent State of Samoa (formerly known as Western Samoa) is not a U.S. national and therefore is not included in the discussion of citizenship in this section.

 

D-5210 Child Citizenship Act of 2000

Revision 13-4; Effective December 1, 2013

The Child Citizenship Act (CCA) of 2000 amended the Immigration and Nationality Act to provide derivative citizenship to certain foreign-born children of U.S. citizens. This applies to individuals who were under age 18 on Feb. 27, 2001, and anyone born since that date. Children included in the provisions of the CCA are:

• adopted children meeting the two-year custody requirement,
• orphans with a full and final adoption abroad or adoption finalized in the U.S.,
• biological or legitimated children, or
• certain children born out of wedlock to a mother who naturalizes.

The CCA provides that foreign-born children who meet the conditions below automatically acquire U.S. citizenship on the date the conditions are met. They are not required to apply for a certificate of naturalization or citizenship to prove U.S. citizenship. These conditions are that the child:

• has at least one parent who is a U.S. citizen (whether by birth or naturalization);
• is under age 18;
• has entered the U.S. as a legal immigrant;
• if adopted, has completed a full and final adoption; and
• lives in the legal and physical custody of the U.S. citizen parent in the U.S.

Adopted children automatically become U.S. citizens if they meet all of the above conditions and were:

• adopted under the age of 16 and have been in the legal custody of and resided with the adopting parent or parents for at least two years;
• adopted while under the age of 18, have been in the legal custody of and resided with the adopting parent or parents for at least two years, and are siblings of another adopted child under age 16;
• orphans adopted while under the age of 16 who have had their adoption and immigration status approved by U.S. Citizenship and Immigration Services (USCIS) (need not have lived with the adoptive parents for two years); or
• orphans adopted under the age of 18 who have had their adoption and immigration status approved by USCIS and are siblings of another adopted child under age 16 (need not have lived with the adoptive parents for two years).

USCIS, under the Department of Homeland Security, is the federal agency formerly known as the Immigration and Naturalization Service (INS) that is responsible for citizenship and lawful immigration to the U.S.

 

D-5220 Compact of Free Association (COFA) Citizens

Revision 21-3; Effective September 1, 2021

The Compacts of Free Association (COFA) are agreements between the United States and three independent states:

• Republic of the Marshall Islands (RMI);
• Federated States of Micronesia (FSM); and
• Republic of Palau (PAL).

Under these agreements, COFA citizens have a special status with the U.S. which allows them to enter the country, work and acquire a Social Security number without obtaining an acceptable immigration status.

COFA citizens are considered qualified non-citizens and are exempt from the five-year waiting period and the seven-year limited period. They are eligible for full Medicaid if they meet all other eligibility requirements.

Acceptable verification of immigration status for COFA citizens includes:

• I-94 or I-766 with the following Class of Admission (COA) Codes:
  • CFA/RMI – Citizen of Republic of the Marshall Islands (RMI) due to the Compact of Free Association
  • CFA/FSM – Citizen of the Federated States of Micronesia (FSM)
  • CFA/PAL – Citizen of the Republic of Palau
• I-766 Employment Authorization Document (EAD) with the following Category Code:
  • A-08 Citizen of the Marshall Islands, Micronesia or Palau admitted as a nonimmigrant
• An unexpired passport with annotations “CFA/RMI,” “CFA/FSM” or “CFA/PAL.”

Related Policy

Qualified Aliens Not Subject to a Waiting Period or Limited Period, D-8320

Revision 13-2; Effective June 1, 2013

A person applying for or receiving Medicaid and declaring to be a U.S. citizen or national must provide evidence of citizenship. Documentation must establish both citizenship and identity.

The following primary evidence documents are acceptable as proof of both citizenship and identity:

• U.S. passport
• Certificate of Naturalization (N-550 or N-570)
• Certificate of U.S. Citizenship (N-560 or N-561)

If a person does not provide one of these primary evidence documents that establish both U.S. citizenship and identity, the person must provide one document that establishes:

• U.S. citizenship; and
• identity.

Levels of evidence of citizenship are documents that establish citizenship based on reliability of evidence. See Appendix V, Levels of Evidence of Citizenship and Acceptable Evidence of Identity Reference Guide. Begin with the second level and continue through the levels to explore the most reliable source of documentation of citizenship available. If a document from the second level is not used, include in the case record the reason why a more reliable source of documentation of citizenship is not available.

Example: If a hospital record of birth is used to document citizenship (third level), include in the case record a reason why a source from the second level is not used – "None of the second level of evidence of citizenship documents are available."

Note: When using the levels of evidence of citizenship, the same document cannot be the source to verify both citizenship and identity.

Example: If a person provides a birth certificate to verify citizenship, the person must provide a document other than a birth certificate to verify identity.

Note: Affidavits are to be used only as a last resort if the person is unable to provide any other documentary evidence of citizenship.

Criteria for acceptable affidavits:

• The person applying for or receiving Medicaid or the person's authorized representative must provide an affidavit explaining why documentary evidence does not exist or cannot be readily obtained.
• Two adults, regardless of the blood relationship to the person, must each complete an affidavit.
• The two adults must attest that they have proof of their own citizenship and identity. These adults are not required to submit proof of citizenship and identity.
• The two adults must provide any available information explaining why documentary evidence establishing the person's claim of citizenship does not exist or cannot be readily obtained.
• Affidavits must be signed under penalty of perjury.

Form H1097, Affidavit for Citizenship/Identity, incorporates the required criteria.

Documentation of citizenship and identity is a one-time activity. Once documentation of citizenship is established and documented in the case record, do not request again even after a break in eligibility. The documentation must be available and the case information must not be purged.

If the individual has a Social Security number (SSN), use Social Security Administration (SSA) records to verify citizenship by submitting a citizenship verification request via Wire Third-Party Query (WTPY). If the WPTY response indicates that citizenship is verified, no additional action is required. If the WTPY response indicates that citizenship is not verified and the individual is not exempt from providing verification of citizenship, allow the individual a WTPY Citizenship Resolution Period using policy in D-5320, Using Wire Third-Party Query (WTPY) to Verify Citizenship.

If the individual has applied for an SSN but has not been issued one and:

• additional information is required to determine eligibility, request the additional information and verification of citizenship. Allow the individual 10 days to provide proof; or
• no other information is required to determine eligibility, allow the individual a period of reasonable opportunity to provide the verification using policy in D-5500, Reasonable Opportunity. If a reasonable opportunity period has been provided, citizenship must be verified before certifying for Medicaid.

After allowing reasonable opportunity or a WTPY Citizenship Verification Resolution Period, if the applicant or recipient refuses or fails to provide proof, deny the individual until proof is provided.

If all applicants or recipients in the household refuse or fail to provide proof of citizenship, deny the Eligibility Determination Group (EDG).

Note: If a person declares U.S. citizenship but cannot provide documentation, do not certify the person for ME-A and D-Emergency.

 

D-5310 Exceptions to Documentation of Citizenship and Identity Requirement

Revision 13-1; Effective March 1, 2013

The following individuals are not required to provide evidence of identity and citizenship when they claim to be U.S. citizens or U.S. nationals and are:

• active SSI recipients.
• denied SSI recipients. If the State Data Exchange (SDX) contains the needed information to verify U.S. citizenship. Use SDX as a valid documentation source of both citizenship and identity when the denial is for any reason other than citizenship. SDX action code N13 is the denial code for citizenship.
• determined to be entitled to or enrolled in Medicare Part A or B. This includes persons determined disabled for Social Security benefits who are in the 24-month period before receiving Medicare.
• receiving Social Security Disability Insurance (SSDI) benefits based on their own disability.
• in foster care and assisted under Title IV-B of the Social Security Act, and are beneficiaries of foster care maintenance or adoption assistance payments under Title IV-E of the Social Security Act.

Note: Neither the ineligible spouse of a person applying for Medicaid nor a parent applying for a child are required to provide evidence of citizenship and identity.

 

D-5320 Using Wire Third-Party Query (WTPY) to Verify Citizenship

Revision 13-2; Effective June 1, 2013

If an applicant has an SSN, use WTPY to verify citizenship. WTPY will return a response indicating that citizenship is verified or not verified for the individual.

If the WTPY response comes back with Codes A or C indicating citizenship is verified, take no further action unless the response also comes back with an indication of death (Code C). If this occurs, treat the death information as a change.

If the WTPY response is returned with any other code indicating that citizenship is not verified and the individual is not exempt from providing verification (see D-5310, Exceptions to Documentation of Citizenship and Identity Requirement), take the following actions:

• Review the information entered into the WTPY request with the information provided by the applicant/recipient. If a typographical error is found, submit a new WTPY request with the correct information.
• If no typographical errors are found, contact the applicant/recipient by phone to ensure the information provided is accurate. If new information is provided, submit another WTPY request with the correct information. Note: Update the case record with the correct information.
• If unable to verify citizenship via WTPY, certify the individual. Allow a WTPY Citizenship Verification Resolution Period to give the individual additional time to provide verification of citizenship using sources found in D-5300, Acceptable Documentation of Citizenship and Identity. The WTPY Citizenship Verification Resolution Period begins with the date the TF0001, Notice of Case Action, is generated.
• Generate Form TF0001 to inform the individual of the WTPY Citizenship Verification Resolution Period. TF0001 informs the individual citizenship verification is needed and lists the names of each individual who must provide citizenship verification and the due date.

The day after the WTPY Citizenship Verification Resolution Period expires, TIERS will generate an alert that will create a task. Deny the individual if he/she has not provided citizenship verification.

Applicants requesting three months prior Medicaid coverage must provide citizenship verification before prior coverage can be provided.

If the applicant was denied and later reapplies:

• Do not allow another WTPY Citizenship Verification Resolution Period to clear discrepancy. This includes situations in which an individual only received a portion of the WTPY Citizenship Verification Resolution Period. Examples: The individual moved out of state before the end of the 95-day period or an individual was added to an existing case and the case has a review due before the end of the 95-day period.
• Allow a WTPY Citizenship Verification Resolution Period to provide verification of citizenship if the individual never received the WTPY Citizenship Verification Resolution Period.
• Do not allow a WTPY Citizenship Verification Resolution Period for individuals who already received reasonable opportunity to provide proof of citizenship.

Revision 09-4; Effective December 1, 2009

Notify a person applying for Medicaid about the requirement to provide proof of citizenship and identity. A person receiving Medicaid must also be notified at their next annual redetermination, if proof of citizenship and identity is not already in the case record.

Use Appendix XV, Notification to Provide Proof of Citizenship and Identity, to provide information about the requirement and some of the common acceptable sources of documentation of citizenship and identity.

Add a copy of Appendix XV to each application and redetermination packet. If documentation is already in the case record (for example, SOLQ/WTPY showing Medicare entitlement or enrollment), do not add a copy of Appendix XV to the application or redetermination packet.

Revision 09-4; Effective December 1, 2009

Inform an applicant or recipient of the reasonable opportunity to provide documentation of citizenship and identity. The reasonable opportunity to provide is different for applicants and recipients. Case action will be different if the person indicates that acceptable documentation does not exist, as opposed to refusing to furnish the documentation.

 

D-5510 Initial Request at Time of Application

Revision 14-4; Effective December 1, 2014

Allow an applicant a reasonable opportunity to provide documentation. If the person makes a good faith effort to provide documentation of citizenship and is unable to locate or does not provide the documentation by the application due date, but meets all other eligibility criteria, do not deny the application based on the lack of documentation of citizenship. If the applicant meets all other eligibility factors except for verification of citizenship, do not delay certifying the application. Form TF0001, Notice of Case Action, instructs the applicant to submit documentation of citizenship within 95 days for each of the individuals listed on the form.

If the person refuses to provide documentation of citizenship within the 95 days, deny the application based on failure to furnish.

 

D-5520 Initial Request at Time of Redetermination

Revision 09-4; Effective December 1, 2009

Reminder: Because Medicare is one of the eligibility criterion for Medicare Savings Programs (MSP), documentation of citizenship is not required for MSP.

If proof of citizenship and identity is not in the case record at the time of redetermination, allow the Medicaid recipient a reasonable opportunity to provide documentation. If the person is making a good faith effort to provide documentation of citizenship and identity and is unable to locate or does not provide the documentation, do not deny eligibility based on the lack of documentation for citizenship or identity at this complete redetermination. Send a notice to the person upon completion of the redetermination informing the person that documentation must be provided by the next complete redetermination in order to continue receiving benefits.

If the person refuses to provide documentation of citizenship and identity, deny based on failure to furnish.

If a Medicaid recipient is denied for failing to provide proof of documentation of citizenship after a reasonable opportunity to provide is given, and the person later reapplies, consider the person as a new applicant when allowing a reasonable opportunity to provide documentation of citizenship and identity.

Revision 09-4; Effective December 1, 2009

If a person is unable to provide documentary evidence of citizenship and identity in a timely manner because of incapacity of mind or body or the lack of an authorized representative to assist, assist the person in obtaining documentary evidence of citizenship and identity by referring the person to appropriate entities.

The following is a nonexclusive list of entities that may be able to provide assistance:

• Department of Family and Protective Services, Adult Protective Services
• Legal Aid
• Social Security Administration
• 2-1-1

Dialing 2-1-1 will connect persons with community-based organizations that may be able to help.

For persons born out of state, some sources to obtain a birth certificate are:

• birthcertificate.com;
• vitalchek.com; and
• usbirthcertificate.net or its toll free number, 1-888-736-2692.

When assisting a person in providing documentary evidence of citizenship and identity, request available documents, regardless of the level of evidence. Ensure the case record comments address the situation.

Revision 09-4; Effective December 1, 2009

§358.209. Social Security Number.

In accordance with 42 CFR §435.910, a person must give his or her social security number to the Texas Health and Human Services Commission as a condition of eligibility, except as provided in §358.205(c) of this subchapter (relating to Alien Status for Treatment of an Emergency Medical Condition).

§358.205. Alien Status for Treatment of an Emergency Medical Condition.

(c) An undocumented non-qualifying alien applying for Medicaid for the treatment of an emergency medical condition is exempt from providing proof of alien status or providing a Social Security number as described in 42 CFR §435.406(b).

§358.217. Application for Other Benefits.

To be eligible for a Medicaid-funded program for the elderly and people with disabilities, a person must apply for and obtain, if eligible, all other benefits to which the person may be entitled, in accordance with 42 U.S.C. §1382(e)(2).

Revision 14-2; Effective June 1, 2014

As a condition of eligibility, a person must furnish HHSC with his/her Social Security number (SSN). If the person is married, the person must also provide his/her spouse's SSN.

State office uses two tape exchanges with the Social Security Administration (SSA) to verify the person’s SSN.

Sources for verification of an SSN are:

• SOLQ or WTPY;
• Social Security card; and
• verification of a Medicare number with suffix A, J1, M, S or T.

The applicant should be given a reasonable opportunity to provide an SSN.

 

D-6210 When a Person Does Not Have an SSN

Revision 11-4; Effective December 1, 2011

Explain to the person the necessity and the procedure for obtaining a Social Security number (SSN) if the person does not have one. Document the explanation in the case record.

Give the person or authorized representative notice that an SSN must be obtained by the first redetermination. This notice can be on the eligibility letter or on Form H1020, Request for Information or Action. The person must apply for and secure an SSN by the redetermination date.

Complete Form H1106, Enumeration Referral, which is found in the Texas Works (TW) Handbook. Upon receipt of Form H1106, the Social Security Administration (SSA) processes an SSN application.

If necessary, give SSA-5, Application for a Social Security Number, to the person and assist the person in completing the SSA-5. Inform the person to forward the SSA-5 to SSA with proof of his/her age, identity and citizenship (or lawful admission to the U.S.).

Grant eligibility at application, if otherwise eligible, pending receipt of an SSN. Tell the person to inform HHSC as soon as the SSN is received. Upon receipt, enter the SSN in the system of record.

At the first redetermination, verify that the person applied for an SSN if the person cannot provide an SSN. Failure of the person or authorized representative to follow through and secure an SSN is grounds for denial at the first redetermination. Document the circumstances of the denial in the case comments.

Revision 09-4; Effective December 1, 2009

Medicaid is intended to be a program of last resort. Therefore, it is important to assess the other benefits for which a person may be eligible based on the person's own activities or on indirect qualifications through family circumstances.

If a person is not receiving potential benefits, notify the person in writing of the requirement to apply for and comply with the application requirements of the other benefit(s).

A person is not eligible for Medicaid if:

• HHSC informs the person on a written, dated notice of his/her potential eligibility for other benefits; and
• the person does not take all appropriate steps to apply for the benefit within 30 days of receipt of such notice.

The notice informs the person or authorized representative that the person must take all appropriate steps to pursue eligibility for other benefits within 30 days of receipt of such notice. Appropriate steps include:

• applying for the benefit; and
• providing the other benefit source with the necessary information to determine eligibility for the benefit.

D-6310 Other Benefits Subject to Application Requirement

Revision 09-4; Effective December 1, 2009

"Other benefits" includes any payments for which a person can apply that are available to that person on an ongoing or one-time basis of a type that includes annuities, pensions, retirement benefits or disability benefits, including:

• RSDI Title II benefits;
• veterans' pension and compensation payments;
• retirement benefits;
• workers' compensation payments;
• pensions; and
• unemployment insurance benefits.

These benefits are common in that they:

• require an application or similar action;
• have conditions for eligibility; and
• make payments on an ongoing or one-time basis.

See D-6340 through Section D-6380 for details regarding benefits subject to the application requirement.

D-6320 Other Benefits Exempt from Application Requirement

Revision 09-4; Effective December 1, 2009

"Other benefits" exempt from the requirement to apply for other benefits are:

• Temporary Assistance for Needy Families (TANF);
• general public assistance;
• Bureau of Indian Affairs general assistance;
• victims' compensation payments;
• other federal (other than SSI), state, local or private programs that make payments based on need; and
• earned income tax credits.

D-6330 Payments That Are Not Other Benefits

Revision 09-4; Effective December 1, 2009

"Other benefits" do not include:

• payments that a person may be eligible to receive from a fund established by a state to aid victims of crime; or
• payments such as child support, alimony and accelerated life insurance.

D-6340 Supplemental Security Income (SSI)

Revision 09-4; Effective December 1, 2009

If a person who has no income applies for Medicaid with HHSC, refer that person to the Social Security Administration (SSA) for SSI benefits. SSI eligibility will provide a greater benefit to the person by allowing the person to receive a cash benefit as well as Medicaid.

Exception: Process the application and do not refer a person who has no income to SSA for SSI if the application is for Medicaid coverage for:

• retroactive months for a deceased person or based on an SSI application; or
• treatment of an emergency medical condition.

D-6341 Reserved for Future Use

Revision 19-4; Effective December 1, 2019

D-6350 Veterans Benefits

Revision 09-4; Effective December 1, 2009

The most common types of benefits from the U.S. Department of Veterans Affairs (VA) are:

• pension;
• compensation;
• educational assistance;
• aid and attendance allowance;
• housebound allowance;
• clothing allowance;
• payment adjustment for unusual medical expenses;
• payments to Vietnam veterans' children with spina bifida; and
• insurance payments for disability insurance and life insurance.

Explore the possibility of receipt of, or potential eligibility for, a VA benefit when it appears that a person is:

• a veteran;
• the child or spouse of a disabled or deceased service person or veteran;
• an unmarried widow or widower of a deceased service person or veteran; or
• the parent of a service person or veteran who died before Jan. 1, 1957, from a service-connected cause.

A person who is potentially eligible for some VA benefits must apply for those benefits. When referring a person to the VA, recommend that the person call the VA first to obtain information on application requirements and proof the person may need to bring.

D-6351 VA Pension or Compensation

Revision 10-1; Effective March 1, 2010

Refer a person for VA pension payments (based on a nonservice-connected disability) if all of the following conditions are met:

• The veteran or deceased service member served at least 90 days, at least one of which was during a wartime period (see D-6352, VA Wartime Periods).
• The person being referred is a veteran, surviving spouse or surviving child.
• The person has not alleged, in a signed statement, having previously applied for the Department of Veterans Affairs Improved Pension Plan (VAIP).

Refer the person for VA compensation payments if the veteran or deceased service person suffered a service-connected disability (even though minor) or died.

Refer a person for VA payment increases for medical expenses. However, do not monitor for the person’s compliance to apply for other benefits when it is to increase the VA payment for medical expenses. These VA payment increases for medical expenses are known as aid and attendance, housebound benefits or additional payments for unusual medical expenses and are considered exempt payments that do not affect eligibility or co-payment.

See the following references:

• E-1710, Medical Care and Services That are Not Income
• E-4315, VA Aid and Attendance and Housebound Payments
• B-8430, Special Reviews

Exceptions:

• Do not refer a person who has been eligible for a VA pension since before 1979.
• Do not refer a person who is receiving the $90 VA pension in an institutional setting.

See the following references:

• E-4311.1, 1979 VA Pension Plan
• E-4311.2, $90 VA Pension and Institutional Setting

D-6352 VA Wartime Periods

Revision 14-1; Effective March 1, 2014

The wartime periods are:

War	Time Periods
World War I	Apr 6, 1917 to Nov 11, 1918
World War II	Dec 7, 1941 to Dec 31, 1946
Korea	Jun 27, 1950 to Jan 31, 1955
Vietnam (served in the Republic of Vietnam)	Feb 28, 1961 to Aug 4, 1975
Vietnam (served other than in the Republic of Vietnam)	Aug 5, 1964 to May 7, 1975
(Persian) Gulf War	Aug 2, 1990 through a date to be set by law or presidential proclamation (per VA)
Operation Enduring Freedom (Afghanistan) and Operation Iraqi Freedom	2001 to present  Note: This war period is not yet listed on the VA's website. Refer person to VA Benefit Counselor at 1-800-827-1000.

D-6353 VA Payments for Dependents

Revision 09-4; Effective December 1, 2009

The VA may take a dependent's needs into account in determining a pension. Usually, however, the VA does not make a pension payment directly to a dependent during the lifetime of the veteran. Instead, the amount of the veteran's basic pension is increased if the veteran has dependents.

Augmented VA payment — A VA pension payment that has been increased for dependents is an augmented VA payment. For Medicaid purposes, the augmented benefit includes a designated beneficiary's portion and one or more dependents' portions.

Apportioned VA payment — A VA compensation payment made directly to the dependent of a living veteran is an apportioned payment. Apportionment is direct payment of the dependent's portion of VA benefits to a dependent spouse or child. The VA decides whether and how much to pay by apportionment on a case-by-case basis. Apportionment reduces the amount of the augmented benefit payable to the veteran or veteran's surviving spouse.

D-6354 Requirement to Apply for Apportionment of Augmented VA Benefit

Revision 09-4; Effective December 1, 2009

To be eligible for Medicaid, a dependent of a veteran must apply for apportionment (direct payment) of an augmented VA benefit if the dependent specifically:

• is the spouse or child of a living veteran, or the child of a deceased veteran with a surviving spouse, and the veteran or surviving spouse receives VA compensation, pension or educational benefits;
• does not reside with the designated beneficiary (that is, the veteran or the veteran's surviving spouse); and
• has not been denied apportionment since living apart from the designated beneficiary.

Dependents who are receiving a VA benefit by apportionment do not receive automatic cost-of-living adjustments. Do not refer these individuals to the VA to request an increase.

D-6410 Deeming Situations

Revision 09-4; Effective December 1, 2009

Do not require a deemor to apply for other benefits. If a deemor applies for and receives other benefits on his/her own initiative, the amount of benefits he/she receives and/or retains is subject to the deeming policies for income and resources.

 

D-6420 Payment Options for Other Benefits

Revision 09-4; Effective December 1, 2009

Most of the types of benefits for which a person must apply offer choices about the method of payment. The person must apply for all other benefits payable at the earliest month and in the highest amount available based on the earliest month.

Note: Irrevocable choices and selections of benefits from pensions or retirement programs made before a person applies for Medicaid do not affect eligibility.

 

D-6421 Survivor's Benefits for Spouses and Other Dependents

Revision 09-4; Effective December 1, 2009

Certain pensions and retirement programs permit a person to elect survivor's benefits for dependents by electing a reduced retirement benefit. Inform the person that he/she must elect the higher current benefit to retain Medicaid eligibility. Election of the reduced retirement benefit will result in the loss of Medicaid eligibility until such time as the pension or retirement program election is changed or the option for change is no longer available.

Some pensions and retirement programs require a spouse to apply a waiver of rights to a survivor's benefit. The person is not penalized for failing to comply with the requirement to apply for other benefits if the reduced retirement benefit results from the spouse’s refusal to sign a waiver of rights to a survivor's benefit.

 

D-6422 Lump Sum or Annuity Payment Option

Revision 09-4; Effective December 1, 2009

If a person can choose between a lump sum or an annuity as the payment method for a benefit, inform the person that he/she must choose the annuity option.
Consider lump sum payments as follows:

• Request for a Lump Sum Payment – If an application has been made for a lump sum payment of the monies on which a potential annuity is based and the benefit source permits the person to change the decision and apply for the annuity, the person must pursue the change to be eligible for Medicaid. If the benefit source does not permit such a change, accept the person's word that the decision is irreversible, absent evidence to the contrary.
• Retroactive RSDI Title II Benefit Lump Sum Payment – Although filing for full retroactive RSDI Title II benefits may result in a lump sum payment, this payment represents the amount of the past due RSDI Title II benefits and is not a fund that determines future regular payments.
• Lump Sum Only Payments – Do not require a person to apply if only a lump sum payment is available. In this situation, the payment is a resource. (This does not include a lump sum death payment under RSDI Title II.) All sources of available support (unless otherwise excluded) are considered in determining eligibility. This is true even if current needs compel a person to sacrifice future pension benefits.

For a purchased annuity, see related policy in Chapter F, Resources, and Chapter I, Transfer of Assets.

 

D-6430 Electing the Month of Entitlement

Revision 09-4; Effective December 1, 2009

If a person can select the month in which benefits begin, whether retroactively or prospectively, direct the person to elect the earliest month benefits can begin, regardless of the impact on other benefits from that program. Election of a later month of entitlement to qualify for higher ongoing benefits or to protect benefits paid to other individuals is cause for denying Medicaid. Election of a later month will result in the loss of Medicaid eligibility until such time as the election is changed or the option for change is no longer available.

 

D-6440 Establishing Eligibility After Denial

Revision 09-4; Effective December 1, 2009

If denial has occurred because of failure to pursue other benefits, establish or reestablish eligibility when:

• the other benefit is no longer available, effective the month following the month the other benefit is no longer available; or
• the person takes the necessary steps to obtain the other benefit, effective the earliest day in a month that the person takes appropriate steps to obtain other benefit.

Revision 09-4; Effective December 1, 2009

A person is eligible for Medicaid, despite failure to apply for other benefits within the 30-day period or to take other necessary steps to obtain other benefits, if there is good reason for not doing so. For example, there is good reason if:

• the person’s guardian or authorized representative is unable to apply for other benefits because of illness; or
• it would be useless to apply because the person had previously applied and the other program has already turned the person down for reasons that have not changed.

According to Public Law 101-508, a person is not required to accept, as a condition of eligibility, payments that a state may make as compensation to victims of crime.

When applying for or receiving benefits under a Medicare Savings Program, a person is not required to apply for SSI benefits in order to be eligible for MSP coverage.

Revision 09-4; Effective December 1, 2009

No Apparent Eligibility — If a person does not meet the basic eligibility requirements for a benefit:

• do not refer the person to apply for that benefit; and
• document the case record with the reason.

Prior Denial — If the person alleges having applied for other benefits previously and having been denied for reasons other than failure to pursue, accept the signed statement regarding the denial, unless there is evidence to the contrary.

Contributions Withdrawn — If a person alleges withdrawal of contributions from a public sector pension, accept the person's signed statement regarding the withdrawal unless:

• the employee was a teacher in a public college or university or was employed by a state or local police/fire department (and no precedent exists stating that, once funds are withdrawn, no benefits are payable); or
• there is evidence to the contrary (for example, prior knowledge indicates funds may not be withdrawn).

Application Pending — If a person alleges an application for another benefit is pending:

• send a verification letter to the benefit source; and
• set up a special review to monitor receipt of the benefit.

Consider the following when assessing the possibility of other benefits a person may be eligible for:

• General identification:
  • Employer's name and address.
  • Name and telephone number of the person who can supply pension information.
• Pension plan:
  • Existence of a pension plan.
  • Statement as to whether or not employees contribute and, if they do, what happens to those contributions upon termination of employment for reasons other than retirement or disability.
  • Vesting requirements.
  • Pension plan provisions for survivors and/or dependents (including divorced spouses).
• Union:
  • Whether or not there is a union.
  • If so, whether the union provides a pension.
  • Name, address and local telephone number of the union.
  • Conditions to qualify for the pension.
  • Union contact for additional information on the pension (including the telephone number).
• Any other pertinent information, such as the date pension information was obtained and recorded.

Revision 09-4; Effective December 1, 2009

§358.219. Third-party Resources.

(a) Medicaid is considered the payor of last resort for a person's medical expenses. As a condition of eligibility, in accordance with 42 CFR §§433.138 - 433.148, an applicant or recipient must:

(1) assign to the Texas Health and Human Services Commission (HHSC) the applicant's or recipient's right to recover any third-party resources available for payment of medical expenses covered under the Texas State Plan for Medical Assistance; and

(2) report to HHSC any third-party resource within 60 days after learning about the third-party resource.

(b) If HHSC determines that a person's employer-based health insurance is cost-effective, the person must participate in HHSC's Health Insurance Premium Payment program as a condition of eligibility. HHSC denies eligibility to a person who voluntarily drops his or her employer-based health insurance or fails to provide HHSC with the information needed to determine cost effectiveness.

Revision 09-4; Effective December 1, 2009

Texas requires, as conditions of Medicaid eligibility, that a person must:

• cooperate in providing any third-party resource (TPR) information to HHSC; and
• agree to the assignment of rights (AOR) of any TPR benefits to HHSC.

Medicaid is usually the payer of last resort. A TPR is a source of payment for medical expenses other than the person, HHSC or Medicaid. A TPR must be applied toward the person's medical and health expenses.

Under state law, an applicant or recipient of Medicaid automatically gives HHSC his/her right to financial recovery from personal health insurance, other recovery sources or personal injuries, to the extent HHSC has paid for medical services. This allows HHSC to recover the costs of medical services paid by the Medicaid program. Any applicant or recipient who knowingly withholds information regarding any sources of payment for medical services violates state law.

Fraud Referrals — Medicaid recipients must report any TPR within 60 days of learning about the coverage or liability. An applicant or recipient who knowingly withholds information regarding any sources of payment for medical services violates state law.

Refer the person for fraud, if the person:

• fails to report any TPR coverage or liability within 60 days; or
• does not reimburse HHSC when a third-party payment for medical services is received and the expenditure is $100 or more.

Denial — Deny the person if the person refuses to:

• cooperate in providing TPR information; or
• agree to the AOR of TPR benefits to HHSC.

See Appendix XVI, Documentation and Verification Guide.

Revision 18-1; Effective March 1, 2018

TPRs include:

• health insurance;
• group health plans;
• government health insurance;
• liability or casualty insurance and court settlements; and
• long-term care insurance policies.

A TPR is any individual, entity or program, including health insurance, that is or may be legally liable to pay all or part of the costs for medical assistance before money from the Medicaid program is spent.

 

D–7310 Examples of Third-Party Resources

Revision 18-1; Effective March 1, 2018

Examples of TPRs include, but are not limited to, the following:

• health insurance;
• self-insured plans;
• group health plans;
• service benefit plans;
• employer, private purchase; and
  • union membership-based health insurance;
  • sheltered workshops;
  • continuation of health insurance coverage under statute (COBRA continuation);
  • and coverage available from an employer under the Employee Retirement Income Security Act (ERISA);
• medical support derived from noncustodial parents;
• armed forces and the public health service;
• pending lawsuits or no-fault clauses or state laws covering accidents, product liability and workers' compensation;
• employee conversion/extension rights;
• fraternal and benefit societies and churches and church groups;
• Insurance purchased or endowed as part of a college fee;
• membership in a health maintenance organization (except for those with a contract under Medicare/Medicaid);
• pharmacy other insurance;
• worker's compensation;
• government health insurance;
• liability or casualty insurance and court settlements;
• insurance (including automobile, homeowners and medical malpractice);
• indemnity plans (if review of the plan determines that the policy provides for payment of health care items or services, including policies that pay a cash benefit to the policyholder if the payment is conditional upon the occurrence of a medical event);
• long-term care insurance policies;
• any other parties that are, by statute, contract, or agreement legally responsible for paying a claim for a health care item or service; and
• Medicare.

Liability or casualty insurance and court settlements — Accidental injuries may result in third parties being liable for medical expenses. The usual sources of payment for medical expenses in these situations are automobile insurance; homeowners insurance; owners', landlords' and tenants' insurance; workers' compensation and lawsuit settlements.

Individual or group health insurance — Health insurance policies include individual or group contracts and commercial hospital, medical and surgical policies. A recipient may have medical insurance coverage from current employment, residual coverage from previous employment or private insurance paid for by the recipient or a relative. A recipient's relative may have personal or group insurance that covers the recipient's medical expenses.

TRICARE, formerly known as CHAMPUS, is a health insurance plan available to dependent children and spouses of active, retired and deceased military services personnel.

Parts A and B of Medicare provide a TPR for Medicaid recipients entitled to Medicare.

Revision 20-4; Effective December 1, 2020

There are two methods of Third-Party Recovery (TPR):

• cost avoidance, in which available third-party benefits are applied before Medicaid payment is made. This is the method of Third-Party Recovery required by the Centers for Medicare and Medicaid Services (CMS); and
• post-payment recovery, where Medicaid pays the medical costs before seeking reimbursement. This method is typically used when Medicaid is unaware of the TPR at the time of billing or the TPR is not eligible for use at the time of billing (e.g., a trust or annuity).

HHSC uses the cost avoidance method of TPR for Medicaid payments to nursing facilities (NF), hospice providers, and non-state intermediate care facilities for persons with intellectual disabilities (ICF/IID). The cost avoidance method requires providers to bill the recipient’s long-term care insurance (if applicable) before billing Medicaid. This ensures that Medicaid is the payer of last resort.

A Medicaid recipient must reimburse HHSC as soon as they receive a third-party payment for medical services already paid by Medicaid.

A provider who receives a third-party payment for medical services already paid by Medicaid must process an adjustment claim and report the third-party payment amount on the claim. The Medicaid paid claim is reduced by the amount of the other insurance payment reported on the adjustment claim.

Providers can contact Texas Medicaid and Healthcare Partnership (TMHP) for assistance with adjustment claims at 800-626-4117, option 3.

Providers may contact TMHP at 800-626-4117, option 6 to report other insurance coverage for a Medicaid recipient.

 

D–7410 Cost Avoidance

Revision 18-1; Effective March 1, 2018

Inform the person to:

• use health insurance as a resource;
• tell medical providers that the person has insurance coverage; and
• show providers any insurance identification card the person may have.

If the person, the employer or other sources indicate that ...	then complete ...
Medicaid-eligible household members have private health insurance coverage,	information about the private health insurance on: the TPR screen in TIERS. This screen will interface with the TMHP TPR Unit. report any changes in insurance coverage for existing recipients via the TPR screen in TIERS.
health insurance coverage is available for Medicaid-eligible household members, but the members are not enrolled in the health insurance plan,	information about the available health insurance on: the TPR screen in TIERS. This screen will interface with the TMHP TPR Unit. The TMHP TPR Unit will use the information to initiate an inquiry about Health Insurance Premium Payment (HIPP) program eligibility.

To contact the TPR Unit with questions or problems concerning TPR:

• HHSC staff may email MCD_Third_Party@hhsc.state.tx.us.
• Medicaid recipients and providers may call the Medicaid TPR Hotline at 800-846-7307, option 2.

HIPP Program Notes: Individuals approved for the HIPP Program receive reimbursement for the employee’s portion of an employer-sponsored health insurance premium payment. For eligibility and co-payment calculations, HIPP reimbursement checks are not considered income.  For co-payment calculations, the reimbursed health insurance premium payment is not considered an incurred medical expense.

TMHP will take action to deny all benefits to a recipient who voluntarily drops his or her health insurance coverage or fails to provide TMHP with the information needed to determine cost effectiveness.

A recipient cannot appeal decisions made by TMHP. To obtain assistance in resolving problems or issues concerning HIPP, contact the TPR HIPP Unit at 800-440-0493.

For more information about the HIPP program, see HHS' HIPP website: https://hhs.texas.gov/services/financial/health-insurance-premium-payment-hipp-program.

Recipients may also call 800-440-0493 for more information.

 

D–7420 Post-Payment Recovery

Revision 18-1; Effective March 1, 2018

Major sources for post-payment recovery are liability or casualty insurance and court settlements resulting from accidental injuries. If a recipient reports an injury that requires medical treatment for which liability or casualty insurance may provide payment, ask the recipient to provide the date of the accident.

Report the recipient’s name, Medicaid number, and date of the accident to the HHSC TPR Unit and Provider Recoupment and Holds.

Third Party Recovery

HHSC OIG/TPR Unit
Mail Code 1354
4900 North Lamar Blvd.
Austin, TX 78751

Information can be sent via email to:

MCD_Third_Party@hhsc.state.tx.us; and

Provider Recoupments and Holds

Texas Health and Human Services Commission
Mail Code W-406
P.O. Box 149030
Austin, TX 78714-9030
701 W. 51st Street
Austin, TX 78751

When the TPR Unit at HHSC becomes aware of accidental injuries, it will seek cost recovery from recipients who receive a health insurance or settlement payment for medical services already paid by Medicaid.

Use Form H1210, Subrogation (Trusts/Annuities/Court Settlements), to report to Provider Claims any potential subrogation funds available from trusts, annuities and court settlements.

When a recipient reimburses HHSC for medical expenses, the reimbursement should be in the form of a personal check, cashier's check or money order. If reimbursement is received from a recipient, follow these steps:

Step	Procedure
1	Give the recipient Form H4100, Money Receipt.
2	Enter the types and dates of the medical services in the "For" section of Form H4100.
3	If unsure about which medical services are involved, attach a memorandum giving as much information as possible about the reimbursement.
4	Attach a copy of any other information identifying the nature of the payment, such as a statement from the insurance company.
5	Send the reimbursement, a copy of Form H4100, and other information, if any, to HHSC Accounts Receivable, P.O. Box 149055, Mail Code 1470, Austin, TX 78714-9055.

State office verifies the actual claims paid by Medicaid and refunds any overpayment.

Revision 18-1; Effective March 1, 2018

Because the Social Security Administration (SSA) determines eligibility for Supplemental Security Income (SSI) recipients, Medicaid eligibility specialists are not routinely involved in TPR information from these individuals. Instead, at the time an SSI recipient is certified for Medicaid and annually thereafter, the state office generates a letter to the recipient requesting information about any insurance coverage they may have. The recipient completes the insurance questionnaire enclosed with the letter and returns it in the envelope provided for that purpose directly to:

Texas Medicaid and Healthcare Partnership (TMHP)
Third Party Resources Unit
P.O. Box 202948
Austin, TX 78720-2948

TMHP enters data from the returned insurance questionnaire into the TPR system. TMHP also maintains a toll-free number (800-846-7307, option 2) that SSI recipients may use to ask questions about the form or about their health insurance.

SSA also reports TPR information for SSI recipients to HHSC. An SSI recipient who refuses to cooperate with HHSC in verifying TPR is ineligible for Medicaid.

Occasionally, an SSI recipient may ask for an explanation or help completing the insurance questionnaire. Explain the purpose of the form and the proper use of available TPRs and help the recipient complete and submit the form, if necessary. If an SSI recipient asks about a change in insurance coverage or about the availability of TPRs related to accidental injury, have the recipient report this information to the TPR Unit at 800-846-7307, option 2 or:

Texas Medicaid and Healthcare Partnership
Third Party Resources Unit
P.O. Box 202948
Austin, TX 78720-2948

 

D–7510 Social Security Administration (SSA) Role and Supplemental Security Income (SSI) Recipients

Revision 09-4; Effective December 1, 2009

In Texas, SSA must inform SSI applicants and recipients and SSI recipients who move to Texas about the requirement under Section D-7200, Cooperation and Assignment of Rights for Medicaid Eligibility.

Revision 17-1; Effective March 1, 2017

Long-term care insurance policies pay for nursing facility care. The policies purchased by individuals specify the benefits covered. Long-term care insurance policies do not affect Medicaid eligibility. For individuals who have such policies, report the policies as a third-party resource (TPR), using Form H1039, Medical Insurance Input.

As of March 1, 2015, HHSC Provider Recoupment and Holds cannot accept other insurance payments for individuals when a managed care organization (MCO) pays the nursing facility claims. Nursing facility providers must contact the appropriate MCO for claims submitted on Medicaid eligible individuals enrolled in MCOs on or after March 1, 2015 with service dates on or after March 1, 2015.

For questions about other insurance on Fee-for-Service (FFS) claims or for claims submitted prior to March 1, 2015, contact HHSC Provider Claims Services at 512-438-2200, Option 4.

Send long-term care insurance checks to Provider Claims Services at the Texas Health and Human Services Commission. The payment of large sums from long-term care insurance companies may affect an individuals' resource eligibility if Provider Claims Services provides a refund.

Procedure for TPR checks received for long-term care insurance coverage on FFS claims:

• give the recipient Form H4100, Money Receipt, correctly documented; and
• send the check, a copy of Form H4100 and other information to:

Provider Recoupments and Holds, W-406
P.O. Box 149081
Austin, TX 78714-9081

The policy and procedures in this section do not apply to Long-Term Care Partnership (LTCP) qualified policies. Information for LTCP qualified policies is located in Chapter P, Long-Term Care Partnership (LTCP) Program.

Revision 18-1; Effective March 1, 2018

The HIPP program is a Medicaid benefit that helps families pay for employer-sponsored health insurance.

To qualify for HIPP, an employee must either be Medicaid eligible or have a family member who is Medicaid eligible. The HIPP program may pay for individuals and their family members who receive, or have access to, employer-sponsored health insurance benefits when it is determined that the cost of insurance premiums is less than the cost of projected Medicaid expenditures.

Note: An employee and the employee's Medicaid-eligible family member must be enrolled in the employer-sponsored health insurance in order to receive HIPP reimbursements.

Medicaid-eligible HIPP enrollees do not have to pay out-of-pocket deductibles, co-payments, or co-insurance for health care services that Medicaid covers when seeing a provider that accepts Medicaid. Instead, Medicaid reimburses providers for these expenses.

HIPP enrollees who are not Medicaid eligible must pay deductibles, co-payments, and co-insurance required under the employer's group health insurance policy.

Report individuals who are potentially eligible for HIPP on Form H1039, Medical Insurance Input. Send Form H1039 to HHSC's Third Party Resource (TPR) Unit, Mail Code 1354, or send via email to: MCD_Third_Party@hhsc.state.tx.us.

For the Medicaid Buy-In for Children (MBIC) program, when employer-sponsored insurance is entered into the Texas Integrated Eligibility Redesign System (TIERS), this information is automatically sent to HIPP. HIPP eligibility does impact the MBIC premium amount. See Section N-7400, Premium Amounts.

HHSC's TPR Unit refers Form H1039 to the current state Medicaid contractor, TMHP. If TMHP determines it is cost-effective for Medicaid to pay the individual's employer-sponsored health insurance premiums, then TMHP sends:

• a letter to the individual and requests verification of the employer-sponsored insurance plan and premium payments; and
• a premium reimbursement to the individual upon receipt of complete documentation and proof of the premium payment.

Note: Because an employer-sponsored health insurance premium deduction has already been counted as part of the recipient's income, a HIPP reimbursement check sent to recipients by TMHP is not income. Do not consider an incurred medical deduction for the reimbursed premium as income for recipients participating in HIPP.

TMHP will terminate HIPP enrollment if the individual is no longer enrolled in  health insurance coverage or fails to provide TMHP with the information needed to determine cost effectiveness or proof of premium payments.

For more information about the HHSC's HIPP program, see HHSC's website: https://hhs.texas.gov/services/financial/health-insurance-premium-payment-hipp-program, or contact the Medicaid HIPP program at MCD_HIPP_Program@hhsc.state.tx.us.

Individuals may call 800-440-0493 for more information. Individuals may also visit the HIPP website at https://hhs.texas.gov/services/financial/health-insurance-premium-payment-hipp-program.

Revision 18-1; Effective March 1, 2018

Another post-payment resource is through the MERP. On March 1, 2005, Texas implemented MERP in compliance with federal Medicaid and state laws. The program is managed by HHSC. Under this program, HHSC may file a claim against the estate of a deceased Medicaid recipient who: 1) was age 55 or older at the time Medicaid services were received; and 2) initially applied for certain long-term care services and supports on or after March 1, 2005. The most complete, current and accurate source of information regarding MERP is the HHS website, Medicaid Estate Recovery Program.

Long-term care services and supports that are subject to MERP include:

• nursing facility services;
• intermediate care facilities for individuals with an intellectual disability or related conditions (ICF/IID) services, which include state supported living centers;
• Medicaid waiver programs, such as:
  • Community Living Assistance and Support Services (CLASS);
  • Deaf Blind with Multiple Disabilities (DBMD);
  • Home and Community-based Services (HCS);
  • Texas Home Living Program (TxHmL); and
  • STAR+PLUS Waiver (SPW);
• Community Attendant Services (CAS); and
• related hospital and prescription drug services.

Notes:

• A person who is placed on an interest list for a Medicaid waiver program is not considered to have applied.
• If a person, aged 55 or older, was eligible for Medicaid or received other Medicaid-paid benefits, such as QMB, SLMB or QI-1, before March 1, 2005, but did not initially apply for or transfer to one of the types of long-term care services and supports subject to MERP until March 1, 2005, or after, the person's estate is subject to recovery of the cost of certain long-term care services and supports received after March 1, 2005.

The acceptance of Medicaid assistance for the covered long-term care services provides a basis for a Class 7 probate claim. (This means there are six other classes of claims that receive priority in payment from the estate before Texas gets paid.) HHSC files a MERP claim in probate court against the estate of a deceased Medicaid recipient to recover the cost of certain Medicaid long-term care services and supports received by the Medicaid recipients. MERP will follow claims procedures specified in the Texas Estates Code and HHSC’s Medicaid Estate Recovery Program rules found at 1 TAC, Part 15, Chapter 373.

For notification requirements, see Section B-2620, HHSC MERP Notification Requirements.

Revision 09-4; Effective December 1, 2009

§358.203. Citizenship and Qualified Alien Status.

(a) In accordance with 42 CFR §435.406, to be eligible for a Medicaid-funded program for the elderly and people with disabilities (MEPD), a person must be:

(1) a citizen or national of the United States (U.S.);

(2) an alien who entered the U.S. before August 22, 1996, who has lived in the U.S. continuously since entry, and who meets the definition of a qualified alien at 8 U.S.C. §1641; or

(3) an alien who entered the U.S. on or after August 22, 1996, who has lived in the U.S. continuously since entry, and who meets the definition of a qualified alien at 8 U.S.C. §1641 with the eligibility limitations in 8 U.S.C. §1612 and §1613.

(b) A person must provide proof of eligibility under subsection (a) of this section that establishes both identity and citizenship or alien status, unless the person:

(1) receives Supplemental Security Income (SSI) or has ever received SSI and was not denied due to citizenship;

(2) is entitled to or enrolled in any part of Medicare, as determined by the Social Security Administration (SSA); or

(3) is entitled to federal disability benefits based on SSA disability criteria.

§358.205. Alien Status for Treatment of an Emergency Medical Condition.

(a) Title XIX of the Social Security Act (42 U.S.C. §1396 et seq.) and 42 CFR §440.255 require the state to provide Medicaid for the treatment of an emergency medical condition to an alien who is ineligible for regular Medicaid due to immigration status. The Texas Health and Human Services Commission administers the program in Texas.

(b) To qualify for Medicaid for the treatment of an emergency medical condition, an alien must:

(1) be:

(A) a qualified alien as defined in 8 U.S.C. §1641 and not meet the requirements to receive Medicaid as described in 8 U.S.C. §1612 and §1613; or

(B) an undocumented non-qualifying alien as described in 8 U.S.C. §1611;

(2) be otherwise eligible for regular Medicaid services; and

(3) require treatment of an emergency medical condition as described in 42 CFR §440.255.

(c) An undocumented non-qualifying alien applying for Medicaid for the treatment of an emergency medical condition is exempt from providing proof of alien status or providing a Social Security number as described in 42 CFR §435.406(b).

Revision 09-4; Effective December 1, 2009

To lawfully remain in the U.S., a person who is not a U.S. citizen or a U.S. national and is present in the U.S. must have authorization from the Department of Homeland Security (DHS).

 

D-8210 United States Citizenship and Immigration Services (USCIS) Documents

Revision 21-3; Effective September 1, 2021
 
Commuter I-551 — An Alien Registration Receipt Card (Type 2) issued to an alien who has been granted Lawful Permanent Resident (LPR) status but lives in Mexico or Canada and commutes to the U.S. to work. The second digit of the ISS/T field identifies the type of card.

Grommeted I-151 — The Alien Registration Receipt Card with a grommet (a hole surrounded by a metal ring), in the upper right corner. This card was previously issued by INS to an alien who had LPR status but lived in Mexico or Canada and commuted to the U.S. to work.

I-94 — The Arrival/Departure Record issued by DHS to all documented nonimmigrants (students, visitors, parolees, refugees and Cuban/Haitian entrants).

I-151 — The version of the Alien Registration Receipt Card issued by the Immigration and Naturalization Service (INS) to aliens from July 1946 through late 1978.

I-551 — The current version of the Alien Registration Receipt Card (Type 1). INS (now DHS) began issuing this card in 1978 to immigrants who have been granted LPR status and are residing in the U.S. The second digit of the ISS/T field identifies the type of card.

I-688 — A temporary resident card that was laminated and issued by INS to legalized aliens and Special Agricultural Workers (SAWs) whose status had been adjusted to lawful temporary resident (LTR). In certain cases, INS placed a label (I-688EXT) on the back of the card to use until the I-551 was issued. This is not a current immigration form and DHS is no longer issuing this document. Currently, there are no valid I-688 cards (or I-688 cards with extension stickers).

I-688A — An employment authorization card issued by INS to legalize SAW applicants who filed an application to adjust their status to LTR. This is not a current immigration form and DHS no longer issues this document. Currently, there are no valid I-688A cards.

I-688B — The employment authorization document that was a laminated card given by DHS to newly admitted nonimmigrants or those with previous employment authorization who needed an extension. The I-688B replaced the “employment authorization” annotation previously placed on other DHS documents. This is not a current immigration form and DHS is no longer issues this document. Currently, there are no valid I-688B cards.

I-688EXT — Form I-688 with an extended period of validity of the Temporary Resident Card. In certain situations, INS placed a sticker on the back of the card. This served as temporary evidence of permanent residence until the alien received an I-551. This is not a current immigration form and DHS no longer issues this document. Currently, there are no valid I-688 cards or I-688 cards with extension stickers.

I-766 — Employment Authorization Document. Currently, the I-766 is the only valid document verifying employment authorization. This form replaced all other employment authorization documents issued previously.

Passport — A travel document issued by a competent authority showing the bearer's origin, identity and nationality, if any, that is valid for the entry of the bearer into a foreign country.

Temporary I-551 — The card issued to either an immigrant who has just been granted a lawful status or to an immigrant who has lost his Alien Registration Receipt Card and has applied for a replacement I-551.

Visa — A document issued by U.S. embassies and consulates in foreign countries that is a permit for a foreign national to proceed to a U.S. port of entry to apply to DHS for admission to the U.S. The DHS immigration office at the port of entry decides the conditions (that is, category of admission and length of stay in the U.S.) based on the visa category.

 

D-8220 Groups of Aliens

Revision 17-4; Effective December 1, 2017

For Medicaid eligibility purposes, an alien is any person who is not a natural-born or naturalized citizen or national of the U.S.

Effective Aug. 22, 1996, the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA) limited an alien’s eligibility for Medicaid.

Most aliens must meet two requirements to be eligible for full Medicaid and/or a Medicare Savings Program (MSP):

• the noncitizen must be in a "qualified alien" category (see Section D-8300, Qualified Alien Categories); and
• meet an LAPR condition for qualified aliens (see Section D-8400, LAPR Conditions for Medicaid).

Generally, aliens are now referred to as:

• qualified aliens; or
• non-qualified aliens.

Qualified aliens are potentially eligible for ongoing full Medicaid benefits and/or MSP. Non-qualified aliens are not eligible for ongoing Medicaid coverage however, may qualify for limited Medicaid eligibility for the treatment of an emergency medical condition only.

Except when it involves undocumented aliens, use the Systematic Alien Verification for Entitlements (SAVE) Verification Information System (VIS) to verify the alien status on all noncitizens.

 

D-8221 Date of Qualifying Classification

Revision 19-4; Effective December 1, 2019

Use SAVE VIS to verify the alien status of all documented non-citizens. If a person is undocumented, do not run SAVE.

A qualified alien’s eligibility is based on the:

• date of entry with a qualifying classification;
• alien's qualifying classification; and
• Medicaid application date.

Use the date of entry into the U.S. and, if different, the date of entry with a qualifying alien classification to determine the correct category for the qualified alien.

The date on the alien's Department of Homeland Security (DHS) document or card often represents the alien's first date of entry into the U.S.

In some cases, an alien may be present in the U.S. without a qualifying classification, depart, and then return to the U.S. with a qualifying alien classification. Other aliens may have entered the U.S. without a qualifying alien classification and remained continuously present in the U.S. until obtaining qualified immigrant status. For these aliens, the date on their DHS document or card reflects the date of entry with a qualifying alien classification or the date the qualifying alien classification was granted, not the alien's original date of entry.

Allow aliens with a DHS document or card showing an entry date on or after Aug. 22, 1996, who claim to have entered before that date, an opportunity to submit evidence of their claimed date of entry. This evidence may include pay stubs, a letter from an employer, or a lease or utility bill in the alien's name.

Verifying continuous presence

DHS maintains a record of arrivals to and departures from the country for most legal entrants. This record may be used to establish that an alien has continually resided in the U. S. since before Aug. 22, 1996.

Verify via SAVE with DHS-USCIS to confirm continuous presence in the U.S. Any single absence from the U.S. of more than 30 days, or a combined absence of more than 90 days, is considered to interrupt "continuous presence."

Other entrants, including aliens who entered the U.S. without USCIS documents, must provide documentary evidence proving continuous presence, such as a letter from an employer, a series of pay stubs or utility bills in the alien's name, spanning the time in question.

Note: Once an alien obtains a qualifying alien status, the person does not have to continuously remain present in the U.S.

Related Policy

Documentation and Verification Guide, Appendix XVI
Initial Request at Time of Application, D-5510
Verification of Alien Status, D-8700
Documentary Evidence by Classification, D-8710
Secondary Verification of Alien Immigration Status, D-8840
Reasonable Opportunity to Provide Verification of Alien Immigration Status, D-8841
Entry Before 1996, D-8910
Entry on or After Aug. 22, 1996-Qualifed Alien No Waiting Period, D-8920
LPR Aliens With or Without Five-Year Waiting Period, D-8930

 

D-8222 Reserved for Future Use

Revision 17-4; Effective December 1, 2017

 

Revision 17-4; Effective December 1, 2017

MEPD provides full Medicaid and/or MSP to qualified aliens whose eligibility is mandatory under federal requirements. Mandatory qualified aliens fall into three categories.  Refer to the following sections for information about the three categories of qualified aliens potentially eligible for full Medicaid and/or MSP:

• Section D-8310, Qualified Aliens Subject to a Seven-Year Limited Period
• Section D-8320, Qualified Aliens Not Subject to a Waiting Period or Limited Period
• Section D-8330, Qualified Aliens with a Five-Year Waiting Period

 

D-8310 Qualified Aliens Subject to a Seven-Year Limited Period

Revision 14-4; Effective December 1, 2014

The following qualified aliens are immediately eligible for full Medicaid and/or MSP benefits, provided they meet other program requirements, but are limited to seven years of eligibility:

• Refugees under Section 207 of the Immigration and Nationality Act (INA).
• Asylees under Section 208 of the INA.
• Aliens whose deportation is being withheld under Section 243(h) of the INA or whose removal has been withheld under Section 241(b)(3) of the INA.
• Cuban/Haitian entrants under one of the categories in Section 501(e) of the Refugee Education and Assistance Act of 1980, or aliens in a status that is to be treated as a "Cuban/Haitian entrant" for Medicaid purposes.
• Amerasian immigrants under Section 584 of the Foreign Operations, Export Financing, and Related Programs Appropriations Act of 1988. "Amerasian immigrants" are by definition lawfully admitted for permanent residence (LAPR), thus they are qualified aliens. If a person is an "Amerasian immigrant" and meets no other condition permitting eligibility, then the person is potentially eligible for Medicaid for seven years beginning with the date "Amerasian immigrant" status was granted.

Note: Amerasians who enter as legal nonimmigrants as defined in Section D-8610, Ineligible Aliens, (for example, foreign students pursuing studies in the U.S.) cannot be qualified aliens unless their classification changes.

• Afghan and Iraqi special immigrants eligible for resettlement assistance, federal benefits and entitlements. When determining eligibility for full Medicaid and/or MSP, treat these aliens as refugees according to provisions of the Department of Defense Appropriations Act for fiscal year 2010, signed by the president on Dec. 19, 2009.

Under federal law, a qualified alien in this category is limited to seven years of potential eligibility for full Medicaid and/or MSP unless the qualified alien fits into another category or becomes a naturalized citizen.

Start the Clock — The clock on the seven years begins to run from the date the person obtains a qualified alien classification, not from the date the person becomes eligible for full Medicaid and/or MSP.

Stop the Clock — The clock on the seven years stops with the beginning of the first month after the seventh anniversary of the date the person obtained qualified alien classification. Once the seven-year period ends, in order to remain eligible for full Medicaid and/or MSP, the alien described in this section must either:

• become a naturalized citizen or meet citizenship status; or
• be eligible for full Medicaid and/or MSP in the same manner as qualified aliens in Section D-8320, Qualified Aliens Not Subject to a Waiting Period or Limited Period.

Consider Medicaid for the treatment of an emergency medical condition when the seven-year period expires and the person does not meet either of the above.

 

D-8320 Qualified Aliens Not Subject to a Waiting Period or Limited Period

Revision 21-3; Effective September 1, 2021
 
Certain aliens are exempt from both the five-year waiting period and the seven-year limited period when they meet certain criteria.

The following aliens are eligible for full Medicaid and or MSP if they meet all other eligibility criteria:

• honorably discharged veterans or active duty members of the U.S. armed forces;
• spouses, unmarried surviving spouses or minor unmarried children of honorably discharged veterans or active duty members;
• Canadian born American Indians;
• members of federally recognized Indian tribes;
• aliens receiving SSI and or Medicaid on Aug. 22, 1996, and lawfully residing in the U.S. on or before Aug. 22, 1996;
• LPRs admitted for permanent residence prior to Aug. 22, 1996, and credited with 40 qualifying quarters of Social Security coverage;
• LPRs lawfully admitted on or after Aug. 22, 1996 and five years have passed since their legal date of entry, and have 40 qualifying quarters of Social Security coverage; and
• Compact of Free Association (COFA) citizens residing in the U.S.

Related Policy

Compact of Free Association (COFA) Citizens, D-5220
Qualified Aliens with a Five-Year Waiting Period, D-8330
Veterans, Armed Forces Active Duty and Dependents, D-8410
American Indians Born Outside the U.S., D-8420
LPR Residing in the U.S. on Aug. 22, 1996, D-8430

 

D-8330 Qualified Aliens with a Five-Year Waiting Period

Revision 14-4; Effective December 1, 2014

Aliens lawfully admitted for permanent residence on or after Aug. 22, 1996, are not eligible for full Medicaid and/or MSP benefits for a period of five years from the date they enter the U.S. or obtain a qualified alien classification, whichever is later, unless they meet:

• certain classifications described in Section D-8310, Qualified Aliens Subject to a Seven-Year Limited Period; or
• one of the LAPR conditions in Section D-8320, Qualified Aliens Not Subject to a Waiting Period or Limited Period.

Start the Clock — The clock on the five-year waiting period begins to run from the date the person:

• enters the U.S. with the qualified alien classification; or
• obtains the qualified alien classification.

Stop the Clock — The clock stops:

• with the beginning of the first month after the fifth anniversary of the date the person obtains the qualified alien classification, or
• earlier than the fifth anniversary if:
  • the alien classification changes and the alien meets criteria in Section D-8310, or
  • the alien meets one of the LAPR conditions in Section D-8320.

Once the five-year period ends, a qualified alien with a five-year waiting period who meets all other eligibility criteria must do one of the following to be eligible for full Medicaid and/or MSP:

• Become a naturalized citizen or meet citizenship status.
• Be credited with 40 qualifying quarters of Social Security coverage.
• Meet an alien classification criterion in Section D-8310 if the clock for the seven years has not ended.
• Meet one of the LAPR conditions in Section D-8320.

Consider Medicaid for the treatment of an emergency medical condition if the person does not meet one of the above or is still within the five-year waiting period.

 

D-8340 Establishing Qualifying Quarters of Social Security Coverage

Revision 14-4; Effective December 1, 2014

The Social Security Administration (SSA) defines a quarter as a period of three calendar months.

• Quarter 1: January, February, March
• Quarter 2: April, May, June
• Quarter 3: July, August, September
• Quarter 4: October, November, December

A quarter of coverage is credit for a requisite (necessary) amount of covered earnings assigned to a calendar quarter on a worker's earnings record.

A qualifying quarter is credit for a requisite (necessary) amount of covered earnings and/or non-covered earnings assigned to a calendar quarter for determining eligibility of an LAPR alien.

Individuals can get up to four qualifying quarters of credit each calendar year based on their own earnings. Individuals also can be credited with additional quarters in a calendar year based on the earnings of a parent or spouse.

To be potentially eligible for full Medicaid and/or MSP, an LAPR alien must be credited with 40 qualifying quarters, either from the alien’s own record, or combined with the quarters earned by a spouse or parent.

Note: The 40-qualifying-quarter requirement does not exempt the individual from the five-year waiting period (bar).

See the policy that follows to determine if the LAPR alien meets the 40-qualifying-quarter requirement.

 

D-8341 Combining Qualifying Quarters of Spouse/Parent

Revision 12-4; Effective December 1, 2012

Quarters from a spouse — Aliens can count their spouse's quarters earned during the marriage in addition to their own quarters to meet the 40 qualifying quarter requirement. For example, if each spouse has 20 quarters, the quarters are added and both spouses are credited with 40 quarters.

Count the spouse's quarters earned during the marriage when the spouse is either a citizen or an alien and any of the following conditions apply:

• The couple is currently married.
• A spouse is deceased and the surviving spouse has not remarried.
• The couple is separated but not divorced.

When determining whether to credit a person's quarters to his spouse, count quarters earned beginning with the quarter from the date of marriage.

Do not count quarters earned by divorced spouses for either ex-spouses.

Note: Aliens who divorce after certification retain their eligible alien status through the end of the current certification period. This also applies to stepchildren.

Quarters from a parent – Aliens also can count the quarters earned by a living or deceased parent in addition to their own quarters to meet the 40 qualifying quarter requirement. In this instance, a parent means the natural or adoptive parent or the stepparent.

Count the parent's quarters when the parent is either a citizen or an alien and the quarters were earned before the child turned 18, including quarters earned before the child was born.

Death of a stepparent does not end the relationship. However, if the parent and stepparent are divorced, the stepparent's quarters are not counted.

Note: Quarters earned by a child are not counted toward the eligibility of a parent.

 

D-8342 Qualifying Quarters Earned on or After Jan. 1, 1997

Revision 12-4; Effective December 1, 2012

Federal law requires that quarters earned on or after Jan. 1, 1997, cannot be credited if the person who earned the quarters received means-tested public benefits.

When determining the total amount of qualifying quarters earned, do not allow any quarters earned on or after Jan. 1, 1997, if the person received TANF, SNAP, Medicaid or SSI benefits in that quarter.

The Wire Third Party Query (WTPY) system response does not reflect receipt of these benefits. Staff should verify if federal means-tested benefits were received by any person contributing quarters so that applicable quarters are deducted before determining the number of qualifying quarters.

Example: An LAPR alien files an application for benefits on Oct. 10, 2012. He has never worked and has no qualifying quarters of his own. He has been married for 30 years and his spouse, who is a U.S. citizen and who has been working since they were married, earned her 40th qualifying quarter in March 2012.

Spouse received SNAP in January 2012 and February 2012; however, she has not been certified to receive SNAP or to be eligible for any other federal means-tested public benefit since February 2012.

Result: As the 40th qualifying quarter was earned while receiving SNAP, it cannot be allowed. Since the spouse continues working, the 40th qualifying quarter is earned in the quarter ending June 2012. Since all 40 qualifying quarters were earned during their marriage, the LAPR alien meets the 40 qualifying quarter determination.

 

D-8343 Non-Covered Wages

Revision 14-4; Effective December 1, 2014

Non-covered wages are those earned by a person whose employer was not required to pay into the Social Security system (such as certain city, federal, school or religious organization employees).

If the alien cannot meet the 40-qualifying-quarter requirement using covered or non-covered earnings verified by the SSA, then obtain sufficient income verification from the employer to determine if the alien earned quarters for the period in question using non-covered earned wages.

If the alien reports self-employment with non-covered earned wages, obtain sufficient information about this employment to verify that the alien:

• was engaged in a trade or business, and
• had net earnings from self-employment.

Acceptable documents include, but are not limited to, pay stubs, employer statements, W-2s, and income tax forms including all applicable schedules. If HHSC already has verification of the income, do not request additional information.

Use the chart below to determine if the person earned sufficient non-covered wages to earn a quarter.

Year	Amount Required for a Quarter	Amount Required for 4 Quarters
2014	$1,200	$4,800
2013	$1,160	$4,640
2012	$1,130	$4,520
2010–2011	$1,120	$4,480
2009	$1,090	$4,360
2008	$1,050	$4,200
2007	$1,000	$4,000
2006	$970	$3,880
2005	$920	$3,680
2004	$900	$3,600
2003	$890	$3,560
2002	$870	$3,480
2001	$830	$3,320
2000	$780	$3,120
1999	$740	$2,960
1998	$700	$2,800
1997	$670	$2,680
1996	$640	$2,560
1995	$630	$2.520
1994	$620	$2,480
1993	$590	$2,360
1992	$570	$2,280
1991	$540	$2,160
1990	$520	$2,080
1989	$500	$2,000
1988	$470	$1,880
1987	$460	$1,840
1986	$440	$1,760
1985	$410	$1,640
1984	$390	$1,560
1983	$370	$1,480
1982	$340	$1,360
1981	$310	$1,240
1980	$290	$1,160
1979	$260	$1,040
1978	$250	$1,000

Example: A person worked for the school district as a custodian from 2001 through 2011. The school district did not pay into the Social Security system. The specialist requested that the person provide verification of earnings for this particular period. (Note: If the State Online Query (SOLQ) shows an F on the 40-quarter record, SSA has verified those non-covered wages, and the specialist does not need to reverify them.)

The person brought a statement from the school district verifying the person’s wages. The person earned $9,000 for 2011. Using the chart above, the income required to earn a quarter for 2011 is $1,120. The person can be credited with four quarters for 2011 because the person earned more than the amount required ($1,120 x 4 = $4,480).

 

D-8344 Procedures for Verifying 40 Quarters

Revision 17-4; Effective December 1, 2017

Determine all persons whose quarters can be included in the quarter coverage count. See D-8341, Combining Qualifying Quarters of Spouse/Parent.

If the alien applicant/recipient and/or person whose quarters will be included did not sign the application form, obtain the person’s signature on Form SSA-3288, Social Security Administration Consent for Release of Information. When a completed and signed Form SSA-3288 cannot be obtained because the person refuses to complete it, SSA cannot release information about that individual.

If a person, other than the LPR applicant, refuses to sign the Form SSA-3288, do not request earnings history for that person. Determine eligibility based on the qualifying quarters of the LPR applicant/recipient. If the LPR applicant/recipient does not meet the qualifying quarter requirement, deny the case.

A signed Form SSA-3288 is not required when requesting information on:

• a deceased individual's Social Security number; or
• a spouse’s Social Security number when the couple is separated but not divorced.

Use the 40 Quarters Verification System in TIERS to request 40 quarters from SSA to determine how many countable quarters are in the LPR's SSA earnings records.

Note:  WTPY may still be used to obtain information on 40 Qualifying Quarters.

Run Inquiry to determine if any person whose quarters are being considered received SSI, SNAP, TANF or Medicaid in any month on or after January 1997. Record the eligibility dates for these benefits so that applicable quarters are deducted from the total before determining if the alien applicant/recipient meets the 40-qualifying-quarter requirement.

Note: Determine if it is possible for the alien to meet the 40-quarter requirement first by obtaining the number of years the alien and each person included in the quarter coverage calculation has lived in the U.S. If the combined number of years totals less than 10 years, the alien will not meet the requirement. (Must earn 4 quarters/year x 10 years = 40 quarters.)

 

D-8345 Response from WTPY

Revision 12-4; Effective December 1, 2012

SSA does not complete the posting of covered earnings quarters for any one year until the following year (around August). For instance, quarters earned in 2011 may not be posted on the WTPY system until August 2012. These quarters are referred to as Lag quarters.

The quarters of covered earnings are based on the calendar year's total earnings. Each year the amount of income needed to earn a quarter changes. State office advises staff of the change each year.

Example: In 2011, an individual must earn $1,120 to earn one quarter. If the individual earned at least $4,480 for 2011 ($1,120 x 4), the individual has four qualifying quarters for the year.

Do not allow credit for an incomplete or future quarter.

Example: The quarter of July-September 2011 cannot be counted until October 2011, even though the individual earned enough income by March 2011 to receive credit for three quarters in 2011.

Note: The WTPY response will not reflect receipt of federal means-tested benefits. Staff should conduct inquiry to verify if SSI, SNAP, TANF or Medicaid benefits were received by any person contributing quarters so that an accurate count of the qualifying quarters is made. See D-8342, Qualifying Quarters Earned on or After Jan. 1, 1997.

Revision 14-4; Effective December 1, 2014

Certain aliens lawfully admitted for permanent residence (LAPR) are immediately eligible for full Medicaid and/or MSP benefits, provided they meet other program requirements and certain LAPR conditions.

A description of the LAPR conditions follows.

 

D-8410 Veterans, Armed Forces Active Duty and Dependents

Revision 14-4; Effective December 1, 2014

This LAPR condition applies to:

• a veteran or active duty member of the U.S. armed forces;
• the spouse of a veteran or active duty member, including a surviving spouse who has not remarried; and
• an unmarried dependent child of a veteran or active duty member.

Verification of honorable discharge or active duty status requires presentation of a copy of the veteran's discharge certificate or current orders showing "Honorable" discharge from, or active duty in, the Army, Navy, Air Force, Marine Corps or Coast Guard.

Neither a general discharge "Under Honorable Conditions" nor service in the National Guard satisfies this LAPR condition.

Contact the local Veterans Affairs (VA) regional office if an applicant presents:

• documentation showing honorable discharge from, or active duty in, any other branch of the military;
• documentation showing any other type of duty (for example, "active duty for training"); or
• if there is any other reason to question whether an applicant satisfies the requirements for this exemption.

Aliens meeting the criteria in this section are immediately eligible for full Medicaid and/or MSP, provided they meet all other eligibility criteria.

 

D-8411 Loss of "Veteran/Active Duty" Status

Revision 14-4; Effective December 1, 2014

Loss of eligibility related to "Veteran/Active Duty" status can occur under the following circumstances:

Change in Active Duty/Veteran Status

A qualified alien who is eligible based on the veteran/active duty policy (including a spouse or dependent child of an active duty member/veteran) loses full Medicaid and/or MSP eligibility the month after the month the active duty member separates from the armed forces with a discharge that is not characterized as honorable or that is based on alien status.

Spouse of Veteran/Active Duty Member

Eligibility as a spouse of a veteran or active duty member of the armed forces ends with the month after the month any of the following occur:

• Remarriage after the veteran's or service member's death.
• Divorce or annulment of the marriage.
• A determination that a marital relationship does not exist.
• Separation of the person and the spouse, which results in the person not being considered a member of the couple.
• The active duty member separates from the armed forces with a discharge that is not characterized as honorable or that is based on alien status.

Unmarried Dependent Child of Veteran/Active Duty Member

Eligibility as an unmarried dependent child of a veteran or active duty member ends with the month after the month any of the following occur:

• Marriage of the child.
• Loss of dependent status.
• The active duty member separates from the armed forces with a discharge that is not characterized as honorable or that is based on alien status.
• Legal adoption by someone other than the veteran or active duty member of the armed forces or the veteran/active duty member's spouse.

 

D-8420 American Indians Born Outside the U.S.

Revision 17-4; Effective December 1, 2017

Although born outside the U.S., the following American Indians are considered qualified aliens and are immediately eligible for full Medicaid and/or MSP, provided they meet all other eligibility criteria.

Certain Canadian-born Indians — Canadian-born Indians who establish "one-half American Indian blood" are considered qualified aliens and may freely cross borders and live and work in the U.S. without Department of Homeland Security (DHS) documentation. Accept as evidence of "one-half American Indian blood" a document that indicates the percentage of American Indian blood in the form of a:

• birth certificate issued by the Canadian reservation; or
• letter, card or other record issued by the tribe.

If the person cannot present any listed document to verify the American Indian status, refer the person to DHS to determine the alien status. Do not accept a Certificate of Indian Status card ("Band" card) issued by the Canadian Department of Indian Affairs or any other document not directly issued by the individual's tribe.

Federally recognized U.S. Indian tribes — U.S. Indian tribes federally recognized under Section 4(e) of the Indian Self-Determination and Education Assistance Act are each authorized by the Bureau of Indian Affairs to define the requirements for tribal membership. Some tribes afford membership to non-U.S. born individuals. If a foreign-born person claims membership in a federally recognized Indian tribe, request a membership card or other tribal document showing membership in the tribe. If the person has a membership card or other tribal document showing membership in the tribe, contact state office. State office will determine if the tribe is included on the list of recognized Indian tribes published annually by the Bureau of Indian Affairs in the Federal Register.

See Appendix V, Levels of Evidence of Citizenship and Acceptable Evidence of Identity Reference Guide, for information on Form I-872, American Indian Card, as evidence of U.S. citizenship. Form I-872 showing the class code "KIC" indicates citizenship status.

 

D-8430 LPR Residing in the U.S. on Aug. 22, 1996

Revision 17-4; Effective December 1, 2017

To be immediately eligible for full Medicaid and/or MSP, an alien living in the U.S. on Aug. 22, 1996 must:

• have received SSI and/or Medicaid on Aug. 22, 1996, and be lawfully residing in the U.S. on or before Aug. 22, 1996 (see Note:); or
• meet another LPR condition or alien classification (see D-8300, Qualified Alien Categories, through D-8400, LPR Conditions for Medicaid).

Note: This includes non-qualified aliens who received Medicaid on Aug. 22, 1996, due to permanent residence under color of law (PRUCOL) and continue to meet PRUCOL criteria.

Consider Medicaid for the treatment of an emergency medical condition if the alien described in this section does not meet another LPR condition or alien classification. See D-8600 Non-Qualified Aliens through D-8620 Illegal Aliens.

Revision 17-4; Effective December 1, 2017

To determine the alien status for retroactive coverage, use the policy in the following:

• Section D-8310, Qualified Aliens Subject to a Seven-Year Limited Period
• Section D-8320, Qualified Aliens Not Subject to a Waiting Period or Limited Period
• Section D-8330, Qualified Aliens with a Five-Year Waiting Period

Note: Before denying SSI, the Social Security Administration (SSA) will test the person for an extension beyond the seven-year limited period. Qualified aliens who were lawfully residing in the U.S. on Aug. 22, 1996 and who are blind or disabled may continue to be eligible for SSI beyond the seventh year, assuming all other factors of eligibility are met, regardless of:

• the alien's age;
• whether onset of blindness or disability occurred before, on or after Aug. 22, 1996; or
• when the SSI application was filed.

If a denied SSI recipient applies for an MEPD program, determine the reason for the SSI denial. If the SSI denial was based on alien status (for example, expiration of the seven-year limited period) to be eligible for an MEPD program, the qualified alien must:

• become a naturalized citizen;
• meet citizenship status; or
• meet an LPR condition in Section D-8320.

Note:  Individuals denied SSI whose alien classification is lawfully residing in the U.S. on Aug. 22, 1996 and are blind or have a disability, are not eligible for continued Medicaid or a Medicare Savings Program.

Revision 14-4; Effective December 1, 2014

Generally, non-qualified aliens are divided into two groups:

• ineligible aliens, and
• illegal aliens.

These groups of non-qualified aliens are not eligible for regular Medicaid and/or MSP. They may be eligible for Medicaid coverage for treatment of an emergency medical condition.

 

D-8610 Ineligible Aliens

Revision 21-3; Effective September 1, 2021

Except for cases involving undocumented aliens, use the Systematic Alien Verification for Entitlements (SAVE) Verification Information System (VIS) to verify the alien status on all noncitizens.

Some aliens may be lawfully admitted to the U.S. as "legal nonimmigrants," but only for a temporary or specified time.

The following categories of people are "legal nonimmigrants":

• foreign government representatives on official business and their families and servants;
• visitors for business or pleasure, including exchange visitors;
• aliens in travel status while traveling directly through the U.S.;
• crewmen on shore leave;
• treaty traders and investors and their families;
• foreign students;
• international organization representation and personnel and their families and servants;
• temporary workers, including agricultural contract workers; or
• members of foreign press, radio, film or other information media and their families.

These aliens are called “ineligible aliens” because they are not eligible for full Medicaid, MSP or ME-A&D Emergency due to the temporary (non-resident) nature of their admission status.

Exception: In some cases, an alien in a currently valid legal nonimmigrant classification may meet the residence rules of Texas. When the residency requirement is met, the person is eligible for Medicaid for the treatment of an emergency medical condition if all other eligibility criteria also are met.

Example 1: A domestic employee for a foreign government representative currently conducting business in Texas receives emergency medical care. She files an application for assistance with the medical expenses. The individual states she does not intend to remain in Texas; she is here only while her employer concludes his business. Result: The individual is not eligible for full Medicaid, MSP or ME-A&D Emergency due to the temporary nature of her admission status.

Example 2: An agricultural contract worker suffers an injury while on the job and is hospitalized. He files an application for assistance with the medical expenses, as he does not have any medical insurance. The person states he intends to remain in Texas. He provides verification of his permanent address and rental agreement. Result: The person is potentially eligible for ME-A&D Emergency because he meets residence requirements.

Reminder: If a legal nonimmigrant’s time has expired with no changes to the classification status, follow the illegal aliens procedures.

Related Policy

Eligibility, D-3200
Illegal Aliens, D-8620

 

D-8611 Documents of Ineligible Aliens

Revision 13-4; Effective December 1, 2013

Types of Department of Homeland Security (DHS) documentation for ineligible aliens who are legal nonimmigrants include, but are not limited to:

• Form I-766, valid employment authorization documents;
• Form I-94, Arrival-Departure Record;
• Form I-185, Canadian Border Crossing Card;
• Form I-186, Mexican Border Crossing Card;
• Form SW-434, Mexican Border Visitor's Permit;
• Form I-95A, Crewman's Landing Permit; and
• Visitor visas, such as a B1 visa for business or a B2 visa for pleasure, tourism or medical treatment.

Explore eligibility for Medicaid coverage for treatment of an emergency medical condition for an alien if there is no proof of alien status.

 

D-8620 Illegal Aliens

Revision 13-1; Effective March 1, 2013

Illegal aliens were either never legally admitted to the United States for any period of time or were admitted for a limited period of time and did not leave the United States when the period of time expired.

Illegal aliens are only eligible for Medicaid for treatment of an emergency medical condition if they meet all other eligibility criteria, including residency requirements. See Section D-3200, Eligibility. Illegal aliens do not have to provide a Social Security number.

When an alien receives a final deportation order but continues to stay, consider the alien to be illegal.

Except for cases involving undocumented aliens, use SAVE VIS to verify the alien status on all non-citizens.

Contact with the Department of Homeland Security (DHS) is not allowed except when the person has given written approval and a request to do so.

If an alien does not wish to contact DHS or give permission, explore eligibility for Medicaid coverage for treatment of an emergency medical condition.

Revision 19-4; Effective December 1, 2019

If otherwise eligible, only qualified aliens are eligible for full Medicaid, Medicare Savings Programs or both (MSP). As part of the Medicaid eligibility determination, verify:

• the alien's qualifying classification; and
• the date the alien obtained the qualifying classification.

Complete verification by:

• obtaining a U.S. Citizenship and Immigration Services (USCIS) document showing alien classification or the immigrant registration number as explained in Section D-8710, Documentary Evidence by Classification, through Section D-8780, Qualified Alien Based on Battery or Extreme Cruelty; and
• using the Systematic Alien Verification for Entitlements (SAVE) Verification Information System (VIS).

Document the:

• alien's status and how you verified it;
• date of entry;
• continuous presence, if necessary to establish eligibility;
• DHS document's expiration date, if any; and
• basis for the alien's eligibility or ineligibility.

If a certified alien's document expires before the next redetermination, re-verify the alien's immigration status. The alien’s immigration status does not require reverification if the USCIS documents have not expired.

Note: If the alien’s USCIS document is expired and the SAVE response shows the person is a Lawful Permanent Resident - Employment Authorized and the Date Admitted is “Response is Indefinite,” the person meets the alien status criteria.

Related Policy

Documentation and Verification Guide, Appendix XVI
Initial Request at Time of Application, D-5510
Date of Qualifying Classification, D-8221
Documentary Evidence by Classification, D-8710
Secondary Verification of Alien Immigration Status, D-8840
Reasonable Opportunity to Provide Verification of Alien Immigration Status, D-8841
Entry Before 1996, D-8910
Entry on or After Aug. 22, 1996-Qualifed Alien No Waiting Period, D-8920
LPR Aliens With or Without Five-Year Waiting Period, D-8930

 

D-8710 Documentary Evidence by Classification

Revision 19-4; Effective December 1, 2019

Use SAVE VIS to verify the alien status of all documented non-citizens. If a person is undocumented, do not run SAVE.

Explore eligibility for Medicaid coverage for treatment of an emergency medical condition for non-citizens who do not have a Medicaid qualifying immigration status or who are undocumented.

Documentary evidence in conjunction with DHS verification is provided via the online SAVE response.

Once the documentary evidence (usually an alien status card) and the SAVE verification have been completed, use the charts in Section D-8900, Alien Status Eligibility Charts, for treatment of the alien status in the eligibility determination process.

Related Policy

Documentation and Verification Guide, Appendix XVI
Initial Request at Time of Application, D-5510
Date of Qualifying Classification, D-8221
Verification of Alien Status, D-8700
Secondary Verification of Alien Immigration Status, D-8840
Reasonable Opportunity to Provide Verification of Alien Immigration Status, D-8841
Entry Before 1996, D-8910
Entry on or After Aug. 22, 1996-Qualifed Alien No Waiting Period, D-8920
LPR Aliens With or Without Five-Year Waiting Period, D-8930

D-8720 Lawfully Admitted for Permanent Residence (LAPR)

Revision 13-1; Effective March 1, 2013

If the alien presents an I-551 (Alien Registration Receipt Card) or other acceptable evidence of LAPR status, query SAVE online to verify the document and status. Some LAPR aliens have conditional permanent resident status. This is indicated by an I-551 valid for only a two-year period. These aliens must apply for removal of the conditional basis 90 days before the second anniversary of the admittance date to the U.S. Failure to do so results in termination of the alien's lawful status. A conditional I-551 is identified by an expiration date two years later than the admittance/adjudication date, and status must be re-verified upon expiration. If the alien is a national of Cuba or Haiti who adjusts to LAPR status under the Nicaraguan and Central American Relief Act (NACARA) or the Haitian Refugee Immigration Fairness Act (HRIFA), contact state office for more information on treatment.

For a LAPR, follow policy in:

• Section D-8320, Qualified Aliens Not Subject to a Waiting Period or Limited Period; or
• Section D-8330, Qualified Aliens with a Five-Year Waiting Period.

 

D-8721 Description of Common Resident Alien Cards

Revision 17-4; Effective December 1, 2017

Permanent Resident Card and Employment Authorization Document (EAD)

As of May 1, 2017, the Permanent Resident Card and EADs:

• display the individual’s photos on both sides;
• show a unique graphic image and color palette:
  • Permanent Resident Cards have an image of the Statue of Liberty and a predominately green palette;
  • EAD cards have an image of a bald eagle and a predominately red palette;
• have embedded holographic images;
• no longer display the individual’s signature; and
• no longer have an optical stripe on the back.

Note:  Permanent Resident Cards and EADs will remain valid until the expiration date shown on the card.  Some older Permanent Resident Cards do not have an expiration date. The older Permanent Resident Cards without an expiration date also remain valid.

Revised I-551

A revised I-551, Alien Registration Receipt Card (Type 1), was first issued in late 1989.

Card Front — Form I-551 is a laminated card. The background is off pink. The agency name is shown in white on a blue background just under the words “RESIDENT ALIEN.” The seal is light blue. The front includes a photograph of the alien's face, fingerprint and signature. An expiration date is always shown. Cards expire 10 years after issue, but may be renewed.

Note: A modified I-551 was first issued in January 1992. All cards issued Feb. 1, 1993, or later are modified. The only difference is a noticeable removal of the background printing behind the fingerprint block.

Card Back — A map of the U.S. appears on the upper portion of the card back, surrounded by an overlapping rainbow print. The lower portion of the back contains four lines of text, the bottom three of which are machine readable and on a white background.

Original I-551

The original Alien Registration Receipt Card (Type 1) was issued from 1977 to late 1989.

Card Front — Form I-551 is a laminated card. The agency name is shown in white on a pastel blue background just under the words "RESIDENT ALIEN." The seal is light pastel blue. The front includes a photograph of the alien's face, fingerprint and signature.

Card Back — A map of the U.S. appears on the card back, overlaid by machine readable typed data. The first digit of the issue/type code indicates the number of alien registration cards issued to the person. The second digit identifies the type card.

I-151

Form I-151 is the version of the Alien Registration Receipt Card issued to aliens by the former Immigration and Naturalization Service (INS) from July 1946 through late 1977. Form I-151 is not a valid immigration document. The card lacks security features and presents more opportunities for alteration and fraud than the immigration documents currently being issued. From 1992 through 1996, the INS conducted a “Green Card Replacement” project to replace the I-151 cards in circulation. Although the card is not a valid immigration document, the person may still retain lawful permanent status.

For pictures of these cards, see Appendix LIV, Description of Resident Alien Cards.

 

D-8730 Refugees

Revision 17-4; Effective December 1, 2017

If an alien presents Form I-766 annotated with "274a.12(a)(3)" or "A3" as evidence of refugee status, query SAVE online to verify the document and status. If the SAVE online response results in a determination of ineligibility, verify alien status using Form G-845 and supplement to Form G-845. The Form I-94 annotated with stamp showing admission under section 207 of the Immigration and Nationality Act (INA) is also a DHS document for refugees.

For a refugee, follow policy in:

• Section D-8310, Qualified Aliens Subject to a Limited Period; or
• Section D-8320, Qualified Aliens Not Subject to a Waiting Period or Limited Period.

 

D-8740 Parolee

Revision 17-4; Effective December 1, 2017

A parolee may present a DHS Form I-94 that indicates the bearer has been paroled pursuant to Section 212(d)(5) of the Immigration and Nationality Act (INA), with an expiration date of at least one year from the date issued or indefinite.

DHS Form I-766 annotated "A4" or "C11" indicates status as a parolee, but does not reflect the length of the parole period.

If the individual cannot provide Form I-94, contact DHS to verify status and length of the parole period before certification.

For a parolee, follow policy in:

• Section D-8310, Qualified Aliens Subject to a Limited Period; or
• Section D-8320, Qualified Aliens Not Subject to a Waiting Period or Limited Period.

 

D-8750 Asylee

Revision 17-4; Effective December 1, 2017

An asylee may present a Department of Homeland Security (DHS) Form I-94 annotated with a stamp showing grant of asylum under Section 208 of the Immigration and Nationality Act (INA), a grant letter from the Asylum Office or an order of an immigration judge.

Derive the date status granted from the date on Form I-94, the grant letter or the date of the court order. If the date is missing from Form I-94, request the grant letter from the alien. If it is not available, verify the date status was granted with DHS.

DHS Form I-766 annotated "A5" indicate status as an asylee. However, the date of the form does not reflect when the status was granted. Request Form I-94, the grant letter from the Asylum Office of DHS or the alien's copy of a court order of the immigration judge granting asylum to obtain the date status was granted. Verify with DHS if none of these are available.

If the alien alleges having been granted asylum within the previous seven years, contact DHS using Form G-845 and Form G-845 supplement with a copy of Form I-551 attached.

For an asylee, follow policy in:

• Section D-8310, Qualified Aliens Subject to a Limited Period; or
• Section D-8320, Qualified Aliens Not Subject to a Waiting Period or Limited Period.

 

D-8760 Deportation Withheld

Revision 17-4; Effective December 1, 2017

For an alien whose deportation was withheld under Section 243(h) of the Immigration and Nationality Act (INA) or whose removal was withheld under Section 241(b)(3) of the INA, obtain one of the following:

•  Form I-766 annotated "A10."
• The alien's copy of the order from an immigration judge showing deportation withheld under Section 243(h) of the INA as in effect prior to 4/1/97 or removal withheld under Section 241(b)(3) of the INA.
• Letter from asylum officer granting withholding of deportation under Section 243(h) of the INA as in effect prior to 4/1/97 or withholding of removal under Section 241(b)(3) of the INA.

Department of Homeland Security (DHS) Form I-766 annotated "A10" indicate deportation was withheld under Section 243(h) of the INA or removal was withheld under Section 241(b)(3) of the INA, but normally do not reflect the date of withholding. Request the alien's copy of the court order to obtain the date of withholding. If not available, verify with DHS.

If the alien alleges having had deportation/removal withheld within the previous seven years, contact DHS using Form G-845 and supplement with a copy of Form I-551 attached.

Note: Aliens who have been granted a suspension of deportation are not eligible for Medicaid benefits on the basis of that status alone. The description and annotations on the DHS documents must be as shown above in order to establish eligibility based on withholding of deportation or removal.

For an alien whose deportation was withheld, follow policy in:

• Section D-8310, Qualified Aliens Subject to a Limited Period; or
• Section D-8320, Qualified Aliens Not Subject to a Waiting Period or Limited Period.

 

D-8770 Cuban/Haitian Entrants

Revision 13-1; Effective March 1, 2013

An alien could meet more than one classification. The seven-year period of limited eligibility, if applicable, begins with the earliest date an alien meets "Cuban/Haitian entrant" classification or one of the other seven-year classifications, such as asylee, refugee, etc. Absent evidence to the contrary, accept any of the following as convincing evidence of Cuban or Haitian nationality for purposes of determining whether an alien is a "Cuban/Haitian entrant:"

• SAVE primary verification (see Section D-8820, Primary Verification of Alien Status).
• DHS or Executive Office of Immigration Review (EOIR) document(s) showing Cuban/Haitian entrant status, or Cuban or Haitian nationality, or Cuba or Haiti as the place of birth.
• Cuban or Haitian passport or identity card.
• Cuban or Haitian birth certificate.
• Secondary verification determination of "Cuban/Haitian entrant" (see Section D-8840, Second Verification of Alien Immigration Status).

For a Cuban/Haitian entrant, follow policy in:

• Section D-8310, Qualified Aliens Subject to a Limited Period; or
• Section D-8320, Qualified Aliens Not Subject to a Waiting Period or Limited Period.

 

D-8780 Qualified Alien Based on Battery or Extreme Cruelty

Revision 17-4; Effective December 1, 2017

An alien who has been, or whose child or parent has been, battered or subjected to extreme cruelty in the United States by a U.S. citizen or lawful permanent resident spouse or parent can be considered a qualified alien.

For the alien and children to emigrate or remain in the United States, the alien’s spouse must file a petition for lawful permanent residence status for the alien relative. Unless the spouse files this petition, the alien and children have no lawful immigrant status and face being deported.

Since the 1994 enactment of the Violence Against Women Act, a battered alien may self-petition for lawful permanent residency via INS Form I-360, Petition for Amerasian, Widow(er) or Special Immigrant, without the cooperation or knowledge of the abuser.

The alien must provide DHS documentation that identifies the alien as the self-petitioning spouse and/or child of an abusive U.S. citizen or lawful permanent resident and does not live with the abuser.

Examples of acceptable DHS documents include:

• I-551 annotated with one of the following status codes: IB-1 to IB-3 or IB-6 to IB-8;
• an I-797, Action Notice, which identifies the alien as a self-petitioning battered alien; or
• other forms of documentation, such as a letter from a DHS judge.

Qualified aliens with a battered alien status do not need to be credited with 40 qualifying quarters of Social Security coverage nor do they have a seven-year limited eligibility period. The following battered aliens meet the alien status criteria if they:

• entered the U.S. and acquired "qualified alien" status prior to Aug. 22, 1996;
• resided in the U.S. before Aug. 22, 1996, adjusted to "qualified alien" status on or after Aug. 22, 1996, and provide proof of continuous residence;
• resided in the U.S. before Aug. 22, 1996, adjusted to "qualified alien" status on or after Aug. 22, 1996, did not provide proof of continuous residence, but meet the five-year waiting period ; or
• entered the U.S. on or after Aug. 22, 1996 and meet the five-year waiting period.

Consider Medicaid for the treatment of an emergency condition when the battered alien does not meet alien status criteria.

 

D-8790 Victims of Severe Human Trafficking

Revision 17-4; Effective December 1, 2017

The U.S. Department of Health and Human Services certifies individuals who meet the victims of severe human trafficking requirements so they may remain in the U.S. up to four years. Law enforcement authorities can extend the status beyond four years for individuals whose presence is required for a continuing investigation.
 
These individuals meet the alien status criteria to be potentially eligible for benefits without a five-year waiting period and continue to meet the eligibility criteria without a limited eligibility period as long as the law enforcement extension continues, or they adjust to another acceptable alien status.
 
Staff must request a copy of the USCIS Notice of Extension to verify the individual has an approved extended Victims of Severe Human Trafficking status based on the law enforcement need. SAVE does not provide verification for victims of trafficking. Staff must call the trafficking verification toll-free number at 866-401-5510 to confirm the validity of the USCIS extension letter.  

After four years or expiration of a law enforcement extension, individuals who have not adjusted to another alien status must leave the U.S. If they remain, they are considered undocumented and ineligible for ongoing benefits.

Revision 17-4; Effective December 1, 2017

The Systematic Alien Verification for Entitlements (SAVE) program's Verification Information System (VIS) is a web-based application that provides alien status information using the applicants' alien registration number.

The SAVE System provides the following types of responses:

• Initial Verification Results: First Name, Last Name, Country, Date of Entry, Date of Birth, Class of Admission (COA) and System Response; and
• Additional Verification Results: Department of Homeland Security (DHS) Response, Expires On, Response Date and DHS Comments.

If the alien’s U.S. Citizenship and Immigration Services (USCIS) document is expired and the SAVE response shows the individual is a Lawful Permanent Resident - Employment Authorized and the Date Admitted is “Response is indefinite,” the individual meets alien status criteria.

Use the SAVE Verification Information System:

• at application;
• when adding a new household member identified as an alien; or
• if a person's alien documentation has expired.

Exceptions:

When SAVE does not contain information about victims of severe trafficking or non-alien family members, call the trafficking verification toll-free number at 866-401-5510 to confirm the validity of the certification letter or Derivative T Visa and to notify the Office of Refugee Resettlement of the benefits for which the individual is applying.

SAVE does not normally contain information about American Indians born outside of the U.S. See Section D-8420, American Indians Born Outside the U.S.

 

D-8810 Getting Permission to Access SAVE

Revision 09-4; Effective December 1, 2009

Supervisors complete and route Form 4743, Request for Applications and System Access, to the regional security officer for employees who need access to the SAVE system.

 

D-8820 Primary Verification of Alien Status

Revision 13-4; Effective December 1, 2013

To obtain primary verification of alien status, follow these steps to access the Systematic Alien Verification for Entitlements (SAVE) System:

1. Open the Verification Information System (VIS) website at https://save.uscis.gov/Web/vislogin.aspx?JS=YES, or in Data Broker through TIERS.
2. Enter your User ID and password.
3. Select Initial Verification from the Case Administration menu. The Initial Verification Information page appears.
4. Enter the document type the applicant provided.
5. Enter the applicant's information as it appears on the document:

• Alien Number – Do not include the letter A when entering the information in SAVE. If the A number has fewer than nine digits, add leading zeros to make it a nine-digit number. USCIS is used on the new I-551 cards instead of Alien Number.
• I-94 Identification Number – Known as the admission number, it consists of an 11-digit field. Enter leading zeros if the I-94 number provided has less than 11 digits.
• Card Number – On older versions of cards, the card number is on the front of the card. It is 13 digits and has three letters in front of the number. On newer versions of the card, the card number is on the back of the card. It is still 13 digits and has three letters in front of the number.
• Last name.
• First name.
• Date of birth.
• Document expiration date, if applicable.

6. Select the benefit type from the Benefits List (Supplemental Nutritional Assistance Program (SNAP) [formerly known as food stamps], Medicaid, TANF).
7. Select Submit Initial Verification. The response appears in the Initial Verification Results section of the same page.
8. The screen displays one of the following messages:

• LAWFUL PERMANENT RESIDENT – EMPLOYMENT AUTHORIZED
• INSTITUTE ADDITIONAL VERIFICATION
• TEMPORARY RESIDENT/TEMPORARY EMPLOYMENT AUTHORIZED

Use the policy found in Section D-8610, Ineligible Aliens, if the message is TEMPORARY RESIDENT/TEMPORARY EMPLOYMENT AUTHORIZED.

9. Review the results and select Print Case Details if using the stand-alone SAVE system. SAVE Case Details should then be imaged and put in the individual's case.

Note: If using Data Broker through TIERS, a copy of the SAVE screen is not needed, as the inquiry will be stored in the Data Broker history.

10. Select Complete and Close Case to close the case (only if additional verification is not necessary). Once a case is closed, the user can view it for an additional 90 days.

Note: Staff should enter the correct alien number as listed on the document, not a default or fictitious number (for example, AAA000000, etc.).

 

D-8830 Additional Verification — Online Process of Alien Status

Revision 09-4; Effective December 1, 2009

To request additional verification:

1. In the Initial Verification Results section, select Request Additional Verification. The Enter Additional Verification Data section appears.
2. Edit the default information, if necessary; enter required information, and include as much information as possible. Use the Special Comments box to enter additional information to the Immigration Status Verifier (ISV) staff.
3. Submit the request by selecting Submit Additional Verification. The response section appears indicating that the request is in process and will return the response within three working days.
4. To view the status of the case, select View Cases from the Case Administration menu. The Case Search page appears.
5. Enter the Case Search Criteria to search for cases based on the following case status:

• all open cases
• cases requiring action
• cases with additional verification responses
• cases in process
• closed cases

Select Display Case Summary List to open the Case Summary List page. The list displays the Case Status for cases that require action, cases in process and closed cases. Click the Verification Number to view the Case Details. The user is able to print the case details, request additional verification and close the case.

If the system is unable to verify the immigration status with the information provided by the user in the automated additional verification request, or the document appears counterfeit, altered or expired, use the manual process in Section D-8840, Secondary Verification of Alien Immigration Status.

 

D-8840 Secondary Verification of Alien Immigration Status

Revision 19-4; Effective December 1, 2019

If staff are unable to verify an alien's immigration status through primary verification procedures, use SAVE to request additional information from the U.S. Citizenship and Immigration Services (USCIS) by requesting a Data Broker Combined Report through TIERS or the Data Broker Portal.

Once a request from USCIS is obtained for verification of immigration status, the information received must be processed. Staff receive one of the following responses from SAVE via the Combined Report in TIERS or in the Data Broker Portal:

• 1st Level Verification - initial verification request in TIERS;
• 2nd Level Verification - situations that require additional (secondary) verification in the Data Broker Portal; and
• 3rd Level Verification - situations that require staff to upload documents for verification in the Data Broker Portal via SAVE.

For the 1st Level Verification, staff enter the information provided by the person into TIERS. Once the information is entered and SAVE is requested, SAVE will return an immediate response back indicating if the information entered was able to be verified with USCIS or if more information is needed.

If the information entered can be verified on the 1st Level Verification, staff will see the alien status, category code, and entry date. If the information entered is unable to be verified against USCIS records, then staff will have to proceed to 2nd or 3rd Level Verification responses to correctly verify the person’s citizenship and alien status.

For 2nd Level Verification and 3rd Level Verification responses, Data Broker automatically requests additional verification from SAVE. Once obtained from SAVE, staff receive an email from the Data Broker vendor notifying them that the verification requested has been returned from SAVE.

For 2nd Level Verification responses:

• The Data Broker vendor sends a subsequent email notifying staff that the verification has been returned from SAVE.
• Staff must then:
  • login to the Data Broker Portal to retrieve the information; and
  • update the Alien/Refugee Details page in TIERS accordingly.

For 3rd Level Verification responses:

• Staff must:
  • upload the verification documents requested into the Data Broker Portal;
  • not mail the documents to USCIS; and
  • ensure only one PDF file containing all required verification documents is uploaded.
• The Data Broker vendor sends a subsequent email notifying staff SAVE has returned the verification.
  • staff must then login to the Data Broker Portal to retrieve the information; and
  • update the Alien/Refugee Details page in TIERS accordingly.

Note: SAVE only populates alien sponsor information into TIERS for the additional verification response. This is unlike initial verification that populates the response data for the applicant in the appropriate ELDS tables on the TIERS Alien/Refugee-Details page.

Related Policy

Documentation and Verification Guide, Appendix XVI
Initial Request at Time of Application, D-5510
Verification of Alien Status, D-8700
Documentary Evidence by Classification, D-8710
Reasonable Opportunity to Provide Verification of Alien Immigration Status, D-8841
Entry Before 1996, D-8910
Entry on or After Aug.22,1996-Qualifed Alien No Waiting Period, D-8920
LPR Aliens With or Without Five-Year Waiting Period, D-8930

 

D-8841 Reasonable Opportunity to Provide Verification of Alien Immigration Status

Revision 14-2; Effective June 1, 2014

If you are unable to verify an alien's immigration status through primary or secondary verification procedures, allow the applicant a reasonable opportunity of 95 days following the date on which a notice is sent to an individual to provide another source of citizenship or alien status verification.

Revision 13-1; Effective March 1, 2013

An alien's eligibility is based on the Department of Homeland Security’s qualifying classification and other criteria as shown in the MEPDH and in the following charts.

D-8910 Entry Before 1996

Revision 17-4; Effective December 1, 2017

Chart A — Entry Before 1996

If the alien entered the U.S. before Aug. 22, 1996, and the USCIS document is an ...

then the alien is ...

I-94 annotated with one of the following INA sections: 207 – Refugee 208 – Asylee 241(b)(3) or 243(h) – Deportation Withheld 212(d)(5) – Cuban/Haitian Entrant 212(d)(5) – showing admission for at least one year – Parolee 203(a)(7) – Conditional Entrant I-766, employment authorization document annotated with one of the following status codes: A3 – Refugee A3 – Conditional Entrant A5 – Asylee A10 – Deportation Withheld I-551 annotated with one of the following status codes: AM1, AM2, AM3, AM6, AM7 or AM8 – Amerasians R8-6 or RE1 to RE9 – Refugees AS6 to AS9 – Asylees R8-6, CH-6, CU-6 or CU-7 – Cuban/Haitian Entrants U.S. Citizenship and Immigration Services (USCIS) letter from Asylum Office Order from an immigration judge: granting asylum, or showing deportation withheld under INA Section 243(h) or 241(b)(3). Consider the date of entry as the date the status is assigned.

eligible if the alien meets the criteria in Section D-8320, Qualified Aliens Not Subject to a Waiting Period or Limited Period. Unless the alien meets the criteria in Section D-8320, consider Medicaid for the treatment of an emergency medical condition.

Note:  Follow your policy clearance request procedures for questions about documents or immigration statuses not listed in this chart.

D-8920 Entry On or After Aug. 22, 1996 – Qualified Alien No Waiting Period

Revision 23-2; Effective June 1, 2023

Chart B — Entry On or After Aug. 22, 1996 – Qualified Aliens With No Waiting Period

If the alien entered the U.S. on or after Aug. 22, 1996, and the USCIS document is an	and
I-94 annotated with one of the following INA sections: 207 – Refugee 208 – Asylee 243(h) or 241(b)(3) – Deportation Withheld 212(d)(5) – Cuban/Haitian Entrant I-766, employment authorization document annotated with one of the following status codes: A3 – Refugee A5 – Asylee A10 – Deportation Withheld I-551 annotated with one of the following status codes: AM1, AM2, AM3, AM6, AM7 or AM8 – Amerasians R8-6 or RE1 to RE9 – Refugees USCIS letter from Asylum Office Derivative T visa annotated with T-1 – victim of severe trafficking (four-year limit) Derivative T visa annotated with T-2, T-3, T-4 or T-5 – family member of victim of severe trafficking (four-year limit) Original certification letter from Office of Refugee Resettlement (ORR) Order from an immigration judge: granting asylum; or showing deportation withheld under INA Section 243(h) or 241(b)(3). Consider the date of entry as the date the status is assigned.	If less than seven years have passed since the date of qualified alien classification, usually the entry date, then the alien is eligible if the alien meets the criteria in as a qualified alien subject to a seven-year limited period. Unless the alien meets the criteria as a qualified alien subject to a seven-year limited period, consider Medicaid for the treatment of an emergency medical condition. Note: Victims of Severe Human Trafficking are limited to four years unless status is extended by law enforcement. If seven years or more have passed from the date of qualified alien classification, usually the entry date, then the alien is eligible if the alien meets the criteria as a qualified alien not subject to a waiting period or limited period. Unless the alien meets the criteria as a qualified alien not subject to a waiting period or limited period, consider Medicaid for the treatment of an emergency medical condition. Note: The refugee retains this eligibility period even if the refugee has adjusted to lawful permanent resident (LPR) status during the seven-year limited period.
I-94 annotated with one of the following INA sections: Section 212(d)(5) – showing admission for at least one year – Parolee Section 203(a)(7) – Conditional Entrant	Not eligible, unless the alien has applied for and been approved by DHS for LPR. If LPR, the alien must meet the LPR conditions as a qualified alien not subject to a waiting period or limited period. Unless the alien meets the criteria as a qualified alien subject to a seven-year limited period, consider Medicaid for the treatment of an emergency medical condition.
Afghan or Iraqi Special Immigrant – Special immigrant status under 101(a)(27) of the INA may be granted to Iraqi and Afghan nationals who have worked on behalf of the U.S. government in Iraq or Afghanistan. Acceptable documentation includes: Passport with a Machine Readable Immigrant Visa (MRIV) or stamp noting that the person has been admitted under a special immigrant visa category IV with one of the following codes: SI-1 or SQ-1 for the principal applicant; SI-2 or SQ-2 for the spouse of the principal applicant; or SI-3 or SQ-3 for the unmarried child under 21 of the principal applicant; and a DHS stamp or notation on the passport (includes DHS/CBP or DHS/USCIS temporary Form I-551 Alien Documentation Identification and Telecommunication (ADIT) stamp) or I-94 showing the date of entry.      or I-551 annotated with an IV code for category SQ-1, SQ-2 or SQ-3. or I-765, Employment Authorization Document (EAD) receipt notice with code SQ-1, SQ-2, SQ-3, SQ-6, SQ-7, and SQ-8. or I-766, Employment Authorization Document (EAD), with code SQ-1, SQ-2, SQ-3, SQ-6, SQ-7, and SQ-8. For special immigrants who are Special Immigrant Parolees (SI/SQ Parole), acceptable documentation includes: I-94 noting Special Immigrant Status (SQ/SI) Parole Section 602(B)(1) AAPA/Sec 1059(a) NDAA 2006 or SQ4/SQ5 SI Parolee notation signed and dated by a USCIS officer: SQ-4 for the principal applicant; or SQ-5 for the spouse or unmarried child under 21 of the principal applicant. or I-765, Employment Authorization Document (EAD), receipt notice with code C11. or I-766, Employment Authorization Document (EAD), with code C11. For special immigrants who are adjusting to LPR status in the U.S., acceptable documentation includes: I-551 annotated with one of the following status codes: SI-6 or SQ-6 for the principal applicant; SI-7 or SQ-7 for the spouse of the principal applicant; or SI-8 or SQ-8 for the unmarried child under 21 of the principal applicant. These special immigrants may also demonstrate nationality with an Afghan or Iraqi passport. For special immigrants who are conditional permanent residents (SI CPRs) adjusting to LPR status in the U.S., acceptable documentation includes: Passport with an MRIV or DHS/CBP stamp noting admission under IV Category with one of the following codes: CQ1 for the principal applicant; CQ2 for the spouse of principal applicant; or CQ3 for the unmarried child under 21 of principal applicant, and a DHS stamp or notation on passport (includes DHS/CBP or DHS/USCIS temporary Form I-551 Alien Documentation Identification and Telecommunication (ADIT) stamp) or I-94, showing the date of entry.      or I-551 with an IV code for category CQ-1, CQ-2, or CQ-3.      or I-765, Employment Authorization Document (EAD) receipt notice with code C11.     or I-766, Employment Authorization Document (EAD), with code C11. Note: The entry date for an Afghan special immigrant must be Dec. 26, 2007, or later. The entry date for an Iraqi special immigrant's entry date must be Jan. 26, 2008, or later.	If less than seven years have passed since the date of qualified alien classification, usually the entry date, then the alien is eligible if the alien meets the criteria as a qualified alien subject to a seven-year limited period. Unless the alien meets the criteria as a qualified alien subject to a seven-year limited period, consider Medicaid for the treatment of an emergency medical condition. If seven years or more have passed from the date of qualified alien classification, usually the entry date, then the alien is eligible if the alien meets the criteria in as a qualified alien not subject to a waiting period or limited period. Unless the alien meets the criteria as a qualified alien subject to a seven-year limited period, consider Medicaid for the treatment of an emergency medical condition. Note: The special immigrant retains this eligibility period even if the special immigrant has adjusted to LPR status during the seven-year limited period.

Note: Submit Form H0005, Policy Clarification Request, for questions about documents or immigration statuses not listed in this chart.

Related Policy

Qualified Aliens Subject to a Seven-Year Limited Period, D-8310

Qualified Aliens Not Subject to a Waiting Period or Limited Period, D-8320 
 

D-8930 LPR Aliens With or Without Five-Year Waiting Period

Revision 17-4; Effective December 1, 2017

Chart B — Entry On or After Aug. 22, 1996 – Qualified Aliens With No Waiting Period

If the LPR alien entered the U.S. on or after Aug. 22, 1996, and the DHS document is an ...

then ...

I-551, Resident Alien Card, and does not meet one of the classification codes in Charts A or B,   Notes: Any status code that appears on the I-551 is acceptable. No I-151s were issued after 1978; therefore, any alien admitted after 1978 will have an I-551. If the LPR alien loses the I-551, the LPR alien may present either an I-94 or a passport with the following annotation: "Processed for I-551, Temporary Evidence of Lawful Admission for Permanent Residence, valid until ______, Employment Authorized." Allow aliens with a DHS document or card showing an entry date on or after Aug. 22, 1996, who claim to have entered before that date, an opportunity to submit evidence of their claimed date of entry.

If five years or less have passed since the date of qualified alien classification, usually the entry date, then the LPR alien is not eligible. Unless the alien meets criteria other than 40 qualifying quarters in Section D-8320, Qualified Aliens Not Subject to a Waiting Period or Limited Period, the LPR alien is only potentially eligible for Medicaid for the treatment of an emergency medical condition during the five-year waiting period. (Having 40 qualifying quarters does not exempt a person from the five-year waiting period.) If more than five years have passed since the date of qualified alien classification, usually the entry date, then the LPR alien is eligible if the LPR alien meets the criteria in Section D-8320. Unless the LPR alien meets the criteria in Section D-8320, consider Medicaid for the treatment of an emergency medical condition.

Chart C — LPR Aliens With or Without the Five-Year Waiting Period

If the LPR alien entered the U.S. before Aug. 22, 1996, and the DHS document is an ...

then ...

I-551, Resident Alien Card, and does not meet one of the classification codes in Charts A or B, Notes: Any status code that appears on the I-551 is acceptable. No I-151s were issued after 1978; therefore, any alien admitted after 1978 will have an I-551. If the LAPR alien loses the I-551, the LAPR alien may present either an I-94 or a passport with the following annotation: "Processed for I-551, Temporary Evidence of Lawful Admission for Permanent Residence, valid until ______, Employment Authorized." Allow aliens with a DHS document or card showing an entry date on or after Aug. 22, 1996, who claim to have entered before that date, an opportunity to submit evidence of their claimed date of entry.

The LPR alien is eligible if the LPR alien meets the criteria in Section D-8320, Qualified Aliens Not Subject to a Waiting Period or Limited Period, or Section D-8430, LPR Residing in the U.S. on Aug. 22, 1996. Unless the LPR alien meets the criteria in Section D-8320 or Section D-8430, consider Medicaid for the treatment of an emergency medical condition.

Follow your policy clearance request procedures for questions about documents or immigration statuses not listed in this chart.

D-8940 Reserved for Future Use

Revision 17-4; Effective December 1, 2017

 

Revision 12-4; Effective December 1, 2012

A sponsored alien is an individual who has been sponsored by a person who signed an affidavit of support (USCIS Form I-864, Affidavit of Support Under Section 213A of the Act, or USCIS Form I-864-A, Contract Between Sponsor and Household Member) on or after Dec. 19, 1997, agreeing to support the alien as a condition of the alien's entry into the U.S.

A sponsor is someone who brings family-based or certain employment-based immigrants to the U.S. and demonstrates that he can provide enough financial support to the immigrant so the individual does not rely on public benefits.

Revision 16-3; Effective September 1, 2016

Note: Sponsor-to-alien deeming policy does not apply to individuals applying for Emergency Medicaid Coverage for Aliens. Please see Section A-2200 for more.

The applicant/recipient must first be eligible based on all eligibility criteria before proceeding with sponsor-to-alien deeming.

Keep in mind that most alien applicants who have sponsors will not be eligible aliens. One example of a sponsored alien who could be eligible (and subject to sponsor-to-alien deeming) is a sponsored legally admitted for permanent residence (LAPR) alien who is the spouse of a veteran of the U.S. Armed Forces.

Deeming of income and resources for the eligibility and copayment budgets apply regardless of whether:

• the alien and sponsor live in the same household;
• the income and resources are actually available to the alien; and
• the type of assistance for which the alien is applying.

This is because the sponsor agreed to support the alien as a condition of the alien's admission to the U.S. when signing the affidavit of support.

If the alien's sponsor is the alien's ineligible spouse or parent, sponsor deeming, not spouse-to-spouse or parent-to-child deeming, applies in the case. If sponsor deeming does not apply, for instance the alien has 40 qualifying quarters or meets another exception in D-9220, then apply spouse-to-spouse or parent-to-child deeming.

The income and resources of the sponsor's spouse are included if the sponsor and his or her spouse live in the same household.

For deeming purposes, a sponsor does not include an organization such as a church congregation or a service club, or an employer who only guarantees employment for an alien upon entry to the U.S. but does not sign an affidavit of support.

 

D-9210 Deeming Period

Revision 12-4; Effective December 1, 2012

The income and resources of an alien are deemed to include the income and resources of the alien's sponsor beginning from the alien's date of admission into the U.S.

The date of admission is the date established by the U.S. Citizenship and Immigration Services as the date the alien is admitted for permanent residence.

Deeming ceases to apply the month after the month:

• the alien becomes a naturalized citizen of the U.S.;
• the sponsor dies; or
• the alien is no longer LAPR and has departed the U.S.

Deeming ceases to apply in the month the LAPR alien can be credited with 40 quarters.

If none of the above events occurs, deeming continues indefinitely.

 

D-9220 Deeming Exceptions

Revision 12-4; Effective December 1, 2012

Sponsor-to-alien deeming does not apply to all aliens.

Deeming does not apply to aliens:

• who were sponsored by an organization or are not required to have sponsors,
• with 40 qualifying quarters,
• with refugee status,
• with asylee status,
• whose deportation has been withheld.

Exceptions also apply when:

• a qualified alien, a qualified alien's child or a qualified alien child's parent has been battered or subjected to extreme cruelty in the U.S., and
  • there is a substantial connection between the battery and the need for benefits, and
  • the individual subject to such battery or cruelty does not live in the same household with the individual responsible for the cruelty or battery, and
  • the Department of Homeland Security (DHS) or the Executive Office for Immigration Review (EOIR) has approved the alien's petition, or has found that the alien's pending petition sets forth a prima facie case, under one of the provisions of the Immigration and Naturalization Act (INA).
    
    Note: When the battery exception is allowed, deeming can be suspended for 12 months. After 12 months, the exception can be continued only under certain specified conditions and on a case-by-case basis.
• sponsor deeming results in denial and the alien is unable to obtain both food and shelter. In determining whether the alien is unable to obtain both food and shelter, consider:
  • all of the alien's own income and resources (including income excluded when determining eligibility); and
  • any cash, food, housing or other assistance provided by other individuals (including the sponsor).
  
  When deeming is suspended under this exception, the only income from the sponsor that is included as the alien's income is the amount of cash or support and maintenance the alien actually receives from the sponsor. A sponsor's resources are considered to be the alien's resources only if the alien has an ownership interest in them, can convert them (if not cash), and is not restricted from using them.
  
  The sponsor may be liable for repayment of benefits received by the alien applicant/recipient when deeming is suspended under this exception.
  
  Note: When this exception is allowed, deeming is suspended for 12 consecutive months. Multiple occurrences of this exception are permissible.

 

D-9230 Providing Verification of Alien Sponsor's Income and Resources

Revision 12-4; Effective December 1, 2012

When sponsor-to-alien deeming applies, the alien is responsible for providing

• a copy of the sponsor's affidavit of support (USCIS Form I-864 or USCIS Form I-864A); or
• name, address and phone number of sponsor and any co-sponsor(s);
• verification of the sponsor's and sponsor's spouse's income and resources; and
• the number of tax dependents claimed by sponsor and sponsor's spouse.

Reminder: Sponsor's spouse's information is required when he is the co-sponsor or lives in the same household as the sponsor.

If the alien fails to provide the requested sponsor verification by the required date, deny the application based on failure to furnish information.

Note: Normal verification procedures apply. For instance, if the type of assistance allows for acceptance of verbal statements as verification, accept the applicant/recipient's declaration for the required information.

Revision 12-4; Effective December 1, 2012

Evaluate the resources of an alien's sponsor and the sponsor's spouse (if living in the same household). Before deeming a sponsor's resources to an alien, allow the same exclusions to the sponsor's resources as for the applicant/recipient.

Next, allocate for the sponsor or for the sponsor and his spouse a portion of the resources. The amount of the allocation is based on the following.

• Sponsor Does Not Live With a Spouse or Spouse is the Applicant/Recipient – equal to the SSI resource limit for an individual.
• Sponsor Lives With a Spouse and Spouse is Not Alien's Sponsor – equal to the SSI resource limit for a couple.
• Sponsor Lives With a Spouse and Spouse is Also a Sponsor of the Alien – equal to the SSI resource limit for two individuals (twice the SSI individual limit).

Add the remainder to the alien's countable resources. If both members of an eligible couple have the same sponsor, the entire amount of the sponsor's resources is deemed to each member. The couple's countable resources include the sum of their deemed resource amounts.

If an alien is sponsored by more than one individual (other than two sponsors who are married to each other and living together), the sponsor-to-alien deeming rules are applied separately to the resources of each sponsor to determine the total resources deemable to the alien.

If only one member of a couple is sponsored, and that member is an ineligible spouse, sponsor-to-alien deeming does not apply to the eligible member of the couple (nor would it be applicable to the ineligible member of the couple).

 

D-9310 Examples of Sponsor-to-Alien Resource Deeming

Revision 12-4; Effective December 1, 2012

Example 1: Sponsor does not live with spouse

After applying all applicable resource exclusions, the specialist determines the sponsor has $3,200 in countable resources. The current resource limit for an individual is $2,000.

$1,200 ($3,200-$2,000) of the sponsor's resources is deemed to the alien.

Example 2: Sponsor lives with non-sponsor spouse

After applying all applicable resource exclusions, the specialist determines the sponsor and sponsor's spouse have combined countable resources of $3,500. The current resource limit for a couple is $3,000.

$500 ($3,500-$3,000) of the sponsor's and sponsor's spouse's resources is deemed to the alien.

Example 3: Sponsor lives with spouse, who is also alien's sponsor

After applying all applicable resource exclusions, the specialist determines the sponsor and sponsor's spouse have combined countable resources of $3,500. The current resource limit for an individual is $2,000.

None of the sponsor's and sponsor's spouse's resources are deemed to the alien, since their value is under $4,000 (twice the individual resource limit of $2,000).

Revision 15-4; Effective December 1, 2015

Evaluate the earned and unearned income of an alien's sponsor and the sponsor's spouse (if living in the same household). Unlike the treatment of resources, the sponsor's income does not receive the same income exclusions given to an applicant.

Include all the income of a sponsor of an alien and, when applicable, the income of the spouse of the sponsor, except for support and maintenance assistance and income excluded under federal laws other than the Social Security Act. See D-9500, Income Excluded from Sponsor-to-Alien Deeming, for a list of this excluded income.

Allocations are given to the sponsor and the sponsor's dependents, if applicable. A dependent is defined as someone for whom the sponsor is entitled to take a deduction on his personal income tax return.

Exception: An alien and an alien's spouse are not considered to be dependents of the alien's sponsor for the purposes of these rules.

The dependent's income is not subtracted from the dependent's allocation.

Next, deduct allocations for the sponsor and the sponsor's dependents as follows:

• an amount equal to the federal benefit rate (FBR) for an individual for the sponsor;
• an amount equal to one-half the FBR for an individual for the spouse living in the same household with the sponsor or an amount equal to the FBR for an individual for the spouse who is also a co-sponsor (spouse allocation is not applicable if the spouse is the applicant/recipient); plus
• an amount equal to one-half the FBR for an individual for each dependent of the sponsor. (If both members of a couple are sponsors, only one allocation is given for each dependent even if the person is a dependent of both spouses.)

Deem the balance of the income to the alien as unearned income. If both members of an eligible couple have the same sponsor, the sponsor's income is deemed to each member. The couple's countable income includes the sum of their deemed income amounts.

If an alien is sponsored by more than one individual (other than two sponsors who are married to each other and living together), the sponsor-to-alien deeming rules are applied separately to the income of each sponsor to determine the total income deemable to the alien.

If only one member of a couple is sponsored and that member is an ineligible spouse, sponsor-to-alien deeming does not apply to the eligible member of the couple (nor would it be applicable to the ineligible member of the couple).

Note: When the sponsor's income is deemed to the alien applicant/recipient, cash, support and maintenance provided by the sponsor are not counted as income unless the indigence exception is granted. See D-9220, Deeming Exceptions.

D-9410 Examples of Sponsor-to-Alien Income Deeming

Revision 24-1; Effective March 1, 2024

The following examples are for demonstration purposes only. They may not reflect the most recent federal benefit rate (FBR) amounts.

Example 1: Sponsor lives with non-sponsor spouse and children. Only the sponsor has income.

An alien applicant has no income, and the sponsor has a monthly earned income of $3,300 and unearned income of $70. The sponsor's dependents (spouse and three children) have no income.

Add the sponsor's earned and unearned income for a total of $3,370 and apply the allocations for the sponsor and his or her dependents.

Total allocations equal $2,829:

• $943 (FBR for an individual) for the sponsor;
• + $471.50 (one-half the FBR for an individual) for the non-sponsor spouse; and
• + $1414.50 (one-half the FBR for an individual, $471.50 each) for the sponsor's three children.

Deduct the allocation amount of $2,829 from the sponsor's total income of $3,370, which leaves $541 to be deemed to the alien as his or her unearned income. This amount is subject to the $20 general income exclusion when determining his or her eligibility.

Example 2: Sponsor lives with non-sponsor spouse and children. Both the sponsor and spouse have income.

An alien couple with no income applies for benefits. The sponsor has earned income of $2,350, and the non-sponsor spouse has earned income of $450. Their two children have no income.

Combine the sponsor's and spouse's income for a total of $2,800 ($2,350 + $450) and apply the allocations for the sponsor and his or her dependents.

Total allocations equal $2,357.50:

• $943 (FBR for an individual) for the sponsor;
• + $471.50 (one-half the FBR for an individual) for the non-sponsor spouse; and
• + $943 (one-half the FBR for an individual, $471.50 each) for the sponsor's two children.

Deduct the allocation amount of $2,357.50 from the sponsor's and spouse's total income of $2,800, which leaves $442.50. This amount must be deemed independently to each applicant. The $885 deemed income ($442.50 each) is unearned income to the alien couple and is subject to the $20 general income exclusion when determining the couple's eligibility.

Example 3: Sponsor lives with spouse, who is also alien's sponsor, and children. Both sponsors have income.

An alien couple with no income is applying for benefits. The sponsor has an earned income of $2,350, and the co-sponsor, who lives with them, has an earned income of $650. Their two children have no income.

Combine the sponsor's and co-sponsor's income for a total of $3,000 ($2,350 + $650) and apply the allocations for the sponsors and dependents.

Total allocations equal $2,829:

• $1,886 (two times the FBR for an individual, $943 each) for the sponsor and co-sponsor; and
• + $943 (one-half the FBR for an individual, $471.50 each) for the two children.

Deduct the allocation amount of $2,829 from the sponsors' total income of $3,000, which leaves $171. This amount must be deemed independently to each applicant. The $342 deemed income ($171 each) is unearned income to the alien couple. It is subject to the $20 general income exclusion when determining the couple's eligibility.

D-9510 Food

Revision 12-4; Effective December 1, 2012

• Value of food coupons under the Food Stamp Act of 1977, Section 1301 of Pub. L. 95-113 (91 Stat. 968, 7 USC 2017(b)).
• Value of federally donated foods distributed under Section 32 of Pub. L. 74-320 (49 Stat. 774) or Section 416 of the Agriculture Act of 1949 (63 Stat. 1058, 7 CFR 250.6(e)(9)).
• Value of free or reduced-price food for women and children under the:
  • Child Nutrition Act of 1966, Section 11(b) of Pub. L. 89-642 (80 Stat. 889, 42 USC 1780(b)) and Section 17 of that Act as added by Pub. L. 92-433 (86 Stat. 729, 42 USC 1786); and
  • National School Lunch Act, Section 13(h)(3), as amended by Section 3 of Pub. L. 90-302 (82 Stat. 119, 42 USC 1761(h)(3)).
• Services, except for wages paid to residents who assist in providing congregate services such as meals and personal care, provided a resident of an eligible housing project under a congregate services program under Section 802 of the Cranston-Gonzales National Affordable Housing Act, Public Law 101-625 (104 Stat. 4313, 42 USC 8011).

 

D-9520 Housing and Utilities

Revision 12-4; Effective December 1, 2012

• Assistance to prevent fuel cut-offs and to promote energy efficiency under the Emergency Energy Conservation Services Program or the Energy Crisis Assistance Program as authorized by Section 222(a)(5) of the Economic Opportunity Act of 1964, as amended by Section 5(d)(1) of Pub. L. No. 93-644 and Section 5(a)(2) of Pub. L. 95-568 (88 Stat. 2294 as amended, 42 USC 2809(a)(5)).
• Home energy assistance payments or allowances under title XXVI of the Omnibus Budget Reconciliation Act of 1981, Public Law 97-35, as amended (42 USC 8624(f)).
  
  Note: This exclusion applies to a sponsor's income only if the alien is living in the housing unit for which the sponsor receives the home energy assistance payments or allowances.
• Value of any assistance paid with respect to a dwelling unit under:
  • the United States Housing Act of 1937;
  • the National Housing Act;
  • Section 101 of the Housing and Urban Development Act of 1965; or
  • Title V of the Housing Act of 1949.
  
  Note: This exclusion applies to a sponsor's income only if the alien is living in the housing unit for which the sponsor receives the housing assistance.
• Payments for relocating, made to persons displaced by federal or federally assisted programs, which acquire real property, under Section 216 of Pub. L. 91-646, the Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970 (84 Stat. 1902, 42 USC 4636).

 

D-9530 Education and Employment

Revision 12-4; Effective December 1, 2012

• Grants or loans to undergraduate students made or insured under programs administered by the Secretary of Education under Section 507 of the Higher Education Amendments of 1968, Pub. L. 90-575 (82 Stat. 1063).
• Any wages, allowances or reimbursement for transportation and attendant care costs, unless excepted on a case-by-case basis, when received by an eligible handicapped individual employed in a project under title VI of the Rehabilitation Act of 1973 as added by title II of Pub. L. 95-602 (92 Stat. 2992, 29 USC 795(b)(c)).
• Student financial assistance for attendance costs received from a program funded in whole or in part under Title IV of the Higher Education Act of 1965, as amended, or under Bureau of Indian Affairs student assistance programs if it is made available for tuition and fees normally assessed a student carrying the same academic workload, as determined by the institution, including costs for rental or purchase of any equipment, materials or supplies required of all students in the same course of study and an allowance for books, supplies, transportation and miscellaneous personal expenses for a student attending the institution on at least a half-time basis, as determined by the institution, under Section 14(27) of Public Law 100-50, the Higher Education Technical Amendments Act of 1987 (20 USC 1087uu).

 

D-9540 Native Americans

Revision 12-4; Effective December 1, 2012

• Types of Payments Excluded Without Regard to Specific Tribes or Groups
  • Indian judgment funds that are held in trust by the Secretary of the Interior or distributed per capita pursuant to a plan prepared by the Secretary of the Interior and not disapproved by a joint resolution of Congress under Public Law 93-134 as amended by Section 4 of Public Law 97-458 (96 Stat. 2513, 25 USC 1408). Indian judgment funds include interest and investment income accrued while such funds are so held in trust. This exclusion extends to initial purchases made with Indian judgment funds. This exclusion does not apply to sales or conversions of initial purchases or to subsequent purchases.
    
    Note: This exclusion applies to the income of sponsors of aliens only if the alien lives in the sponsor's household.
  • All funds held in trust by the Secretary of the Interior for an Indian tribe and distributed per capita to a member of that tribe are excluded from income under Public Law 98-64 (97 Stat. 365, 25 USC 117b). Funds held by Alaska Native Regional and Village Corporations (ANRVC) are not held in trust by the Secretary of the Interior and therefore ANRVC dividend distributions are not excluded from countable income under this exclusion.
    
    Note: This exclusion applies to the income of sponsors of aliens only if the alien lives in the sponsor's household.
  • Up to $2,000 per year received by Indians that is derived from individual interests in trust or restricted lands under Section 13736 of Public Law 103-66 (107 Stat. 663, 25 USC 1408, as amended).
• Payments to Members of Specific Indian Tribes and Groups
  • Per capita payments to members of the Red Lake Band of Chippewa Indians from the proceeds of the sale of timber and lumber on the Red Lake Reservation under Section 3 of Public Law 85-794 (72 Stat. 958).
  • Per capita distribution payments by the Blackfeet and Gros Ventre tribal governments to members that resulted from judgment funds to the tribes under Section 4 of Public Law 92-254 (86 Stat. 65) and under Section 6 of Public Law 97-408 (96 Stat. 2036).
  • Settlement fund payments and the availability of such funds to members of the Hopi and Navajo Tribes under Section 22 of Public Law 93-531 (88 Stat. 1722) as amended by Public Law 96-305 (94 Stat. 929).
    
    Note: This exclusion applies to the income of sponsors of aliens only if the alien lives in the sponsor's household.
  • Judgment funds distributed per capita to, or held in trust for, members of the Sac and Fox Indian Nation, and the availability of such funds under Section 6 of Public Law 94-189 (89 Stat. 1094).
    
    Note:This exclusion applies to the income of sponsors of aliens only if the alien lives in the sponsor's household.
  • Judgment funds distributed per capita to, or held in trust for, members of the Grand River Band of Ottawa Indians, and the availability of such funds under Section 6 of Public Law 94-540 (90 Stat. 2504).
    
    Note: This exclusion applies to the income of sponsors of aliens only if the alien lives in the sponsor's household.
  • Any judgment funds distributed per capita to members of the Confederated Tribes and Bands of the Yakima Indian Nation or the Apache Tribe of the Mescalero Reservation under Section 2 of Public Law 95-433 (92 Stat. 1047, 25 USC 609c-1).
  • Any judgment funds distributed per capita or made available for programs for members of the Delaware Tribe of Indians and the absentee Delaware Tribe of Western Oklahoma under Section 8 of Public Law 96-318 (94 Stat. 971).
  • All funds and distributions to members of the Passamaquoddy Tribe, the Penobscot Nation and the Houlton Band of Maliseet Indians under the Maine Indian Claims Settlement Act, and the availability of such funds under Section 9 of Public Law 96-420 (94 Stat. 1795, 25 USC 1728(c)).
    
    Note: This exclusion applies to the income of sponsors of aliens only if the alien lives in the sponsor's household.
  • Any distributions of judgment funds to members of the San Carlos Apache Indian Tribe of Arizona under Section 7 of Public Law 93-134 (87 Stat. 468) and Public Law 97-95 (95 Stat. 1206).
    
    Note:This exclusion applies to the income of sponsors of aliens only if the alien lives in the sponsor's household.
  • Any distribution of judgment funds to members of the Wyandot Tribe of Indians of Oklahoma under Section 6 of Public Law 97-371 (96 Stat. 1814).
  • Distributions of judgment funds to members of the Shawnee Tribe of Indians (Absentee Shawnee Tribe of Oklahoma, the Eastern Shawnee Tribe of Oklahoma and the Cherokee Band of Shawnee descendants) under Section 7 of Public Law 97-372 (96 Stat. 1816).
  • Judgment funds distributed per capita or made available for programs for members of the Miami Tribe of Oklahoma and the Miami Indians of Indiana under Section 7 of Public Law 97-376 (96 Stat. 1829).
  • Distributions of judgment funds to members of the Clallam Tribe of Indians of the State of Washington (Port Gamble Indian Community, Lower Elwha Tribal Community and the Jamestown Band of Clallam Indians) under Section 6 of Public Law 97-402 (96 Stat. 2021).
  • Judgment funds distributed per capita or made available for programs for members of the Pembina Chippewa Indians (Turtle Mountain Band of Chippewa Indians, Chippewa Cree Tribe of Rocky Boy's Reservation, Minnesota Chippewa Tribe, Little Shell Band of the Chippewa Indians of Montana, and the nonmember Pembina descendants) under Section 9 of Public Law 97-403 (96 Stat. 2025).
  • Per capita distributions of judgment funds to members of the Assiniboine Tribe of Fort Belknap Indian Community and the Papago Tribe of Arizona under Sections 6 and 8(d) of Public Law 97-408 (96 Stat. 2036, 2038).
  • Up to $2,000 of per capita distributions of judgment funds to members of the Confederated Tribes of the Warm Springs Reservation under Section 4 of Public Law 97-436 (96 Stat. 2284).
    
    Note: This exclusion applies to the income of sponsors of aliens only if the alien lives in the sponsor's household.
  • Judgment funds distributed to the Red Lake Band of Chippewa Indians under Section 3 of Public Law 98-123 (97 Stat. 816).
  • Funds distributed per capita or family interest payments for members of the Assiniboine Tribe of Fort Belknap Indian Community of Montana and the Assiniboine Tribe of the Fort Peck Indian Reservation of Montana under Section 5 of Public Law 98-124 (97 Stat. 818).
  • Distributions of judgment funds and income derived therefrom to members of the Shoalwater Bay Indian Tribe under Section 5 of Public Law 98-432 (98 Stat. 1672).
  • All distributions to heirs of certain deceased Indians under Section 8 of the Old Age Assistance Claims Settlement Act, Public Law 98-500 (98 Stat. 2319).
    
    Note: This exclusion applies to the income of sponsors of aliens only if the alien lives in the sponsor's household.
  • Judgment funds distributed per capita or made available for any tribal program for members of the Wyandotte Tribe of Oklahoma and the Absentee Wyandottes under Section 106 of Public Law 98-602 (98 Stat. 3151).
  • Per capita and dividend payment distributions of judgment funds to members of the Santee Sioux Tribe of Nebraska, the Flandreau Santee Sioux Tribe, the Prairie Island Sioux, Lower Sioux, and Shakopee Mdewakanton Sioux Communities of Minnesota under Section 8 of Public Law 99-130 (99 Stat. 552) and Section 7 of Public Law 93-134 (87 Stat. 468), as amended by Public Law 97-458 (96 Stat. 2513; 25 USC 1407).
  • Funds distributed per capita or held in trust for members of the Chippewas of Lake Superior and the Chippewas of the Mississippi under Section 6 of Public Law 99-146 (99 Stat. 782).
  • Distributions of claims settlement funds to members of the White Earth Band of Chippewa Indians as allottees, or their heirs, under Section 16 of Public Law 99-264 (100 Stat. 70).
  • Payments or distributions of judgment funds, and the availability of any amount for such payments or distributions, to members of the Saginaw Chippewa Indian Tribe of Michigan under Section 6 of Public Law 99-346 (100 Stat. 677).
    
    Note: This exclusion applies to the income of sponsors of aliens only if the alien lives in the sponsor's household.
  • Judgment funds distributed per capita or held in trust for members of the Chippewas of Lake Superior and the Chippewas of the Mississippi under Section 4 of Public Law 99-377 (100 Stat. 805).
  • Judgment funds distributed to members of the Cow Creek Band of Umpqua Tribe of Indians under Section 4 of Public Law 100-139 (101 Stat. 822).
  • Per capita payments of claims settlement funds to members of the Coushatta Tribe of Louisiana under Section 2 of Public Law 100-411 (102 Stat. 1097) and Section 7 of Public Law 93-134 (87 Stat. 468), as amended by Public Law 97-458 (96 Stat. 2513; 25 USC 1407).
    
    Note: This exclusion applies to the income of sponsors of aliens only if the alien lives in the sponsor's household.
  • Funds distributed per capita for members of the Hoopa Valley Indian Tribe and the Yurok Indian Tribe under Sections 4, 6 and 7 of Public Law 100-580 (102 Stat. 2929, 2930, 2931) and Section 3 of Public Law 98-64 (97 Stat. 365; 25 USC 117b).
    
    Note: This exclusion applies to the income of sponsors of aliens only if the alien lives in the sponsor's household.
  • Judgment funds held in trust by the United States, including interest and investment income accruing on such funds, and judgment funds made available for programs or distributed to members of the Wisconsin Band of Potawatomi (Hannahville Indian Community and Forest County Potawatomi) under Section 503 of Public Law 100-581 (102 Stat. 2945)
    
    Note: This exclusion applies to the income of sponsors of aliens only if the alien lives in the sponsor's household.
  • Judgment funds distributed per capita, or held in trust, or made available for programs, for members of the Seminole Nation of Oklahoma, the Seminole Tribe of Florida, the Miccosukee Tribe of Indians of Florida and the independent Seminole Indians of Florida under Section 8 of Public Law 101-277 (104 Stat. 145).
    
    Note: This exclusion applies to the income of sponsors of aliens only if the alien lives in the sponsor's household.
  • Per capita distributions of settlement funds under Section 102 of the Fallon Paiute Shoshone Indian Tribes Water Rights Settlement Act of 1990, Public Law 101-618 (104 Stat. 3289) and Section 7 of Public Law 93-134 (87 Stat. 468), as amended by Public Law 97-458 (96 Stat. 2513; 25 USC 1407).
  • Settlement funds, assets, income, payments, or distributions from Trust Funds to members of the Catawba Indian Tribe of South Carolina under Section 11(m) of Public Law 103-116 (107 Stat. 1133).
  • Settlement funds held in trust (including interest and investment income accruing on such funds) for, and payments made to, members of the Confederated Tribes of the Colville Reservation under Section 7(b) of Public Law 103-436 (108 Stat. 4579).
    
    Note: This exclusion applies to the income of sponsors of aliens only if the alien lives in the sponsor's household.
  • Judgment funds distributed under Section 111 of the Michigan Indian Land Claims Settlement Act, (Pub. L. 105-143, 111 Stat. 2665).
  • Judgment funds distributed under Section 4 of the Cowlitz Indian Tribe Distribution of Judgment Funds Act, (Pub. L. 108-222, 118 Stat. 624).
• Receipts from Lands Held in Trust for Certain Tribes or Groups—
  • Receipts from land held in trust by the federal government and distributed to members of certain Indian tribes under Section 6 of Public Law 94-114 (89 Stat. 579, 25 USC 459e).
    
    Note: This exclusion applies to the income of sponsors of aliens only if the alien lives in the sponsor's household.
  • Receipts derived from trust lands awarded to the Pueblo of Santa Ana and distributed to members of that tribe under Section 6 of Public Law 95-498 (92 Stat. 1677).
  • Receipts derived from trust lands awarded to the Pueblo of Zia of New Mexico and distributed to members of that tribe under Section 6 of Public Law 95-499 (92 Stat. 1680).

 

D-9550 Other

Revision 12-4; Effective December 1, 2012

• Any assistance to an individual (other than wages or salaries) under the Older Americans Act of 1965, as amended by Section 102(h)(1) of Pub. L. 95-478 (92 Stat. 1515, 42 USC 3020a).
• Amounts paid as restitution to certain individuals of Japanese ancestry and Aleuts for losses suffered as a result of evacuation, relocation, and internment during World War II, under the Civil Liberties Act of 1988 and the Aleutian and Pribilof Islands Restitution Act, Sections 105(f) and 206(d) of Public Law 100-383 (50 USC App. 1989 b and c).
• Payments made on or after Jan. 1, 1989, from the Agent Orange Settlement Fund or any other fund established pursuant to the settlement in the In Re Agent Orange product liability litigation, MDL No. 381 (E.D.N.Y.) under Public Law 101-201 (103 Stat. 1795) and Section 10405 of Public Law 101-239 (103 Stat. 2489).
• Payments made under Section 6 of the Radiation Exposure Compensation Act, Public Law 101-426 (104 Stat. 925, 42 USC 2210).
• The value of any child care provided or arranged (or any payment for such care or reimbursement for costs incurred for such care) under the Child Care and Development Block Grant Act, as amended by Section 8(b) of Public Law 102-586 (106 Stat. 5035).
• Payments made to individuals because of their status as victims of Nazi persecution excluded pursuant to Section 1(a) of the Victims of Nazi Persecution Act of 1994, Public Law 103-286 (108 Stat. 1450).
• Any matching funds from a demonstration project authorized by the Community Opportunities, Accountability, and Training and Educational Services Act of 1998 (Pub. L. 105-285) and any interest earned on these matching funds in an Individual Development Account, pursuant to Section 415 of Pub. L. 105-285 (112 Stat. 2771).
• Any earnings, Temporary Assistance for Needy Families matching funds, and interest in an Individual Development Account, pursuant to Section 103 of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (Pub. L. 104-193, 42 USC 604(h)(4)).
• Payments made to individuals who were captured and interned by the Democratic Republic of Vietnam as a result of participation in certain military operations, pursuant to Section 606 of the Departments of Labor, Health and Human Services and Education and Related Agencies Appropriations Act of 1996 (Pub. L. 105-78).
• Payments made to certain Vietnam veterans' children with spina bifida, pursuant to Section 421 of the Departments of Veterans Affairs and Housing and Urban Development, and Independent Agencies Appropriations Act of 1997 (Pub. L. 104-204, 38 USC 1805(a)).
• Payments made to the children of female Vietnam veterans who suffer from certain birth defects, pursuant to Section 401 of the Veterans Benefits and Health Care Improvement Act of 2000 (Pub. L. 106-419 (38 USC 1833(c)).
• Payments of the refundable child tax credit made under Section 24 of the Internal Revenue Code of 1986, pursuant to Section 203 of the Economic Growth and Tax Relief Reconciliation Act of 2001, Public Law 107-16 (115 Stat. 49, 26 USC 24 note).
• Assistance provided for flood mitigation activities as provided under Section 1324 of the National Flood Insurance Act of 1968, pursuant to Section 1 of Public Law 109-64 (119 Stat. 1997, 42 USC 4031).
• Payments made to individuals under the Energy Employees Occupational Illness Compensation Program Act of 2000, pursuant to Section 1 [Div. C, Title XXXVI Section 3646] of Public Law 106-398 (114 Stat. 1654A-510, 42 USC 7385e).

Revision 12-4; Effective December 1, 2012

If deeming income or resources from a sponsor results in the alien being found:

Ineligible — indicate on the notice that the denial was a result of deeming income or deeming resources from the alien's sponsor.

Eligible — indicate on the notice that the sponsor(s) may be liable for repayment of benefits received by the alien applicant/recipient.