Revision 12-1; Effective March 1, 2012

§360.101. Overview and Purpose.

(a) This chapter governs the eligibility requirements for the Medicaid Buy-In Program (MBI), which is authorized under §531.02444 of the Texas Government Code, and which provides Medicaid benefits under the option explained in §1902(a)(10)(A)(ii)(XIII) of the Social Security Act (42 U.S.C. §1396a(a)(10)(A)(ii)(XIII)). All references in this chapter to MBI mean the Medicaid Buy-In Program.

(b) MBI is administered by the Texas Health and Human Services Commission (HHSC). All references in this chapter to HHSC mean the Texas Health and Human Services Commission.

(c) MBI provides Medicaid benefits to working persons with disabilities, regardless of age, who apply for Medicaid and meet the requirements explained in this chapter.

(d) Nothing in these rules shall be construed to violate the maintenance of eligibility requirements of section 5001 of the American Recovery and Reinvestment Act of 2009 (Public Law 111-5) and make eligibility standards, methodologies, or procedures under the Texas State Plan for Medical Assistance (or any waiver under section 1115 of the Social Security Act (42 U.S.C. §1315)) more restrictive than the eligibility standards, methodologies, or procedures, respectively, under such plan (or waiver) that were in effect on July 1, 2008.

§360.103. Applying and Providing Information.

(a) A person applies for MBI by completing an application for MBI and submitting it to HHSC. The date of receipt of the signed application by HHSC is the application filing date, and thus establishes the application month explained in §360.119 of this chapter (relating to Medical Effective Date).

(b) HHSC notifies an MBI recipient in writing when it is time to redetermine the recipient's eligibility. This usually occurs once per year, although HHSC may require a person to reapply sooner if HHSC determines that a special review of the person's eligibility is appropriate. An MBI recipient must reapply when HHSC sends written notice of the requirement to the recipient's case address of record. The written notice explains the deadline to reapply. If an MBI recipient fails to reapply by the deadline stated in the written notice, HHSC may terminate the recipient's MBI eligibility.

(c) HHSC sends in writing to the person's case address of record the eligibility decision on an application, reapplication, or reported change. If the person disagrees, the person has the right to request a fair hearing to appeal HHSC's decision, as explained in HHSC's fair hearing rules in Chapter 357 of this title (relating to Hearings).

(d) An applicant for MBI must provide HHSC with all requested documentation and information that HHSC advises is necessary to determine the applicant's eligibility. If the applicant fails or refuses to provide requested information by the date specified in a written request from HHSC, HHSC may deny the application for failure to furnish information. When this occurs but the person later provides the requested information, the date that the requested information is provided to HHSC becomes the application filing date explained in subsection (a) of this section.

(e) A person who applies for or is receiving MBI must report to HHSC within 10 calendar days any information that may impact the person's eligibility. If a person fails to comply with the requirements of this subsection, HHSC may redetermine the person's eligibility as of the date the information should have been reported to HHSC.

§360.105. Citizenship, Immigration Status, and Residency.

To be eligible for MBI, a person must meet the citizenship, immigration status, and residency requirements in Chapter 358, Subchapter B, of this title (relating to Nonfinancial Requirements).

§360.107. Disability.

To be eligible for MBI, a person must meet the definition of disabled as defined by the Social Security Administration for purposes of the federal Supplemental Security Income program, as explained in 20 CFR §416.905 and §416.906, except the requirement that the person be unable to engage in any substantial gainful activity does not apply.

§360.109. Work.

To be eligible for MBI, a person must be working and earning income. The person must provide evidence of earnings that is satisfactory to HHSC.

§360.111. Income.

(a) Earned income.

(1) To be eligible for MBI, a person's monthly countable earned income must be less than 250% of the federal poverty level.

(2) Countable earned income means earned income for purposes of the Supplemental Security Income (SSI) program minus all applicable exclusions and exemptions, as explained in 20 CFR §§416.1110 - 416.1112.

(b) Unearned income is entirely excluded under this section, but is considered in the determination of a person's monthly premium amount, as explained in §360.117 of this chapter (relating to Cost Sharing).

§360.113. Resources.

(a) To establish and maintain eligibility for MBI, a person's countable resources must be equal to or less than $3,000 plus the amount of the Supplemental Security Income (SSI) resource limit for an individual that is explained in 20 CFR §416.1205. Countable resources means resources for SSI purposes as defined in 20 CFR §416.1205, minus all applicable exemptions and exclusions explained in 20 CFR §§416.1207 - 416.1239.

(b) In addition to the exemptions and exclusions explained in subsection (a) of this section, the following are not countable resources under this section:

(1) Independence accounts.

(A) An independence account (IA) is a segregated account in a financial institution, the purpose of which is to save for future health care and work-related expenses to increase an individual's independence and employment potential.

(B) Only a person's own earned income may be deposited into an IA, and amounts deposited cannot exceed 50% of the person's gross earnings. If for any SSA Qualifying Quarter a person deposits more than 50% of the person's gross earnings into an account that is designated as an IA, the account loses its IA designation and the funds in the account become a countable resource for the 12-month period beginning with the first month after the SSA Qualifying Quarter. An SSA Qualifying Quarter is a three-month period that ends on March 31, June 30, September 30, and December 31 of each calendar year and during which a person's reported earnings and FICA contributions are enough for SSA to give the person Social Security wage credits.

(C) Only health care or work-related expenses may be paid from an IA. For any SSA Qualifying Quarter, if funds in an IA account are used for any other purpose, the account loses its IA designation and the funds in the account become a countable resource for the 12-month period beginning with the first month after the SSA Qualifying Quarter.

(2) Retirement related tax-sheltered accounts. Retirement related tax-sheltered accounts include IRAs, 401(k)s, TSAs, and KEOUGHs that comply with IRS regulations.

§360.115. Deeming of Income and Resources.

(a) For purposes of MBI eligibility, each person is considered a household of one.

(b) If a person lives with a spouse, the person and spouse are each considered a household of one. The assets of each spouse are considered only with respect to that spouse. In the case of assets owned jointly by both spouses, one half is considered with respect to each spouse.

(c) If a person is a minor and lives with his or her parents, the assets of the parents are not considered with respect to the eligibility of the minor.

§360.117. Cost Sharing.

(a) Monthly premiums. As a condition of establishing initial MBI eligibility and to remain eligible, a person must pay monthly premiums, as explained in this section, based on the amount of the person's countable earned and countable unearned income. A person may be exempt from paying monthly premiums as described in subsection (h) of this section.

(b) Countable earned income. For purposes of this section, countable earned income is as defined in 20 CFR §416.1110 and §416.1111, minus:

(1) earned income that is excluded by federal law, as explained in 20 CFR §416.1112(b); and

(2) mandatory payroll deductions for federal income tax, FICA, and retirement withholding.

(c) Countable unearned income. For purposes of this section, countable unearned income means unearned income, as defined in 20 CFR §§416.1120 - 416.1123, minus the exclusions and exemptions explained in 20 CFR §416.1124.

(d) Calculation of monthly premium. The monthly premium amount equals the amount of a person's countable unearned income for the month that exceeds the Supplemental Security Income (SSI) federal benefit rate for an individual, plus:

(1) $20 when monthly countable earned income is above 150% of the federal poverty level (FPIL) up to and including 185% of the FPIL;

(2) $25 when monthly countable earned income is above 185% of the FPIL up to and including 200% of the FPIL;

(3) $30 when monthly countable earned income is above 200% of the FPIL up to and including 250% of the FPIL; or

(4) $40 when monthly countable earned income is above 250% of the FPIL.

(e) Upper limit on monthly premiums. The upper limit for the total monthly premium per person is $500. If the unearned income premium amount plus the earned income premium amount equals or exceeds $500, then the total monthly premium remains at $500.

(f) Payment of monthly premiums to establish initial eligibility. If the calculation explained in subsection (d) of this section results in an amount greater than $0, HHSC sends the person a written notice of the person's potential eligibility as described in this subsection. The initial eligibility period begins with the earliest benefit month and continues through the end of the latest benefit month identified on the written notice of the person's potential eligibility. This subsection explains the procedures that are followed and the requirements the person must meet to establish eligibility under this section for any or all of the months within the initial eligibility period. The steps are as follows:

(1) HHSC determines that the person is potentially eligible if the person meets all eligibility requirements for MBI other than the requirements of this section.

(2) HHSC sends the person a written notice (the notice) of the person's potential eligibility. The notice identifies the earliest month of potential eligibility and the amount of the monthly premiums due for each month in the initial eligibility period.

(3) The notice also includes:

(A) the total amount in monthly premiums that must be paid to obtain MBI coverage for the entire initial eligibility period; and

(B) the deadline by which payment must be submitted.

(4) The person chooses whether to pay the monthly premiums for either the entire initial eligibility period or for only a portion of the initial eligibility period (according to the months during which the person desires MBI coverage).

(5) The person submits to HHSC, by the deadline stated in the notice, either the total amount due as explained in the notice or a lesser amount if the person is not seeking coverage for the entire initial eligibility period.

(6) If the person submits payment of less than the total amount due to obtain MBI coverage for the entire initial eligibility period, HHSC applies the amount submitted first to satisfy the monthly premium for the month following the month of the notice, then to each prior month of potential eligibility, in reverse chronological order. After this, if any amount remaining is less than the premium for a full month's coverage, HHSC refunds that amount to the person.

(7) HHSC notifies the person of MBI eligibility and of the beginning date of MBI coverage, based on the amount submitted by the person under paragraph (5) of this subsection.

(8) If no amount is submitted by the deadline stated in the notice, or if the amount submitted is less than one month's premium such that it is refunded to the person as explained in paragraph (6) of this subsection, HHSC denies the person MBI eligibility. A person denied under this paragraph must file a new application for MBI before eligibility can be established.

(g) Payment of monthly premiums after initial eligibility. Monthly premiums after a person establishes initial eligibility under subsection (f) of this section are due and payable to HHSC no later than the last calendar day of each month, and are applied to the following month's eligibility and coverage of MBI benefits. If a monthly premium payment that is due is not received by HHSC by the end of the month, after written notice, HHSC may terminate the person's MBI eligibility.

(h) An MBI recipient residing in a federally declared disaster area is exempt from paying monthly premiums for up to three months beginning with the month in which the disaster is declared. A recipient will only be exempt from paying monthly premiums once per disaster.

§360.119. Medical Effective Date.

Beginning with the three months before the application month, the eligibility effective date for MBI coverage is the first day of the first month in which a person meets all eligibility criteria, including the timely payment of monthly premiums as explained in §360.117 of this chapter (relating to Cost Sharing).

Revision 22-3; Effective September 1, 2022

The MBI program is a Medicaid program for people with disabilities who are working and earning more than the allowable limits for regular Medicaid. MBI allows people with disabilities who are working to earn more income without the risk of losing vital health care coverage. The income limit is up to 250% of the federal poverty level (FPL). A person may have to pay a monthly premium as a condition of eligibility. The amount of the premium is determined on a sliding scale, based on the recipient’s earned and unearned income.

MBI recipients receive a Your Texas Benefits Medicaid ID card. If a recipient is eligible for both Medicare and Medicaid, prescriptions are available through a Medicare Part D Prescription Drug Plan.

All regular MEPD policies apply to this program except for the eligibility items specifically identified in this chapter. For example, citizenship and Texas residency are not addressed in this chapter. Therefore, follow regular MEPD policies for citizenship and Texas residency.

All eligibility requirements for this program must be verified. MBI is not a client-declaration program.

M-1310 MBI and Home and Community-Based Services Waivers

Revision 16-2; Effective June 1, 2016

If a person is currently eligible for Medicaid Buy-In (MBI) and requests waiver services, the Long-Term Services and Supports (LTSS) programs (such as STAR+PLUS Waiver) do not require a change in Medicaid type program for payment of services. Do not do a program transfer for ME-Waivers.

Do not calculate a copay for individuals who are MBI-eligible and receive waivers services. A person is not subject to a financial copay unless financial eligibility is determined using the 300% of Supplemental Security Income, Special Income Group limit, e.g., ME-Waivers.

M-1320 MBI and Medicare Savings Programs

Revision 11-4; Effective December 1, 2011

An MBI-eligible applicant/recipient can also have:

• Qualified Medicare Beneficiary (QMB)
• Specified Low-Income Medicare Beneficiary (SLMB)

An MBI-eligible applicant/recipient cannot have:

• Qualifying Individuals-1 (QI-1). The applicant/recipient must choose between MBI and QI-1.
• Qualified Disabled Working Individuals

Note: Deeming of income and resources and support and maintenance applies to the Medicare Savings Program.

Revision 11-4; Effective December 1, 2011

MBI has no age limit.

Revision 19-4; Effective December 1, 2019

All persons applying for the Medicaid Buy-In (MBI) program must meet the Supplemental Security Income definition of disability. If the person does not have an established Social Security Administration disability determination, request the determination from HHSC's Disability Determination Unit. Follow normal MEPD policy for disability determinations. For MBI, the disability requirement also applies to persons age 65 or older.

The MBI program allows an exception to the requirement that the person be unable to engage in any substantial gainful activity (SGA). For purposes of MBI, a person who is able to engage in SGA still might meet disability requirements because SGA is disregarded in deciding whether the person meets the definition of disabled for MBI.

Related Policy

Disability, D-1400
Requesting a Decision from the Disability Determination Unit (DDU), D-2300

Revision 15-4; Effective December 1, 2015

Being a household of one means an applicant/recipient is not penalized for assets owned by the spouse. For example, if one member of a couple applies for the MBI program, only the assets of the applicant are considered when determining eligibility for the program. If both an applicant/recipient and spouse own the asset, only half of the asset is considered owned by each spouse. If the person applying for the MBI program is a minor and lives with his or her parents, the assets of the parents are not considered the minor's assets. Consider an MBI recipient/applicant a household of one, regardless of the living arrangement or age. Do not deem income or resources. Do not consider support and maintenance. If an applicant lives with a spouse who is eligible for Medicaid, the applicant and spouse are each considered a household of one.

Revision 11-4; Effective December 1, 2011

Exclude the following resources for MBI:

• Retirement-related accounts
• Independence accounts
• Plan to Achieve Self Support (PASS)
• $3000 MBI Resource Exclusion

M-4110 Retirement Accounts

Revision 11-4; Effective December 1, 2011

For the MBI program, Retirement-related accounts are not countable. These accounts include Individual Retirement Accounts, 401(K)s, Tax Sheltered Annuities, and Keoghs that comply with Internal Revenue Service regulations, and Keogh or HR-10 plans which are qualified employer plans set up by a self-employed individual.

 

M-4120 Independence Accounts

Revision 11-4; Effective December 1, 2011

An Independence Account is a separate designated account for health care and/or work-related expenses. For the MBI program, exclude an Independence Account if all:

• funds from the account are used for health care or work-related expenses, and
• deposits into the Independence Account are:
  • from the person's earned income, and
  • equal to or less than 50% of the person's gross earnings for the SSA qualifying quarter.

For the MBI program, count an Independence Account if any:

• funds from the account are used for non-health care or non-work related expenses, and/or
• deposits into the Independence Account:
  • exceed 50% of the person's earnings for the SSA qualifying quarter,
  • are from sources other than the person's earnings or interest earned on the Independence Account, and
  • include income from another person.

Evaluate the account at each complete redetermination. If the person takes action requiring the Independence Account to be counted, the exclusion for the Independence Account is lost. Consider the account as a countable resource for 12 calendar months beginning with the first month after the SSA qualifying quarter during which the exclusion was lost. The person may again request designation of an Independence Account after the 12-month countable period.

Example: John Smith deposited a $900 gift from his grandmother into the Independence Account in May. The exclusion of the Independence Account was lost. The balance of the Independence Account is a countable resource effective July 1 through June 30 of next year. Effective July of next year, Mr. Smith may request designation of an Independence Account.

If counting the resource results in denial, follow current denial process.

 

M-4130 Plan for Achieving Self-Support (PASS)

Revision 11-4; Effective December 1, 2011

See Section F-4400, Plan for Achieving Self-Support (PASS).

Do not count the resources and income that are essential for accomplishing the objectives of an SSA or HHSC approved PASS as long as the PASS is in effect. Any money set aside for a PASS must be identifiable from other funds – usually a separate bank account.

PASS resources are considered "set aside" when they are one or more of the following:

• Owned by the individual
• Used to pay for expenses, including expenses already incurred
• Used directly in the job
• Saved for future expenses

Information concerning a PASS and forms for exemption consideration are located on the SSA website at www.ssa.gov/online/ssa-545.pdf.

Send any PASS that needs HHSC approval to OFS Policy, State Office, Mail Code 2090.

For the MBI program, exclude any PASS resources if:

• Resources are part of the PASS
• PASS is approved and in effect
• Money is in a separate PASS account

For the MBI program, end the PASS if the person has neither:

• Met milestones as scheduled in the PASS
• Set funds aside as agreed in the PASS
• Spent funds as agreed in the PASS

Evaluate the person's ongoing compliance with the PASS at:

• Each complete redetermination
• The report of a change
• Reapplication

If the PASS ends, count the PASS resources the month after the PASS end date. If counting the resources results in the person exceeding the resource limit, follow current denial process.

 

M-4140 $3,000 MBI Resource Exclusion

Revision 11-4; Effective December 1, 2011

Before comparing the countable resources to the $2,000 resource limit and after allowing all exemptions, exclusions and Special MBI Resource Exclusions (Retirement Accounts, Independence Accounts, PASS), deduct an additional $3,000 MBI resource exclusion.

Revision 13-3; Effective September 1, 2013

To be eligible, a person must be working and earning income. The person must provide proof of employment. Consider any of the following as proof of employment:

• Tax payment verification under the Federal Insurance Contribution Act (FICA); or
• Tax payment verification under the Self-Employment Contribution Act (SECA); or
• A written explanation that substantiates the person is in an employed status.

Treatment of income will be different for the MBI income eligibility budget and the post eligibility premium budget.

Income limits are subject to change annually. See Appendix XXXI, Budget Reference Chart, for current limits.

Revision 23-2; Effective June 1, 2023

To be eligible for MBI, a person must have countable income less than 250 percent of the federal poverty level (FPL).

Monthly Income Limits for the MBI Program

Date Range	250% FPL
March 1, 2023 to Present	$3,038
March 1, 2022 to Feb. 28, 2023	$2,832
March 1, 2020 to Feb. 28, 2021	$2,659
March 1, 2019 to Feb. 29, 2020	$2,603
March 1, 2018 to Feb. 28, 2019	$2,530
March 1, 2017 to Feb. 28, 2018	$2,513
March 1, 2016 to Feb. 28, 2017	$2,475
March 1, 2015 to Feb. 29, 2016	$2,453
March 1, 2014 to Feb. 28, 2015	$2,432
March 1, 2013 to Feb. 28, 2014	$2,394
March 1, 2012 to Feb. 28, 2013	$2,328
March 1, 2011 to Feb. 29, 2012	$2,269
March 1, 2010 to Feb. 28, 2011	$2,257

Revision 11-4; Effective December 1, 2011

Do not consider unearned income in the income eligibility budget for MBI. The income eligibility test for the MBI program is based on all gross earned income from wages and self-employment based on a monthly amount.

Exclusions to the monthly gross earned amount are allowed in the MBI program. The exclusions are subtracted in a mandatory order. The 10 potential exclusions in the mandatory order are:

1. Earned income tax credit payments
2. Child tax credit
3. Infrequent or irregular income equal to or less than $30 per month
4. Earned income of blind or disabled student
5. $20 general income
6. $65 earned income
7. Impairment-related work-related expenses
8. One half of remaining earned income
9. Blind work-related expenses
10. PASS-related earned income

Note: If the person fails to provide verification for the exclusion, do not allow the exclusion in the income eligibility budget. Do not deny the case for "failure to provide" verification.

M-6110 Earned Income Tax Credit Payments Exclusion

Revision 11-4; Effective December 1, 2011

See Section E-2210, Income Tax Credits. An earned income tax credit (EITC) is a special tax credit that reduces the federal tax liability of certain low-income working taxpayers. This tax credit may or may not result in a payment to the taxpayer. EITC payments are allowed as an advance from an employer or as a refund from the Internal Revenue Service (IRS) and are excluded from income, regardless of the tax year involved. Normally this is exempt income – never considered as income and never deducted. For the MBI program, deduct the EITC in the month received from the employer or divide the annual EITC refund from the IRS by 12 to get the monthly EITC exclusion.

 

M-6120 Child Tax Credit Exclusion

Revision 11-4; Effective December 1, 2011

The child tax credit is the annual amount. Divide the annual child tax credit by 12 to get the monthly child tax credit exclusion. Child tax credit exclusions apply only to the MBI program. Use the federal tax return or other IRS documentation for sources of verification.

M-6130 Infrequent or Irregular Income Exclusion

Revision 11-4; Effective December 1, 2011

The first $30 of infrequent or irregular earned income is excluded in the Income Eligibility Budget. See Section E-9000, Infrequent or Irregular Income.

M-6140 Earned Income - Blind or Students with Disabilities Exclusion

Revision 11-4; Effective December 1, 2011

See Section E-2220, Student Earnings. For the MBI program, consider all gross monthly earned income and allow the income exemption when the MBI person is:

• blind or disabled,
• a student,
• younger than age 22.

See Special Income Exemption for Student in Appendix XXXI, Budget Reference Chart, for the monthly and yearly amount limits for the exemption.

M-6150 $20 General Income Exclusion

Revision 11-4; Effective December 1, 2011

Since unearned income is not considered in the MBI Income Eligibility Budget, subtract the $20 general income exclusion from the remaining earned income after subtracting the first four exclusions.

See Section M-6100, Income Eligibility Budget, for mandatory order of allowable exclusions.

 

M-6160 $65 Earned Income Exclusion

Revision 11-4; Effective December 1, 2011

Subtract the $65 earned income exclusion from the remaining earned income after subtracting the first five exclusions. Do not subtract the normal "one half of the remaining earnings" as part of the $65 earned income exclusion until Step 8 in the mandatory order of allowable exclusions.

M-6170 Impairment-Related Work-Related Expense (IRWE) Exclusion

Revision 11-4; Effective December 1, 2011

This exclusion is based on the SSI work incentive for persons who are determined to be disabled. The cost of certain items and services that a person with impairment needs in order to work can be deducted from earnings, even though such items and services also are needed for normal daily activities. The IRWE exclusion is subtracted if the MBI person is under age 65 and the items are used to pay expenses directly related to the impairment and needed in order to work.

In the following table, possible IRWE exclusion items are listed. There are also items that are not allowed as IRWE items. Allow only the possible IRWE exclusion item if the person's earnings are used to pay the cost of the item.

Possible IRWE Exclusion Items	Prohibited IRWE Exclusion Items
Attendant care services Drugs to control disabling condition Expendable medical supplies Medical devices and equipment Medical services to control disabling condition Non-medical equipment/services Other work-related equipment/services Physical therapy Prostheses Service animal expenses Structural home modifications Training to use impairment-related item Transportation Vehicle Modification	Expenses that will be reimbursed Health and life insurance premiums Routine annual physical examinations Routine optician services (unrelated to a disabling visual impairment) Routine dental examinations

M-6180 Blind Work-Related Expense (BWE) Exclusion

Revision 11-4; Effective December 1, 2011

This exclusion is based on the SSI work incentive for persons who are determined to be legally blind. From the earnings of the legally blind MBI person, an exclusion for most work-related expenses, whether or not they relate to blindness, is allowed. The MBI person must be:

• legally blind,
• under age 65,
• if age 65 or older, must have received SSI payment due to blindness for the month before attaining age 65.

In the following table, possible BWE exclusion items are listed. There are also items that are not allowed as BWE items. Allow only the possible BWE exclusion item if the person's earnings are used to pay the cost of the item.

Possible BWE Exclusion Items

Prohibited BWE Exclusion Items

Attendant care services Child care Drugs to control disabling condition Expendable medical supplies Federal, state and local income taxes Fees, licenses and dues Mandatory pension contributions and savings plans Meals consumed during work or school hours Medical devices and equipment Medical services to control disabling condition Non-medical equipment/services Other work-related equipment/services Physical therapy Prostheses Service animal expenses Structural home modifications Training to use impairment-related item Transportation Vehicle modification

Expenses that will be reimbursed Expenses claimed on a self-employment tax return General educational development In-kind payments Health and life insurance premiums Meals consumed outside of work hours Self care items Voluntary pension contributions and savings plans Work-related items furnished by others

 

M-6190 PASS-Related Earned Income Exclusion

Revision 11-4; Effective December 1, 2011

See Section F-4400, Plan for Achieving Self-Support (PASS), and Section M-4130, Plan for Achieving Self-Support (PASS). This exclusion is based on the SSI work incentive for persons who are determined to be blind or disabled. Any earned income used to fulfill an SSA or HHSC-approved PASS is excluded from the person's earnings as long as the PASS is in effect.

The following are allowable PASS expenses only if the person intends to pay the expense and the expense is necessary to meet an occupational goal. If the expense is reimbursable, it is not allowable.

Possible PASS Exclusion Items

Attendant care services Basic living skills training Business-related expenses Child care Drugs to control disabling condition Expendable medical supplies Federal, state and local income taxes Fees, licenses and dues Finance and services charges Job coaching/counseling services Job search or relocation expenses Mandatory pension contributions and savings plans Meals consumed during work or school hours Medical devices and equipment Medical services to control disabling condition

Non-medical equipment/services Other work-related equipment/services PASS preparation fees Physical therapy Prostheses Service animal expenses Shelter and food due to temporary absence from permanent residence Specialized clothing and appropriate attire Structural home modifications Subscription costs for publications for academic or professional purposes Training to use impairment-related item Transportation Vehicle modification

A person may have more than one PASS during the person's lifetime; however, a person is limited to only one PASS at a time.

The SSI work incentives – IRWE, BWE, PASS – allow for earned income exclusions to occur for a person. A person may have an IRWE, a BWE, and a PASS at the same time. Expenses allowed, as an income exclusion from one of the SSI work incentives, must be mutually exclusive unless the expense is for a different reason. For example, child care is allowable under a BWE or a PASS. If the child care is for work and attending night school, allow the expense as an exclusion under one or both of the SSI work incentives depending on what is available to the person. Another example would be transportation. Transportation is allowable under IRWE and BWE. If the gas expense is for work and attending training, allow the expense as an exclusion under one or both of the SSI work incentives depending on what is available to the individual.

Revision 24-1; Effective March 1, 2024

Premium Budgeting Steps

There are three steps to calculate the premium amount.

Note: While unearned income is excluded in the income eligibility budget, it is used in the calculation of the premium amount.

Step 1

Unearned Income

The unearned income premium amount is based on unearned income after allowable exemptions and exclusions.

Note: Support and maintenance does not apply to the MBI program.

Find the unearned income premium amount by subtracting the SSI federal benefit rate amount for one person from the person's countable unearned income.

Step 2

Earned Income

Find the earned income premium amount by adding:

• gross earned income minus mandatory payroll deductions; and
• any countable earned self-employment income.

This calculation results in the net earnings. If the net earnings are equal to or less than 150 percent of the federal poverty limit (FPL), the monthly premium is $0. If the net earnings exceed 150 percent of the FPL, the MBI person must pay a monthly premium based on the earned income amount. Compare the net earnings amount to the FPL ranges to find the earned income premium amount.

The 2023 FPL ranges for the earned income premium amounts are listed in the chart below. Income limits are subject to change annually.

2023 FPL Range	Earned Income Premium Amount
Earnings at or below 150% FPL (less than or equal to $1,823)	$0
Earnings above 150% FPL up to and including 185% FPL (greater than $1,823 up to and including $2,248)	$20
Earnings above 185% FPL up to and including 200% FPL (greater than $2,248 up to and including $2,430)	$25
Earnings above 200% FPL up to and including 250% FPL (greater than $2,430 up to and including $3,038)	$30
Earnings above 250% FPL (greater than $3,038)	$40

Step 3

Add the unearned income premium amount to the earned income premium amount to get the total monthly MBI premium amount.

Total Monthly Premium Limit

The total monthly premium may not exceed $500. If the unearned income premium amount plus the earned income premium amount is greater than or equal to $500, then the total monthly premium is $500.

Examples

Below are three examples for calculating the MBI premium.

Example 1

A person has $974 in unearned monthly income. After applying all deductions, the remaining earned income is $1,250.

Step 1: Subtract the SSI federal benefit rate amount for one person from the person's countable unearned income.

Description	Amount
Unearned income	$974
SSI federal benefit rate	–$943
Unearned income premium amount	$31

Step 2: Compare the net earned income to the chart showing the FPL ranges to find the earned income premium amount.

Description	Amount
Net monthly earnings	$1,250
Earned income premium amount	$0

Step 3: Add the unearned income premium amount to the earned income premium amount to get the total monthly MBI premium amount.

Description	Amount
Unearned income premium amount	$31
Earned income premium amount	+$0
Total monthly premium	$31

Example 2

A person has $974 in monthly unearned income and $1,915 in monthly earned income, after applying all deductions.

Step 1: Subtract the SSI federal benefit rate amount from the person's countable unearned income.

Description	Amount
Unearned income	$974
SSI federal benefit rate	–$943
Unearned income premium amount	$31

Step 2: Compare the net earned income to the chart showing the FPL ranges to find the earned income premium amount.

Description	Amount
Net monthly earnings	$1,915
Earned income premium amount	$20

Step 3: Add the unearned income premium amount to the earned income premium amount to get the total monthly MBI premium amount.

Description	Amount
Unearned income premium amount	$31
Earned income premium amount	+$20
Total monthly premium	$51

Example 3

A person has $1,500 in monthly unearned income and $1,889 in monthly earned income, after applying all deductions.

Step 1: Subtract the SSI federal benefit rate amount from the person's countable unearned income.

Description	Amount
Unearned income	$1,500
SSI federal benefit rate	–$943
Unearned income premium amount	$557

Step 2: Compare the net earned income to the chart showing the FPL ranges to find the earned income premium amount.

Description	Amount
Net monthly earnings	$1,889
Earned income premium amount	$20

Step 3: Add the unearned income premium amount to the earned income premium amount to get the total monthly MBI premium amount.

Description	Amount
Unearned income premium amount	$557
Earned income premium amount	+$20
Total monthly premium	$577*

* The total of the unearned income premium amount plus the earned income premium amount is $577. However, the total monthly premium cannot exceed $500.

Related Policy

Budget Reference Chart, Appendix XXXI

Revision 11-4; Effective December 1, 2011

The eligibility begin date for MBI is the first day of the first month in which a person meets all eligibility criteria and pays the required premium, if any is required. Eligibility is established in TIERS, but eligibility is not granted until the first premium is paid. Eligibility is in a suspended status until an MBI person pays the premium. Once the premium is paid, actual eligibility is granted

Revision 11-4; Effective December 1, 2011

Eligibility for three prior months to the application month is available with this program.

The coverage date is determined by the application file date and the first premium amount the person chooses to pay. Since potential eligibility is determined up to three months prior to the application file month, the person has the option of choosing the months of coverage. Payments are applied to months in reverse chronological order, beginning with the current or the following month, backwards, up to three months prior.

Payment must be for a full month. Partial month payments will be refunded to the individual. Form H0052, Medicaid Buy-In Refund Notice, will be sent to the individual stating that partial payments are not accepted. The notice also will state that it can take up to 60 days for the refund.

M-8310 Disposition

Revision 11-4; Effective December 1, 2011

Since MBI eligibility is determined in TIERS, an initial eligibility determination group (EDG) is created with a "Suspended" status. This will be used when the MBI EDG is approved for potential eligibility. The EDG status will be updated based on vendor communication. The EDG status will be updated to "Approved" when vendor communication confirms that at least one month's premium has been received. The EDG status will be updated to "Denied" when vendor communication confirms that the payment was not received by the due date. If the payment is received during the adverse action time period then the EDG is reopened.

 

M-8320 Eligibility Summary

Revision 16-4; Effective December 1, 2016

When the Medicaid Buy-In (MBI) potential eligibility EDG is disposed, Form TF0001, Notice of Case Action, is automatically sent to batch but must not be sent to the individual. Instead, the eligibility worker sends a manual Form H0053, Medicaid Buy-In Potential Eligibility Notice, containing the premium amount(s) and the premium due date. If the eligibility worker sends Form H0053 before cut-off, the premium payment is due at the end of the same month and is applied to the following month. If the individual does not make the first payment by the due date, deny the case.

On the first day of every month, TIERS automatically generates Form H0051, Medicaid Buy-In Premium Payment Notice, which is mailed directly to the individual. The notice has a coupon attached and a postage-paid envelope enclosed. The individual submits the premium payment, along with the coupon, by the due date. Failure to make the premium payment by the due date will cause the individual to be denied. Adverse action requirements pertain to MBI.

If an individual whose MBI eligibility was denied for failure to submit premium payments reapplies for MBI, the individual must pay all past due premium payments and current monthly payments to be reinstated into the program. All past due premiums and current premiums must be paid by the due date on Form H0053 sent to the individual for the reapplication.

Note: Premium payments must be received in the form of a check or a money order payable to MBI.

The premium payment address is:
Medicaid Buy-In
P.O. Box 650868
Dallas, TX 75265-9843

Once MBI receives the premium payment and the EDG is disposed, Form TF0001, Notice of Case Action, is automatically sent to batch but must not be sent to the individual. Instead, the eligibility worker sends a manual Form H0054, Medicaid Buy-In Eligibility Notice, containing the month(s) of eligibility and the corresponding premium amount(s) received.

Revision 13-3; Effective September 1, 2013

The first premium payment is due based on the date of disposition.

• If disposed before the current month's cutoff, the payment is due by the end of the disposition month.
• If disposed after the current month's cutoff, the payment is due by the end of the following disposition month.

Example 1: Month of application: May. Prior months: April, March and February. If cutoff is May 15, and the MEPD Specialist disposes the case on May 11, the due date of all premiums for ongoing and all prior months (if the individual wants coverage for all) would be May 31,20XX. So payment is due for:

• June – ongoing month and mandatory, must be paid first;
• May – month of application and optional;
• April – prior month one and optional;
• March – prior month two and optional; and
• February – prior month three and optional.

Note: If the individual wants those optional months, he or she must pay in reverse chronological order. This means the ongoing month must be paid first, then the previous month, then the month before that and so forth. Like the order in the example above.

Example 2: Month of application: May. Prior months: April, March and February. If cutoff is May 15, and the MEPD Specialist disposes the case on May 19, the due date of all premiums for ongoing and all prior months (if the individual wants coverage for all) would be June 30, 20XX. So payment is due for:

• July – ongoing month and mandatory, must be paid first;
• June – month after month of application and optional;
• May – month of application and optional;
• April – prior month one and optional;
• March – prior month two and optional; and
• February – prior month three and optional.

Note: If the individual wants those optional months, he or she must pay in reverse chronological order. This means the ongoing month must be paid first, then the previous month, then the month before that and so forth. Like the order in the example above.

 

M-8410 Ongoing Premium Due Dates

Revision 13-3; Effective September 1, 2013

Monthly premiums are due the end of each month. If payment is not received by the end of the month, the coverage will be terminated at the end of the following month.

• If the remaining amount due is received two days prior to cutoff, then there is no interruption in coverage.
• If the remaining amount due is received after the deadline for payment (two days before cutoff), the individual is denied and the payment will be applied to any unpaid months the individual received benefits.
• Funds are to be applied to satisfy the ongoing month and any months premiums were not paid.
• After 12 months from the denial for non-payment the individual can reapply without having to pay any unpaid premium.

Example 1: Payment Received Timely: The due date for the May premium is April 30, 20XX, and cutoff is May 15. If no payment is received by April 30, 20XX, the MEPD Specialist will send a manual denial notice to the individual on that date, but will NOT run eligibility (EDBC) and deny the case at that time. If payment IS received between the due date (end of previous month) and two days prior to cutoff (in this example, May 13, 20XX) there will be no disruption in coverage.

Example 2: Payment Not Received Timely: The due date for the May premium is April 30,20XX, and cutoff is May 15. If no payment is received by April 30, 20XX, the MEPD Specialist will send a manual denial notice to the individual on that date, but will NOT run eligibility (EDBC) and deny the case at that time. If payment IS NOT received by two days prior to cutoff (in this example, May 13, 20XX) the MEPD Specialist will run eligibility (EDBC) and deny the case on May 14, 20XX, and document it in case comments. No denial notice needs to be sent at this time because one was previously sent.

 

M-8411 Non-Sufficient Funds for Ongoing Cases

Revision 13-3; Effective September 1, 2013

Ongoing cases for MBI are certified or approved cases. Individuals are currently on the program as they have made premium payments. Their EDG is in approved status.

The vendor will notify the individual through written notice of non-sufficient funds (NSF) when they occur. The vendor notifies the MEPD Specialist if non-sufficient funds occur.

• If payment is not rectified and received within the adverse action period (two days before next month's cutoff), it will be treated as a non-payment and the case denied.
• If the individual makes a replacement payment within the adverse action period (two days before cutoff), there will be no disruption in benefits.
• If the individual makes a replacement payment after the adverse action period (two days before cutoff) the case will be denied and the payment will be applied to any unpaid months where benefits were received. If there is any remaining payment, it will be refunded to the individual.

 

M-8412 Non-Sufficient Funds for Suspended Eligible Cases

Revision 13-3; Effective September 1, 2013

Suspended-eligible cases are cases where benefits have not been approved due to pending premium payments. The EDG stays in suspended status until payment is made, eligibility is determined and the case is disposed.

If the premium is not paid because of non-sufficient funds (NSF), the vendor will notify the individual through written notice of non-sufficient funds. The vendor notifies the MEPD Specialist if NSF occurs.

• If no replacement payment is made, benefits will not be granted and the case will be denied.
  • Example – Cutoff is June 20, 20XX. The MES disposes the case on June 10, 20XX. The premium payment is due June 30, 20XX. If no premium payment is received by June 30, 20XX, the case is denied.
• If the individual makes a replacement payment prior to the due date (end of the month) benefits will be granted.
  • Example A – Cutoff is June 20, 20XX. The MES disposes the case on June 10, 20XX. The Premium payment is due June 30, 20XX. The Premium payment received June 15, 20XX. On June 22, 20XX, vendor notifies MEPD the payment was NSF. The individual replaces/rectifies the premium on June 25, 20XX. MES approves the case and benefits granted.
  • Example B – Cutoff is June 20, 20XX. MES disposes the case on June 22, 20XX (after cutoff). The Premium payment is due July 31, 20XX. The Premium payment is received July 1, 20XX. On July 10, 20XX, the vendor notifies MEPD the payment was NSF. The individual replaces/rectifies the premium on July 15, 20XX. MES approves the case and benefits granted.
  • Note: The individual has to pay the ongoing month first, then any optional month, such as prior months, if this was an application.
• If the individual makes a replacement payment after the due date (end of the month) benefits will be denied and payment will be refunded.
  • Example — Cutoff is June 20, 20XX. The MES disposes the case on June 10, 20XX. The Premium payment is due June 30, 20XX. The Premium payment is received June 15, 20XX. On June 20, 20XX, the vendor notifies the MEPD the payment was NSF. The individual sends a replacement premium on June 25, 20XX, but it is not received until July 5, 20XX. MES denies the case and benefits on June 30, 20XX. The monies are refunded to the individual.

Note: If the NSF notification is received after the due date (end of the month), ongoing rules will apply.

Example – Cutoff is June 20, 20XX. The MES disposes the case on June 10, 20XX. The individual received notice to pay the premium on June 20, 20XX. The premium is received on June 30, 20XX; the vendor notifies MEPD and MES approves the case. On July 4, 20XX, the vendor notifies MEPD the payment is NSF. Because the NSF notification was received after the due date – end of the month – MES must use the ONGOING policy. See M-8411,Non-Sufficient Funds for Ongoing Cases.

 

M-8420 Premium Payment Notices

Revision 15-3; Effective September 1, 2015

On the first day of every month, TIERS automatically generates Form H0051, Medicaid Buy-In Premium Payment Notice, which is mailed directly to the person. The notice has a coupon attached and a postage-paid envelope enclosed. The person submits the premium payment, along with the coupon, by the due date. Failure to make the premium payment by the due date will cause the person to be denied. Adverse action requirements pertain to MBI. A person whose MBI eligibility is denied for failure to submit premium payments must pay all past due premium payments and current monthly payments to be reinstated into the program.

Note: Premium payments must be received in the form of a check or a money order payable to MBI.

The premium payment address is:
MBI
P.O. Box 650868
Dallas, TX 75265-0868

Once MBI receives the premium payment and the EDG is disposed, Form TF0001, Notice of Case Action, is automatically sent to batch but must not be sent to the person. The eligibility worker sends a manual Form H0054, Medicaid Buy-In Eligibility Notice, containing the month(s) of eligibility and the corresponding premium amount(s) received.

 

M-8430 Presidential-Declared Emergency (PDE)

Revision 12-1; Effective March 1, 2012

A PDE hardship exemption will automatically be granted to recipients living in the declared area and premiums waived for three months. Recipients do not have to request a hardship for PDE. TIERS will send an "emergency special notice" to inform recipients at the start of the PDE period that the premiums have been waived. There is no limit to how many PDEs for which a recipient may have premiums waived; however, a recipient may only have up to three months of premiums waived once per emergency.

For MBI recipients, the waiver of premiums for a PDE begins in the month in which the emergency is declared and continues forward for a total of three consecutive months. Premiums for retroactive months will not be waived. Any premiums received and applied to a month in which a PDE is in effect will be refunded.

Example 1: A PDE is declared for March through May. Premiums may be waived for March, April and/or May. Premiums may be waived for one, two or three months, depending on the date the person is approved for MBI.

Example 2: The PDE period is declared for March through May.

March is the month in which the MBI application is received by HHSC. On April 18, the individual residing in a PDE area is approved for MBI. The individual is eligible to have monthly premiums waived for April and May.

Example 3: The PDE period may be longer than three months (e.g., declared in March, extended through July – five months).

Regardless of the length of the PDE, the recipient may only have premiums waived for three consecutive months (e.g., March, April and May), regardless of the PDE time period. In the third month for which premiums have been waived, Form H0051, Medicaid Buy-in Premium Payment Notice, which has a payment coupon attached, should be mailed no later than the 20th requesting payment for the month of June, even though the emergency period has not ended.

Revision 21-1; Effective March 1, 2021

In addition to the MEPD denial codes for all programs, there are eleven denial reasons specific to the MBI program. The correct reason for denial must be manually entered in the case comments section of Form TF0001, Notice of Case Action, before the system generates and sends out the notice. Use the following denial reasons for MBI as appropriate.

1. You failed to pay your MBI premium by the due date.
2. Your Independence Account is a countable resource from <mmddyy> through <mmddyy> for one or more of the following reasons:
   • Money was used for non-health care or non-work related expenses.
   • Deposits exceed 50% of your earnings for the Social Security Administration qualifying quarter.
   • Deposits are from sources other than earnings or interest earned on this account.
   • Deposits include income from another individual.
3. Your countable income increased because you did not pay a designated impairment-related work expense (IRWE) with your income.
4. Your countable income increased because you did not pay a designated blind work-related expense (BWE) with your income.
5. The resources excluded as part of your Plan to Achieve Self-Support (PASS) are now countable because you have not met the goal dates in your PASS.
6. The resources excluded as part of your PASS are now countable because funds have not been set aside as agreed.
7. The resources excluded as part of your PASS are now countable because funds have not been spent as agreed.
8. The income excluded as part of your PASS is now countable because you have not met the goal dates in your PASS.
9. The income excluded as part of your PASS is now countable because funds have not been set aside as agreed.
10. The income excluded as part of your PASS is now countable because funds have not been spent as agreed.
11. You did not meet the requirements of completing a Social Security Administration Qualifying Quarter.

M-8510 Redeterminations

Revision 11-4; Effective December 1, 2011

Redeterminations for MBI follow regular MEPD policy for redeterminations.

Streamlining methods and passive reviews are not allowed for an MBI redetermination. 

M-8520 Appeals

Revision 13-1; Effective March 1, 2013

HHSC is responsible for all appeals including those concerning premiums.

If an individual is dissatisfied with HHSC's decision concerning his eligibility for medical assistance, he has the right to appeal through the appeal process established by HHSC. In certain circumstances, the individual is entitled to receive continued benefits or services until a hearing decision is issued. Whether an individual is entitled to continued assistance is based on requirements set forth in appropriate state or federal law or regulation of the affected program. See the Fair and Fraud Hearings Handbook.

Revision 22-3; Effective September 1, 2022

A recipient will only receive one Your Texas Benefits Medicaid card, which is intended to be the recipient’s permanent card. A recipient’s Your Texas Benefits Medicaid card will only be replaced if the card is damaged, lost or stolen. 

Related Policy

Your Texas Benefits Medicaid Card, R-2300