Chapter R, Case Disposition

R-1000, Medical Effective Date and Notices

Revision 15-2; Effective June 1, 2015

 

R-1100 Texas Administrative Code Rules

Revision 09-4; Effective December 1, 2009

 

§358.540. Medical Effective Date.

(a) If a person is eligible for a Medicaid-funded program for the elderly and people with disabilities (MEPD), the Texas Health and Human Services Commission (HHSC) includes in the notice of eligibility the date that the person's Medicaid benefits will begin, which is known as the medical effective date.

(b) HHSC determines the medical effective date:

(1) in accordance with 42 CFR §435.914, as the first day of the month in which a person meets all eligibility criteria, which may be up to three months before the date of application if:

(A) during the three months before the month of application, the person received MEPD services covered under the Texas State Plan for Medical Assistance; and

(B) would have been eligible for MEPD at the time the services were received if the person had applied (or someone had applied on behalf of the person), regardless of whether the person is alive when application for MEPD is made; or

(2) as approved by the Centers for Medicare and Medicaid Services for a §1915(c) waiver program.

§358.535. Notice of Eligibility Determination.

(a) After making an initial eligibility determination, the Texas Health and Human Services Commission (HHSC) sends the applicant, in accordance with 42 CFR §435.912:

(1) a written notice of eligibility, including notice of any co-payment the person must pay and the medical effective date described in §358.540 of this subchapter (relating to Medical Effective Date); or

(2) a written notice of ineligibility, explaining the reason for the decision and the specific provision supporting the decision.

(b) After making an eligibility redetermination, HHSC sends the recipient a written notice of any change in eligibility or co-payment.

(c) The written notice informs the applicant or recipient of the right to request a hearing to appeal the eligibility determination. The hearing is held in accordance with 42 CFR Part 431, Subpart E and HHSC's fair hearing rules in Chapter 357 of this title (relating to Hearings).

 

R-1200 Medical Effective Date

Revision 12-2; Effective June 1, 2012

 

The medical effective date (MED) is the first day of the month an applicant meets all eligibility criteria, up to three months before the date of application, in which:

  • the applicant had unpaid or reimbursable, medical expenses, regardless if the person is alive when the application is made;
  • the applicant entered a nursing facility, intermediate care facility for persons with intellectual disabilities (ICF/ID) or state supported living center; or
  • the applicant is approved for Home and Community-Based Services waiver services. (See below when re-establishing coverage following denial because of non-receipt of redetermination packet.)

For individuals transferring from Supplemental Security Income (SSI) to MEPD (excluding Medicare Savings Program recipients), the MED is the day after the effective date of denial (under ME – SSI).

Report the MED correctly on all applications processed. The MED is used to initiate all medical benefits to the person and payments to providers.

The MED for Community Attendant Services (formerly 1929(b)) may be the first of the month in which:

  • the application was received; or
  • an eligibility decision was made.

If a person is within the resource limit as of 12:01 a.m. on the first day of the month in which the application is received and there is no indication that the person exceeds the resource limit in the month the eligibility decision is made, the resources do not need to be verified as of 12:01 a.m. for the decision month.

When re-establishing Home and Community-Based Services waiver services following denial due to non-receipt of redetermination packet:

Prior months' eligibility and ongoing eligibility for the financial Medicaid eligibility component is contingent upon Department of Aging and Disability Services (DADS) verification of receipt of waiver services. Coordinate financial case actions with a DADS case manager.

The following examples are for the financial Medicaid eligibility component for waivers and are not intended to address any situation with continuous Q benefits.

  • Example 1: A case is denied because of non-receipt of redetermination packet effective June 30. In October, the redetermination packet is received. The redetermination is treated as an application. The person met all financial eligibility criteria for October and all months since denial. DADS has verified waiver services were provided continuously since June. The MED is July 1 and there is no break in coverage.
  • Example 2: A case is denied because of non-receipt of redetermination packet effective March 31. In October, the redetermination packet is received. The redetermination is treated as an application. The person met all financial eligibility criteria for October and all months since denial. DADS has verified waiver services were provided continuously since March. The MED is July 1. This is a break in coverage since the MED is the first day of the month up to three months before the receipt of the application/redetermination.
  • Example 3: A case is denied because of non-receipt of redetermination packet effective Jan. 31. In June, the redetermination packet is received. The redetermination is treated as an application. The person met all financial eligibility criteria for February and all months since denial. DADS has verified waiver services stopped effective Feb. 28. The MED is June 1 or first of the month waiver services begin. There is a break in coverage.

For funding purposes, there are four types of Medicaid coverage:

  • Regular coverage — Medicaid pays a premium to cover the cost of services provided by physicians and hospitals. Other services, such as drugs and nursing facility care, are paid for directly by Medicaid.
  • Institutional coverageDADS provides all Medicaid services to eligible individuals in state supported living centers. No premium is paid.
  • Community Attendant Services (formerly 1929(b)) coverage — Medicaid pays for primary home care, but no other Medicaid services are provided to the Community Attendant Services recipient.
  • Qualified Medicare Beneficiary coverage — Medicaid pays Medicare premiums, deductibles and coinsurance for persons who are enrolled in Medicare Part A, have income below the specified percentage of the federal poverty level and have resources no more than twice the limits for the SSI program.

A person may qualify for prior eligibility only, for current eligibility only or for future eligibility, or for a combination of the three. For processing and accounting purposes, eligibility is further divided into three types:

  • Prior eligibility — This indicates Medicaid coverage for a period before the month of application. Prior coverage is determined in whole-month increments, except in cases involving death or birth, or ME – A and D-Emergency.
  • Current eligibility — This Medicaid coverage begins on or after the month of application.
  • Future eligibility — This Medicaid coverage is limited to Qualified Medicare Beneficiary coverage. Coverage begins the first of the month after eligibility is determined.

References

See Section R-1230, Qualified Disabled and Working Individuals (QDWI), for the procedure to obtain the MED for MC-QDWI(Qualified Disabled and Working Individuals).

See Chapter Q, Medicare Savings Programs, for procedures involving continuous Medicaid Qualified Medicare Beneficiary (MQMB) coverage.

See Chapter Q for issues related to QMB and co-payment.

See Section Q-2700, QMB Medical Effective Date.

 

R-1210 Medicare Skilled Nursing Facilities

Revision 12-2; Effective June 1, 2012

 

The medical effective date for a person in a Medicare skilled nursing facility (SNF) potentially can be as early as the first day of the month of entry to the nursing facility or the first day of a prior month. If eligible, this will ensure payment of any other medical expenses (including returns to the hospital during the initial 20 days of full Medicare coverage). At certification, the eligibility worker must verify and document in TIERS case comments section that the individual:

  • remains in the SNF section; or
  • has been discharged to a Medicaid-certified facility.

Medicare approval of the applicant for the SNF bed meets the medical necessity (MN) requirement. If the MED is prior to the applicant's move to the Medicaid-only bed, the MN requirement has been met.

Note: If the person remains in the SNF when the case is certified, it is recommended that a special review be scheduled to monitor for the completed MN determination when SNF does end.

See Chapter H, Co-Payment, for issues related to the 30 consecutive day stay requirement and the appropriate income limit.

Examples:

  • Marsha Ford is admitted to an SNF as full Medicare on 11-15-XX. The 21st SNF day is 12-05-XX. The application is received 12-14-XX. Application is ready to certify 01-03-XX. The eligibility worker verifies that Ms. Ford has unpaid/reimbursable hospital bills for 11-XX. Ms. Ford is still in the SNF bed and has met all eligibility criteria as of 12:01 a.m. 11-01-XX. MED = 11-01-XX. Co-payment begins 12-05-XX.
  • Fred McDaniel is admitted to an SNF as full Medicare on 03-24-XX. The 21st SNF day is 04-13-XX. The application is received 04-05-XX. He is discharged from the SNF to a Medicaid bed on 05-20-XX. Application is ready to certify 06-15-XX. Mr. McDaniel meets all eligibility criteria as of 12:01 a.m. 03-01-XX. MED = 03-01-XX. Co-payment begins 04-13-XX. MN is not necessary, as MED is prior to discharge to Medicaid-only bed.

 

R-1220 Out-of-State Transfers

Revision 12-2; Effective June 1, 2012

 

If a person from another state declares an intention to live in Texas and meets Texas eligibility requirements, contact the Medicaid agency of the former state of residence. Request that the agency notify HHSC about Medicaid eligibility and the denial, including its effective date. The denial effective date is the last day for which the person's former state of residence will pay Medicaid claims. This is not necessarily the denial effective date on the former state's computer system.

Texas residency is met the first day of the month of move to Texas with the intent to remain in Texas.

If the person did not receive any form of Medicaid in the former state of residence, the earliest MED is the first day of the month of move to Texas, regardless of the actual date of the move. Follow MED policy for month of application and three months prior.

Exception: For QMB, coverage begins the first of the month after eligibility is determined.

If the person did receive Medicaid in the former state of residence, the MED for the person in Texas is no earlier than the day following the date his/her former state of residence will pay Medicaid claims.

If an out-of-state person receives SSI and indicates that he/she intends to live in Texas, refer him/her to a Social Security office. That office makes the SSI (and Medicaid) residence determination.

Examples:

  1. A person was not receiving any form of Medicaid in another state, moved to Texas on July 7 and applied to have the Medicare premium paid. The application for Medicare Savings Programs was filed on July 28. The person met all eligibility criteria in July for Specified Low Income Medicare Beneficiaries (SLMB).

    The MED for SLMB is July 1. Prior months would not be applicable in this situation because the person did not reside in Texas before July.
  2. A person was not receiving any form of Medicaid in another state, moved to Texas on July 30 and entered a nursing facility (NF) that day. An application for MEPD was filed on Aug. 14. The individual met all eligibility criteria in July for Medicaid and QMB.

    In this situation, July is a prior month. Because coverage for a prior month must begin the first day of that month, the MED is July 1. The MED for QMB in Texas is the first day of the month following the month in which QMB eligibility is determined.
  3. A person was receiving Medicaid in another state, moved to Texas on Jan. 15 and entered an NF that day. The application for ME – Nursing Facility was filed on Feb. 10. Medicaid coverage in the other state ended on Jan. 15. The individual met all eligibility criteria in January.

    In this situation, January is a prior month. Because coverage for a prior month must begin the first day of that month, the MED would normally be Jan. 1. If the MED were reported as Jan. 1, there would be federal financial participation (FFP) for two states for the same time period (Jan. 1-15), which is prohibited by federal regulations. Because the correct MED in this case is Jan. 16, the file date must be adjusted to reflect the date following Medicaid closure in the other state, or Jan. 16. Case comments should explain the file date discrepancy.
  4. A person was an SSI recipient in another state and moved to Texas on July 7.

    Because the Social Security Administration (SSA) determines SSI entitlement, HHSC uses the effective date in Texas as communicated by the State Data Exchange (SDX) tape. This date should be the first day of the month following the month in which the SSI recipient moves to Texas.
  5. A person who was a QMB recipient in another state, moved to Texas on July 7 and applied to have the Medicare premium paid. The application for Medicare Savings Programs was filed on July 28.

    If QMB coverage in the other state ended during July, the effective date of QMB coverage in Texas should be no earlier than Aug. 1. The other state is payer of record for Medicare buy-in for July 1993 and receives FFP for that purpose. Any buy-in attempt by Texas for that month will be rejected by the federal system. Because of the prohibition against dual FFP, QMB eligibility cannot be divided between two states for a given month.
  6. The person received ME – Nursing Facility with Q benefits in a Texas NF, but moved out-of-state in April and began receiving Medicaid in the other state. The person returned to a Texas NF on Nov. 15 and applied for MEPD on Nov. 15. The person never received QMB benefits in the other state, although he/she appears to have been eligible since leaving Texas.

    The other state will pay no claims after Nov. 15; therefore, the MED for ME – Nursing Facility with may be no earlier than Nov. 16, because November is the month of application. In this situation, there is no continuous Q to ensure. The person did not have QMB coverage in the other state, and HHSC cannot grant QMB coverage for the period of time he/she lived out of state, as he/she was not a Texas resident. The effective date of QMB coverage in Texas is the first day of the month following the month in which QMB eligibility is determined.

 

R-1230 Qualified Disabled and Working Individuals (QDWI)

Revision 09-4; Effective December 1, 2009

 

The MED is influenced by whether a person enrolls for Medicare coverage during the initial enrollment period (IEP) but before his/her present Medicare entitlement ends, after the IEP begins but after his entitlement ends, or following the IEP. HHSC considers the date the person enrolled for continuation of his Medicare entitlement when determining the MED. The MED does not precede the earliest date the person is entitled to reinstatement of his/her Part A coverage. Otherwise, use the same procedures for determining the MED for all other MEPD non-institutional groups (including retroactive coverage).

The following chart may be used as a reference for the MED determination policies and examples.

Enrollment Period Month Activities
Initial Enrollment
Period (IEP)
April
May
Client notified his free Part A entitlement will end.
  June End of client's free entitlement.
  July
August
September
First month client meets QDWI criteria.
General Enrollment
Period (GEP)
January
February
QDWI coverage effective July 1.
  March End of GEP.

The following apply when determining the MED:

  • The IEP for a person who has been notified that his free entitlement to Medicare Part A coverage will end is a seven-month period. The enrollment period begins the month the person is notified.

    Example: A person is notified in April that his free entitlement to Part A coverage ends at the end of June. His initial enrollment period begins in the month of notification (April) and ends at the end of October. To reinstate his Part A coverage, he must enroll with SSA before the end of October. He then must apply with the department for QDWI benefits.
  • In the case of a person who enrolls in an IEP before meeting QDWI criteria and applies for QDWI benefits, the MED is the first day of the month he meets the QDWI criteria.

    Example: A client is notified in April that her free entitlement to Medicare Part A coverage ends at the end of June. She enrolls for reinstatement of her Part A coverage with SSA in April and applies for and is determined eligible for QDWI benefits with HHSC in May. The earliest MED she can have for QDWI benefits is July 1 because it is the first month she meets QDWI criteria and is allowed to purchase Part A coverage.
  • If a person enrolls in the first month that he meets all QDWI criteria except for reinstatement (fourth month of the initial enrollment period), and applies for QDWI benefits, the medical effective date is effective the first of the following month.

    Example: A person is notified in April that his free entitlement to Medicare Part A coverage ends at the end of June. He enrolls for reinstatement of his Part A coverage with SSA in July and applies for and is determined eligible for QDWI benefits in July. The earliest MED date he can have for QDWI benefits is August 1 because that is the first month he is entitled to reinstatement of his Part A coverage.
  • If a person enrolls in the second month that she meets all QDWI criteria except for reinstatement (fifth month of the IEP) and applies for QDWI benefits, the medical effective date is effective the second month after enrollment.

    Example: A person is notified in April that her free entitlement to Medicare Part A coverage ends at the end of June. She enrolls for reinstatement of her Part A coverage with SSA in August and applies for and is determined eligible for QDWI benefits in September. The earliest MED she can have for QDWI benefits is October 1 because that is the first month she is entitled to reinstatement of her Part A coverage.
  • If a person enrolls in the third or fourth month that he meets all QDWI criteria except for reinstatement (sixth or seventh month of the IEP) and applies for QDWI benefits, the MED is effective the first day of the third month following the month he enrolled.

    Example: A person is notified in April that his free entitlement to Medicare Part A coverage ends at the end of June. He enrolls for reinstatement of his Part A coverage with SSA in September and applies for and is determined eligible for QDWI benefits in October. The earliest MED he can have for QDWI benefits is December 1 because that is the first month he is entitled to reinstatement of his Part A coverage.
  • If a person enrolls during the general enrollment period (GEP), the MED is always effective July 1.

    Example: A person is notified in April that her free entitlement to Medicare Part A coverage ends at the end of June. She does not enroll during the IEP and decides to enroll during the GEP, from January through March 31, of the next year. The earliest MED she is allowed is the July 1 following her enrollment.

 

R-1300 Notices

Revision 15-2; Effective June 1, 2015

 

Note: See Appendix XI, Reference for Notification Forms, to find the right form to send to the applicant or recipient.

For Eligibility:

Send the applicant or recipient a written notice of eligibility for each program. On the eligibility notice, include the MED and any co-payment amount.

Note: For Mason Manor cases, see Appendix XXIII, Procedure for Designated Vendor Number to Withhold Vendor Payment, to find the appropriate forms and explanation to send to the applicant or recipient.

For Ineligibility:

Send the applicant or recipient a written notice of ineligibility for each program. On the ineligibility notice, explain the reason for the decision and the appropriate chapter of this handbook that supports the decision.

For redeterminations, tell a recipient about any change in eligibility or co-payment, if applicable. See Appendix XI.

Address the notice to the applicant or recipient or, if addressed to an authorized representative, say that the information is about the applicant or recipient. All information on notices must be accurate.

Make sure each written notice tells the applicant or recipient about the right to ask for a hearing to appeal the eligibility decision.

Mail the written notice to the applicant or recipient within two working days after the date of the eligibility decision.

Send each applicant or recipient a copy of the HIPAA — Notice of Privacy Practices or HIPAA — Notice of Privacy Practices (Spanish) upon certification.

R-2000, Other Actions and Notifications

Revision 14-1; Effective March 1, 2014

 

R-2100 Persons Discharged to Hospitals from Institutional Settings

Revision 09-4; Effective December 1, 2009

 

When a recipient in a long-term care facility is discharged to a Medicaid-certified hospital, the recipient continues to be eligible during his/her absence. Redetermine eligibility if the recipient does not re-enter the nursing facility after discharge from the hospital.

To monitor a recipient in a nursing facility who is discharged to a hospital, use a tracking system. This ensures prompt awareness of a change in the recipient's status, such as death or a return to the community after he/she is discharged to a hospital.

The following procedures are recommended for establishing a tracking system:

  • Immediately upon receipt of Form 3618, Resident Transaction Notice, showing discharge to a hospital, establish a control record for the recipient. Use Form 3618 as the control record or prepare a card file record. The control file may be maintained separately by each eligibility specialist or centrally for all eligibility specialists in an office.
  • At least every 15 calendar days, confirm the recipient's status and location. Contact the nursing facility first because the recipient may have been readmitted. If he/she has not returned to the facility, the facility may supply the name of the hospital or the authorized representative to determine if the recipient is still a patient. Follow up with the hospital or authorized representative every 15 days until the recipient returns to the nursing facility, is discharged to another living arrangement or dies.
  • If the recipient is no longer in the hospital, remove the control record from the file and take action to update the case, if required.

 

R-2200 Reserved for Future Use

Revision 12-2; Effective June 1, 2012

 

 

R-2300 Your Texas Benefits Medicaid ID Card

Revision 16-3; Effective September 1, 2016

 

When a person is certified for regular Medicaid benefits, HHSC promptly issues a Your Texas Benefits Medicaid ID card, which individuals will use to receive services.

  • Individuals only receive one Your Texas Benefits Medicaid ID card, which is intended to be the individual's permanent card.
    • If the individual's Medicaid coverage ends but they later regain coverage, the individual can use the same Your Texas Benefits Medicaid ID card.
    • If the individual loses the card, they can get a replacement card by calling 1-855-827-3748.
  • Individuals should carry and protect their Your Texas Benefits Medicaid ID card just as they do their driver's license or credit card.
  • The Your Texas Benefits Medicaid ID card is plastic like a credit card.
    • It will have a magnetic strip that holds the individual's Medicaid ID number.
    • Providers are able to use that number and the provider website (YourTexasBenefitsCard.com) to determine if the individual is covered by Medicaid.
  • The Your Texas Benefits Medicaid ID card will come printed with the following information on the front:
    • individual's name and Medicaid ID number;
    • managed care program name (if STAR Health);
    • date the card was issued; and
    • billing information for pharmacies.
  • The back of the card will come printed with a statewide toll-free phone number and a website (YourTexasBenefitsCard.com) where individuals can get more information on the Your Texas Benefits Medicaid ID card.
  • Individuals should use the card when they go to a Medicaid doctor or dentist visit or when they go to the pharmacy. The office staff can use the card to help determine if the individual is covered by Medicaid.
  • If the individual forgets the Your Texas Benefits Medicaid ID card, the doctor, dentist or pharmacy can verify that person's Medicaid coverage by calling the TMHP Contact Center at 1-800-925-9126 or visiting TMHP's TexMedConnect website and checking the individual's Medicaid ID number. Providers also can verify eligibility by using the secure website (YourTexasBenefitsCard.com) designed for use with the Your Texas Benefits Medicaid ID card, or by calling 1-855-827-3747 (7 am to 7 pm Monday - Friday, and 9 am to 5 pm Saturday).
  • If an individual loses the Your Texas Benefits Medicaid ID card and needs quick proof of eligibility, HHSC staff at a local benefits office can still generate a temporary Form H1027-A, Medicaid Eligibility Verification.
  • The Your Texas Benefits Medicaid ID card and the YourTexasBenefitsCard.com provider website are designed to give providers another way to verify the individual's Medicaid coverage. Providers are able to instantly access their Medicaid patient's Medicaid-related:
    • THSteps Alerts listing the last check-up dates for dental/medical services;
    • health Summary information;
    • prescription drug history and health events including diagnosis and treatment; and
    • vaccination history.
    Individuals can choose to not allow their Medicaid doctors and other providers to see their Medicaid-related health history through the provider website. Individuals can "opt out" by calling 1-855-827-3748 (toll-free) or through YourTexasBenefits.com MEHIS client portal.
  • The website will give providers a way to capture information showing when their Medicaid patient receives treatment.

HHSC does not issue Your Texas Benefits Medicaid ID cards for residents of a state supported living center because Medicaid state institutions are responsible for all medical care for Medicaid-eligible residents. HHSC sends each state institution a monthly listing of all Medicaid individuals currently shown on computer files as living in that facility.

Note: HHSC does not issue a Your Texas Benefits Medicaid ID card for Community Attendant Services (CAS) recipients unless they are eligible for Qualified Medicare Beneficiary Program (QMB).

 

R-2400 Issuance of Form H1027, Medicaid Eligibility Verification

Revision 16-3; Effective September 1, 2016

 

Occasionally, a recipient who needs medical services may lack current medical care identification.

HHSC may issue a Medicaid verification letter to an eligible Medicaid recipient who lacks a Your Texas Benefits Medicaid ID card if the:

  • recipient is newly certified and has not received the initial card; or
  • current card has been lost or destroyed.

Note: Do not issue Form H1027 to Community Attendant Services, SLMB or QDWI individuals (ME-Community Attendant with no QMB, MC-SLMB and MC-QDWI).

Form H1027 is issued in three versions. Issuance of the appropriate version of Form H1027 is dependent on the benefits the recipient is currently eligible for and receiving. Following is a brief description of each version of Form H1027.

Form H1027-A, Medicaid Eligibility Verification, is issued to recipients who are eligible for and receiving Medicaid benefits only.

Form H1027-B, Medicaid Eligibility Verification – MQMB, is issued to recipients who are eligible for and receiving both Medicaid and Qualified Medicare Beneficiary (QMB) benefits.

Form H1027-C, Medicaid Eligibility Verification – QMB, is issued to recipients who are eligible for and receiving QMB benefits only. Do not issue Form H1027-C to recipients who are receiving Medicaid benefits.

Reference: For additional information regarding client eligibility for QMB, see Chapter Q, Medicare Savings Programs.

Reminder: To ensure that the appropriate form is issued to an eligible person, only intake screeners and TANF, Medicaid, LTC (ME/CCAD), foster care or adoption assistance eligibility specialists and supervisors are authorized to complete the form.

Form H1027-A, Form H1027-B or Form H1027-C must be issued only to eligible persons who need verification of their current eligibility for benefits and who have no access to a current Your Texas Benefits Medicaid ID card. The forms are issued only for the current month and never for retroactive periods of eligibility.

Verify a recipient's current eligibility by:

  • contacting Data Integrity; or
  • checking inquiry in TIERS.

Note: If unable to verify the recipient's eligibility because of computer problems, follow regional procedures to verify eligibility.

After verifying eligibility, complete the appropriate Form H1027.

After completing the appropriate Form H1027, have the form approved, signed and dated by the unit supervisor. The supervisor may also approve the form by telephone. If obtaining the supervisor's approval by telephone, note "by telephone" on the approval line. If the unit supervisor is not available, the lead eligibility specialist in the locality may approve the form.

Reference: For additional information about issuing Form H1027, refer to the instructions. See Chapter B, Applications and Redeterminations, for emergency manual certification procedures.

 

R-2500 Explanation of Benefits

Revision 12-2; Effective June 1, 2012

 

Form H3086, Explanation of Benefits (EOB), is mailed each month to a random sample of Medicaid recipients. The EOB is a statement of all Medicaid services that were billed and paid on the recipient's behalf in the preceding month.

The EOB is mailed with a return envelope. If a recipient has a question about reported Medicaid services, the recipient circles the service in question, enters a contact telephone number and returns the EOB to state office. The recipient can call 1-800-252-8263 if questions arise about the EOB information.

If a recipient contacts HHSC about a questionable EOB, explain the purpose of the EOB. If a question still exists, instruct the recipient to mail the EOB to:

Office of Inspector General/Medicaid Provider Integrity
Mail Code 1361
P.O. Box 82500
Austin, TX 78708-9920

If the EOB is readily available, record on the EOB the recipient statement about the discrepancy. (Example: "Client states she has never seen a Dr. Jones.")

After an EOB is returned to state office, the EOB analyst checks the service in question for possible billing errors. If a billing error is found, appropriate action is taken to correct the files. The EOB analyst notifies the recipient that correction has been made. If no billing error can be found, the EOB is referred to the appropriate local office for a contact with the recipient.

When an EOB from state office is received, attempt to contact the recipient and discuss the reason for returning the EOB. The contact may be by telephone, office visit or home visit. Do not contact the provider of service under any circumstance.

If the recipient did not understand the purpose of the EOB, or if the problem can be resolved by talking to him/her, check the appropriate box on the EOB-Form Letter (FL) 1 and return the EOB-FL 1 and EOB to state office.

If the recipient alleges that the service in question was not received, reports an additional charge or reports other problems in relation to the service questions, check the appropriate box, record the recipient's statement in the space provided on the EOB-FL 1 and return the EOB-FL 1 and EOB to state office. (A cover memorandum is not necessary.) After the EOB is returned to state office, the EOB is referred to the Texas Medicaid and Healthcare Partnership (TMHP) for further investigation, and no further action on the part of the eligibility specialist is required.

If a provider of services has questions about an EOB, explain the purpose of the EOB. If additional information is requested, or a service listed is in question, ask the provider to telephone TMHP using the provider contact information below:

  • Automated Inquiry System (AIS) – 1-800-925-9126
  • TMHP Contact Center – 1-800-925-9126

Reminder: Only services billed and paid appear on the monthly EOB.

 

R-2600 Reserved for Future Use

Revision 14-1; Effective March 1, 2014

 

 

R-2700 Notification of Pre-Screening Result for Medicaid

Revision 12-2; Effective June 1, 2012

 

Occasionally, for purposes of receiving assistance from drug companies or other private entities, a person will request a pre-screening for Medicaid in conjunction with a request for a letter to substantiate the results of the pre-screening.

Form H1035, Pre-Screening Result for Medicaid, is used to notify an interested person of the pre-screening results for Medicaid if:

  • the notice is requested by the person;
  • the pre-screening is based on a verbal conversation;
  • an official determination of eligibility is not conducted; and
  • the person does not appear eligible for Medicaid.

 

R-3000, Automated Systems

Revision 18-2; Effective June 1, 2018

 

R-3100 Establish Processing Deadlines

Revision 12-2; Effective June 1, 2012

 

When taking an application, designated staff complete Application Registration. Applications are tracked using TIERS and Data Mart reports.

When the application is for a person who is younger than 65 and has never had a disability determination, the eligibility specialist must pend for Disability on the Disability – Details page and run Eligibility Determination and Benefit Calculation (EDBC) to override the application due date default of 45 days. The application due date will be 90 days from the file date. If the application is not pended appropriately, the application will be delinquent in 45 days.

Sometimes an application cannot be certified before the 45th/90th day. In these cases complete Form H1215, Report of Delay in Certification, and submit the form for approval. Once approval for the delay is received, send Form H1247, Notice of Delay in Certification, to the applicant and the facility administrator. Enter appropriate information in TIERS to initiate the delay in certification.

Note: Do not send Form H1247 if certification is delayed because Home and Community-Based Services waiver services are pending. No notification is required for those cases because services have not yet begun.

Applications for which delay-in-certification procedures have been followed are excluded from the delinquent count in timeliness reports. However, the exclusion is only for a specific period of time, as follows:

  • Applications for persons age 65 or older are excluded for 135 days (45 + 90-day extension); however, if the application is still pending on the 136th day, it will be counted as delinquent.
  • Applications for persons under age 65 who have never had a disability determination 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 45/90-day limit, plus the 90-day extension, must be denied. A new application will be necessary to reconsider eligibility.

 

TIERS Delay Reasons Drop-down

  • 30-day consecutive requirement not met
  • Medical necessity decision is pending
  • Level of care decision is pending
  • Disability determination pending
  • Home and Community-Based Services waiver services pending
  • Nursing facility pending certification
  • New resource/information received after 30th day
  • Resource spend-down
  • Miscellaneous
  • CC Pending
  • Documentation of citizenship and identity
  • Legal review of documents

 

R-3200 Case Number

Revision 12-2; Effective June 1, 2012

 

When an application for assistance is entered into the system for the first time a unique 10-digit application number is assigned. The application number begins with the letter T. The letter T changes to the number one when the application moves to Data Collection and becomes a case. The case number is unique to that household. The household members may consist of more than one individual on more than one HHSC programs including Texas Works as well as MEPD programs.

If a certified member of the household leaves the household and establishes a new household, a new case is created and a new case number is assigned for the member who left the original household.

 

R-3210 Association of Case Number

Revision 12-2; Effective June 1, 2012

 

When a former recipient reapplies for assistance during File Clearance, determine if the individual should be associated to a former case number. This includes associating a former case number to a person who applies for ME – A and D-Emergency.

 

R-3300 Client/Individual Number

Revision 12-2; Effective June 1, 2012

 

The first time a person is certified by HHSC, a unique client/individual number is automatically assigned by state office. Once assigned, the number must be used by all program areas. The client/individual number is used in the system to locate identification information, certain types of income, Medicaid coverage and the numbers for all Edges in which the person appears.

Individuals certified under the legacy system (SAVERR) had their client numbers changed to nine-digit individual numbers at TIERS conversion.

 

R-3310 Association of Client/Individual Number

Revision 12-2; Effective June 1, 2012

 

During application registration, a procedure called File Clearance is performed on each individual that is recorded on the Individual Logical Unit of Work (LUW).

File Clearance is a process that compares the demographic information for an applicant (SSN, name, date of birth, gender and so on) against information in the Master Client Index (MCI). The MCI is a database containing information on all individuals known to the agency. Known to the agency means the individual has been on an application or case in either TIERS or the SAVERR legacy system.

File Clearance identifies and displays individuals whose information may match the application individual. If a match occurs, staff must investigate the matches to determine whether the applicant is in fact one of these people, or is a person completely new to the agency. The purpose of this process is to avoid duplicate individual information and duplicate cases or applications by reassigning the existing client/individual number.

Note: TIERS scores a match at 100% only when the first name, last name, SSN, DOB and gender are provided and that information matches an existing individual. Many instances exist where no Social Security number is available, and it sometimes is not required; therefore, staff should not assume the person is new to the system when the score is not a 100% match. Staff must be sure the person is new to the system before creating a new client/individual number and avoid creating multiple client/individual numbers for the same person.

When an individual is a match for an applicant, staff have various options that depend on whether the need is to match the application to an entire case or only to selected individuals. Associate the application to an existing TIERS case or application, or add TIERS individuals from an existing case to the new application.

 

R-3400 Merge and Separate Client/Individual Numbers

Revision 12-2; Effective June 1, 2012

 

Situations may arise when a person is erroneously assigned more than one client/individual number or when two or more people are assigned the same client/individual number. Eligibility specialists must resolve the situation by requesting the client/individual numbers be merged or separated, depending on the situation.

Staff use the TIERS functional area on the left navigation bar named Merge/Separate to request a merge or separate and the following procedures.

 

Merge

Use Request Merge when more than one Individual number has been assigned to a single person.

  • Enter a minimum of two, up to 10 Individual numbers to be merged and enter the mandatory comments explaining the reason for the merge request.
  • Upon entry of the Individual number in the Individual number field and clicking on the Add button, the demographic information associated with that Individual number will be displayed in the Selected Individuals section. If it is not the correct person, delete the entry using the delete icon or use the binoculars icon to search for the individual using demographic data. This is similar to the individual search in Inquiry.
  • Once all of the Individual numbers and mandatory comments are entered, click the Submit button to send the request to Data Integrity.

 

Separate

Use Request Separate when more than one person is assigned to a single Individual number.

  • Enter one Shared Individual number and up to three Individual numbers to be separated. Enter mandatory comments explaining the reason for the separate request.
  • Upon entry of the Individual number in the Shared Individual number field or demographic information and clicking on the Add button, the demographic information associated with that Individual number will be displayed in the Selected Shared Individuals and Shared ID above is to be separated to these individuals sections if it is not the correct person. Delete that entry using the delete icon or use the binoculars icon to search for the individual using demographic data, similar to the individual search in Inquiry.
  • Once all of the Individual numbers and mandatory comments are entered, click the Submit button to send the request to Data Integrity.

When the eligibility specialist enters an Individual number that already exists on a merge or separate request, it cannot be requested again and a validation message will be displayed. When TIERS displays a validation message, staff must either correct the information, if entered incorrectly, or use Search Merge/Separate to determine if the Individual number(s) on the request are associated with the same Individual number.

 

Tracking Progress

Use Search Merge/Separate to track the progress of the request. Some requests will take longer than others. This may occur when the Individual received MEPD coverage in addition to the Texas Works benefits they receive in TIERS. These requests are placed on hold until the request can be processed in TIERS.

Data Integrity staff can mark an Individual number as a potential duplicate (PD) when a merge or separate request is made. Staff cannot select an Individual number for addition to new cases if it is marked as PD, which limits the potential for the wrong Individual number to be awarded benefits or coverage in error.

Questions about a merge or separate request should be sent to the Data Integrity mailbox at tiers_statepaidmedicaid@hhsc.state.tx.us

 

R-3500 Information Maintained in Automated System

Revision 12-2; Effective June 1, 2012

 

When a person is certified for assistance, the following information is kept electronically:

  • Identification data
  • Client/Individual number
  • Name
  • Birth date
  • Sex
  • Race
  • Social Security account number
  • Social Security claim number
  • Client Residence County Code

The county related to the person's home address is used. For residents of a long-term care facility, record the county for the facility address. The person's residence county should be updated whenever there is a change of address involving a new county. This entry is used to identify a person who is eligible or required to enroll in managed care. It is also used by the Service Authorization System Online (SASO).

 

R-3600 Reserved for Future Use

Revision 12-2; Effective June 1, 2012

 

 

R-3700 Automated Verification Systems

Revision 12-2; Effective June 1, 2012

 

Through interagency agreements, several automated verification systems have become available to staff. This has allowed staff to obtain necessary verifications in a more efficient and timely manner. All systems require specific password permission for access.

 

R-3710 Automated Status Verification Index

Revision 12-2; Effective June 1, 2012

 

The Automated Status Verification Index (ASVI) is a Department of Homeland Security (DHS) online system used to verify immigration status of non-citizens applying for benefits. The system is accessed through UNISCOPE EMULATION. Information is obtained using the individual's Alien Registration Number. Result response time is generally immediate.

If the Alien Registration Number is found by the system, the following information will be displayed:

  • Alien number
  • Last name
  • First name
  • Middle name
  • Date of birth
  • Country of birth
  • Alternate ID
  • Social Security number
  • Date of entry
  • USCIS (formerly INS) status
  • Verification number

Residency status is reported with one of the following messages:

  • Lawful Permanent Resident/Employment Authorized
  • Institute Secondary Verification
  • Temporary Resident/Temporary Employment Authorized

Refer to Section D-8000, Alien Status, for additional policy and verification information.

A user guide, ASVI/SAVE System, contains detailed information regarding access and data interpretation. The guides are available through unit supervisors.

 

R-3720 Texas Workforce Commission

Revision 12-2; Effective June 1, 2012

 

A person who loses employment may be entitled to unemployment benefits through the Texas Workforce Commission (TWC). TWC information is obtained through a Data Broker report. The Data Broker report will verify quarterly earnings and unemployment benefits. Information is obtained using the person's name and Social Security number. A match will result if the person has applied, is receiving or has received unemployment benefits with TWC.

A match by name will provide: the person's name, alias name, address, telephone number, Social Security number and date of birth. After a positive name search, the person's Social Security number may be used to verify the TWC records.

Available information includes:

  • if the person has applied for benefits;
  • wages the person earned (per quarter) during the past 24 months;
  • the status of a current claim; and
  • the amount of weekly unemployment benefits, deductions and payment dates.

 

R-3730 State Online Query/Wire Third Party Query

Revision 12-2; Effective June 1, 2012

 

State Online Query (SOLQ) is a Social Security Administration (SSA) automated system used to verify Social Security and Supplemental Security Income (SSI) benefits. The system is Windows-based. It uses the individual's name, Social Security number (SSN) or Social Security claim number (SSCN) and date of birth to identify and provide the appropriate records. When an inquiry match occurs, the response provides all available benefit information attributable to a particular claim number. SOLQ responses are not to be printed. SOLQ responses provide current information and are available immediately after request in the system.

If the individual has entitlement under more than one SSCN, those numbers will be identified. You must submit separate inquiries to obtain data related to those claims.

Information includes:

  • Standard Response — individual name, date of birth, verified SSN and error messages regarding any discrepancies between inquiry and response match.
  • Title II (RSDI) — individual demographics, enrollment in Medicare Part A and/or Part B, supplementary medical income benefits (SMIB) premium deduction, benefit amounts and dates, unearned income, disability onset dates, etc.
  • Title XVI (SSI) — individual demographics, Medicaid, SSI payment history, benefit amount, payment status code, resource and earned income leads, etc.

Note: The SOLQ system is available only in TIERS. The response only includes information for individuals in TIERS.

If more detailed information is needed, it is recommended to request a WTPY.

Wire Third Party Query (WTPY) is an SSA automated overnight batch process system used to verify Social Security and SSI benefits. Information is obtained using the person's name, SSN or SSCN, and date of birth. Response is usually received on the next business day following transmittal of the inquiry, provided the request is transmitted by 2:30 p.m. If the request is transmitted after that time, the response will be delayed one day.

If an inquiry match occurs, the response will provide all available benefit information attributable to a particular claim number. If a person has entitlement under more than one SSCN, those numbers will be identified. Separate inquiries are not necessary. The programming logic within the WTPY system will do an automated request within three business days on the newly discovered SSCNs. Staff do not have to create additional requests to obtain data related to those claims.

Information will include:

  • Standard Response — Name, date of birth, verified SSN and error messages regarding any discrepancies between inquiry and response match.
  • Title II (RSDI) — Demographics, enrollment in Medicare Part A and/or Part B, SMIB premium deduction, benefit amounts and dates, unearned income, disability onset dates, etc.
  • Title XVI (SSI) — Demographics, Medicaid, SSI payment history, benefit amount, payment status code, resource and earned income leads, etc.
  • 40 Quarters — Used for legal permanent residents, their spouses or parents. Response will provide employment history, identify the qualifying quarters and give the type income received during that period. Note: Response time for this data is within two days of transmittal (rather than one day as with other WTPY information).
  • Citizenship Verification — Effective Feb. 1, 2011. WTPY makes citizenship verification available, and is available for use by HHSC to verify citizenship for Texas Works and MEPD applicants.

The Wire Third Party Query User Guide contains detailed information regarding data interpretation. The 40 Quarters Operations Guide and 40 Quarters Response contain information outlining inquiry and response interpretation of 40 Quarters data.

Reminder: Federal tax information is provided through SOLQ and WTPY. Federal tax information is confidential. It is not to be shared with unauthorized individuals. SOLQ and WTPY responses should not be printed.

 

R-3740 Asset Verification System (AVS)

Revision 18-2; Effective June 1, 2018

The Asset Verification System (AVS) is an automated system used to request information from banking institutions on people applying for certain MEPD programs. The AVS is available through the Data Broker system and is accessed through TIERS. Use a person’s name and Social Security number  to identify and provide information on the appropriate financial records.

AVS information must be requested for the following MEPD programs at application, renewal, add a person, and program transfer requests only when consent is provided:

  • State Group Home (TA 12 ME);
  • State Supported Living Center (TP 10 ME);
  • Non-State Group Home (TP 15 ME);
  • State Hospital (TP 16 ME);
  • Nursing Facility (TP 17 ME);
  • Waiver Program (TA 10 ME);
  • Program of All-Inclusive Care for the Elderly (PACE) (TA 10 ME);
  • Pickle (TP 03 ME);
  • Disabled Adult Child (TP 18 ME);
  • Disabled Widow(er) (TP 21 ME);
  • Early Aged Widow(er) (TP 22 ME); and
  • Medicaid Buy-In (MBI) Program (TP 87 ME).

 

R-3741 AVS Consent

Revision 18-2; Effective June 1, 2018

Consent to access AVS is required for a person whose assets are considered in the eligibility determination for AVS applicable MEPD Programs.  Individuals who must provide consent are:

  • the applicant or recipient (or the individual’s legal guardian, power of attorney, or authorized representative);
  • parents whose resources are deemed to a minor child;
  • a spouse whose resources are deemed to the applicant or recipient; or
  • the community spouse for spousal impoverishment cases. 

A person provides consent by submitting a signed application or renewal form that contains the asset verification consent language. If the application or renewal form does not contain the AVC language, or does not contain the signature of the person whose assets are considered in the eligibility determination, staff must pend for a signed  Form H0003, Agreement to Release Your Facts.  Only request AVS information for someone who has provided consent.

Deny an applicant or recipient if consent is not provided from all people whose assets are considered in the eligibility determination or if a written request to revoke consent to access AVS is received.  Do not run AVS if consent is not provided or after a request to revoke consent is received.

 

R-3742 AVS Requests

Revision 18-2; Effective June 1, 2018

When consent is provided, run the determination to process eligibility but do not dispose the case.

  • If all eligibility requirements are met, initiate the AVS request. 
  • If a person does not meet all eligibility requirements, do not initiate the AVS request; process the denial.

For initial applications, request 60-months of AVS information.  For reapplications, annual redeterminations, and program transfers, request AVS information only for the months between the last AVS response and the current transaction.  If AVS was not previously requested, request 60-months of AVS information.

 

R-3743 AVS Responses

Revision 18-2; Effective June 1, 2018

AVS responses provide information on both disclosed and undisclosed financial accounts.

Initial AVS responses are received immediately and include information from the major banking institutions. 

In addition to the immediate initial responses, Data Broker will also provide enhanced AVS responses when financial information is identified for additional banking institutions not included in the immediate AVS response. The enhanced AVS response is available on the Data Broker report a minimum of 15 days after the initial AVS request.  Do not delay disposing the case when an enhanced AVS response is pending if all other information needed to make an eligibility determination is provided. Regardless of when the agency receives an enhanced AVS response, the response is treated as an agency reported change.

 

R-3744 Consideration of AVS Information

Revision 18-2; Effective June 1, 2018

Determine eligibility based on the AVS response received via Data Broker.

For both immediate and enhanced AVS responses, if the AVS information is consistent with the client-provided information, complete the eligibility determination.

If the AVS information is new or inconsistent, but does not affect eligibility, do not pend for verification. Enter the new information in TIERS and complete the eligibility determination.

If the AVS information is new or inconsistent and the applicant or recipient is potentially ineligible, pend the case and request verification from the applicant or recipient before completing the eligibility determination.

If the applicant or recipient fails to provide verification of new or inconsistent AVS information, enter the AVS information in the case and deny the case using the appropriate AVS denial reason code.

R-4000, Automated Data Exchanges and Tape Matches

Revision 12-4; Effective December 1, 2012

 

HHSC and its eligibility staff periodically receive information through a data exchange with the Social Security Administration via electronic files. Some exchanges automatically update client data in TIERS, while others provide potentially new information concerning income or resources. The more common exchanges and tape matches are described in the following sections.

 

R-4100 Beneficiary and Earnings Data Exchange

Revision 12-2; Effective June 1, 2012

 

The Beneficiary and Earnings Data Exchange (BENDEX) is an automated data information exchange received from SSA. HHSC initiates the process by sending SSA a tape containing a person's identifying information. The BENDEX data is SSA's response. The data exchange is performed twice per month.

BENDEX data matches SSA recipient information against the TIERS information. Data matches include recipient's name, sex, date of birth, Social Security number, Social Security claim number and RSDI amount. Should there be a discrepancy in data, an ALERT will be generated for the individual case in the Task List Manager (TLM) and sent to the eligibility specialist for clearance.

At the time of SSA's annual Cost of Living Adjustment (COLA), HHSC receives a BENDEX that is used to update RSDI amounts on all current cases.

 

R-4110 Social Security Administration Deceased Individual Report

Revision 12-3; Effective September 1, 2012

 

The Deceased Individual Report from SSA identifies individuals receiving benefits from both SSA and HHSC who have been reported as deceased to SSA. SSA provides the date of death reported to their agency.

 

R-4200 State Data Exchange

Revision 12-2; Effective June 1, 2012

 

The State Data Exchange (SDX) is an automated data information exchange received from SSA. The SDX tape contains all newly certified Texas SSI recipients and current SSI recipients with updated/changed information. HHSC normally receives SDX data five to six times per month, but not necessarily weekly.

SDX data matches SSI recipient information against all case and client information.

 

R-4210 Contacting Data Integrity

Revision 12-2; Effective June 1, 2012

 

Incorrect SSI information can be temporarily changed or corrected by the Office of Eligibility Services (OES), Business Services, Data Integrity area. Processing of the next SDX tape with updated information on that person will override temporary information entered by Data Integrity. Permanent corrections or changes must be completed by SSA and will be reflected on subsequent SDX tapes.

Staff can request the Data Integrity area make a temporary correction. Staff must also inform the person of the need to make a permanent correction at the local SSA office. A person should never be told to contact the Data Integrity area directly. Follow local procedures for contacting Data Integrity.

 

R-4300 Income and Eligibility Verification System

Revision 10-4; Effective December 1, 2010

 

The Income and Eligibility Verification System (IEVS) was established as part of the Deficit Reduction Act (DEFRA) of 1984, which required state agencies administering Temporary Assistance for Needy Families (TANF), food stamps (now SNAP) and Medicaid programs to conduct tape matches as part of the verification process. IEVS data includes taxable income reported to the Internal Revenue Service (IRS). Income may have been earned through existing resources or generated by the liquidation of a resource. IEVS data also includes wage information from the Texas Workforce Commission (TWC) and self employment and earned data from the Social Security Administration (SSA).

The first IEVS tape match occurred in April 1987, and now occurs at regular intervals. An annual IRS tape match is processed on all active recipients in August or September to obtain data from the last tax year. The system receives quarterly wage data from TWC and the annual self employment and earned data from SSA. The files are run against the system of record using the Social Security number and first four letters of the recipient's last name. If a match occurs, the Automated System for Office of Inspector General (ASOIG) will create, assign and distribute an IEVS worksheet to the designated MEPD specialist for investigation.

DEFRA and IEVS regulations require state agencies to safeguard the tape match data. For more IEVS information, refer to Section C-2400, Safeguarding Federal Income Data, Appendix XVII, System Generated IEVS Worksheets Legends for IRS Tax Data, and HHSC training.

 

R-4400 Employees Retirement System

Revision 10-4; Effective December 1, 2010

 

A tape match is conducted between HHSC and the Employees Retirement System of Texas (ERS) once every three months. A match is also conducted when it is known that ERS will issue a one-time supplemental payment (13th check) to certain annuitants, a cost-of-living increase or other adjustment of benefits.

HHSC provides a tape containing names of current MEPD recipients and their Social Security numbers. ERS matches agency data against its own data base. A response tape is created containing income information for each matched recipient.

When the response tape is run against the system of record, a report is generated for each person matched. Each report indicates the ERS gross and net income amounts and any deductions. The report is considered to be acceptable verification.

Verification of ERS income for new applicants is accomplished by sending Form H1214, Request for Pension Information.

If the request is based on information obtained on the Automated System for Office of Inspector General (ASOIG) MATCH Worksheet, Income and Eligibility Verification Data, use Form H1214-FTI, Request for Pension Information. Check the Yes box. Do not include a copy of the ASOIG MATCH Worksheet with the request.

ERS may issue a one-time supplemental payment (13th check) to certain annuitants. The issuance of the check is not predictable and is not included in the ongoing budget. Consider the 13th check as a lump sum payment.

 

R-4500 Teacher Retirement System

Revision 09-4; Effective December 1, 2009

 

A tape match is conducted between HHSC and the Teacher Retirement System of Texas (TRS) once every three months. A match is also conducted if it is known that TRS will issue a one-time supplemental payment (13th check) to certain annuitants, a cost-of-living increase or other adjustment of benefits.

HHSC provides a tape containing names of current MEPD recipients and their Social Security numbers. TRS matches agency data against its own data base. A response tape is created containing income information for each matched recipient.

When the response tape is run against the system of record, a report is generated for each person matched. Each report will indicate the TRS gross and net income amounts and any deductions. The report is considered to be acceptable verification.

Verification of TRS income for new applicants is still accomplished by sending Form H1297, Request for Information from Teacher Retirement System of Texas. The form must be annotated to indicate the person is a new applicant.

TRS may issue a one-time supplemental payment (13th check) to certain annuitants. The issuance of the check is not predictable and is not included in the ongoing budget. Consider this 13th check as a lump sum payment.

 

R-4600 Public Assistance Reporting Information System (PARIS)

Revision 12-4; Effective December 1, 2012

 

Public Law 110-379 mandates the implementation and use of Public Assistance Reporting Information System (PARIS) by all states. PARIS is a centralized federal database used for cross-state matching. A quarterly interstate match of all active/hold clients will allow HHSC to comply with the federal mandate and further the efforts in identifying possible fraud and recovery of state and federal funds. PARIS matches will include TIERS MEPD, TANF/Medicaid and SNAP recipients.

HHSC will use the PARIS data match to ensure individuals enrolled in Medicaid or other public assistance benefits in one state are not receiving duplicate benefits based on simultaneous enrollment in the Medicaid program or other public benefit programs in another state. Clearance action on interstate worksheets must have the recipient's residency verified via the verification letter OIG 5079, Request for Verification of Residence.

Effective July 19, 2010, the Office of Inspector General (OIG) released a modified version of the current Automated System for Office of Inspector General (ASOIG) System. The July 19th deployment includes both IEVS and interstate matches. Changes to the current ASOIG application are to an ASOIG Menu module. The IEVS Menu module has been changed to Matched Menu module and Interstate has been added as a choice under Source. Selection of Interstate allows end users to access PARIS worksheets. Other than the addition of worksheets from the PARIS matches, there are no changes to the current process that generates, assigns and distributes worksheets from matches with TWC, IRS and SSA. The modified ASOIG System will continue to allow end users to access reports, view and clear worksheets, create referrals, create interstate referrals, view and add comments, search and transfer worksheets, view related worksheets, and generate correspondence. The print location for verification letter, OIG 5079, is limited to LOCAL.