Section 15000, Pre-Enrollment Activities and Financial Eligibility Related to HCS and TxHmL

Revision 20-4; Effective October 15, 2020

 

15100 Research Preventing Dual Enrollment

Revision 20-4; Effective October 15, 2020

 

A person cannot be enrolled in more than one 1915c waiver. If a person accepts a Home and Community-based Services (HCS) or Texas Home Living (TxHmL) enrollment offer, the local intellectual and developmental disability authority (LIDDA) must determine if the person is currently enrolled in another waiver program before the HCS or TxHmL begin date can be determined. The LIDDA will ask the person/legally authorized representative (LAR) if they currently receive any Medicaid services and verify by accessing the Service Authorization System Online (SASO) to determine if the person is currently receiving other Medicaid services or is enrolled in another waiver program.

SASO instructions:

Service Group Description
1 Nursing Facility
2 CLASS
4 SSLC
5 ICF/IID-State Operated
6 ICF/IID Non-State Operated
7 Community Care
8 Hospice
9 LTC Support Services
10 Swing Bed
11 PACE
21 HCS
14 LIDDA Targeted Case Management
22 TxHmL
16 DBMD
  MDCP (Contact PES)
19 STAR+PLUS Waiver

 

If the person receives other Medicaid Services, the LIDDA uses Appendix I, Mutually Exclusive Services, to determine if the services being received are mutually exclusive to enrollment in HCS or TxHmL. When using the table, if an “x” appears in the square where two services intersect, the two may not be received at the same time. However, if the square is blank, the two services may be received at the same time. Some services may be received simultaneously if certain conditions apply—if the square shows a number, refer to the explanation for that number below the table.

The LIDDA must:

 

15200 Persons Enrolled in STAR+PLUS Waiver (SPW) or MDCP

Revision 20-4; Effective October 15, 2020

 

If a person is enrolled in SPW (service group 19) or Medically Dependent Children Program (MDCP) [contact Program Eligibility and Support (PES)] and chooses to enroll in Home and Community-based Services (HCS) or Texas Home Living (TxHmL), the local intellectual and developmental disability authority (LIDDA) will:

If CARE data entry is complete by the 20th day of the month before the IPC begin date, PES will notify Health Plan Operations (HPO) of the person’s enrollment into HCS or TxHmL and request SPW or MDCP disenrollment. However, if CARE data entry is not completed by the 20th day of the month before the IPC begin date, the LIDDA must coordinate with the case manager or service coordinator of the other program to change their end date to the end of the next month and change the IPC begin date to the first day of the following month.

For delayed enrollments or if the person or LAR has changed their decision about enrolling in HCS or TxHmL, the LIDDA must delete the enrollment data entry from CARE and immediately contact PES.

 

15300 Determine if the Person is a Medicare Beneficiary    

Revision 19-4; Effective September 9, 2019

 

The US Government site for Medicare is Medicare.gov.

The local intellectual and developmental disability authority (LIDDA) will:

 

15400 Financial Eligibility

Revision 19-4; Effective September 9, 2019

 

Texas Health and Human Services Commission (HHSC) requires all persons to meet financial eligibility for enrollment in the Home and Community-based Services (HCS) and Texas Home Living (TxHmL) waiver program. After enrollment, financial eligibility must be maintained for the person to continue participation in the program. Persons eligible for certain types of Medicaid coverage are financially eligible for the program; however, not all types of Medicaid coverage ensure eligibility.

 

15410 Financial Eligibility at Pre-Enrollment

Revision 20-4; Effective October 15, 2020

 

The local intellectual and developmental disability authority (LIDDA) checks the Client Assignment and Registration (CARE) System screen C63, Medicaid Eligibility Search. The screen displays the Medicaid eligibility information for a person as it appears in the Texas Integrated Eligibility Redesign System (TIERS).

Note: When entering the L09, Register Client Update, screen in CARE, the LIDDA must enter the person’s Social Security number and Medicaid number exactly as they appear in the C63, Medicaid Information, screen.

 

15411 No Medicaid

Revision 20-4; Effective October 15, 2020

 

If a person is not currently receiving Medicaid benefits or receives Medicaid benefits under a Medicaid program type that is not accepted for enrollment in the Home and Community-based Services (HCS) or Texas Home Living (TxHmL) programs, the person/legally authorized representative (LAR) must apply for Supplemental Security Income (SSI) benefits through the Social Security Administration (SSA) or apply for Medicaid through Texas Health and Human Services Commission (HHSC). The LIDDA must offer to assist the person/LAR with submitting the application and explain the time frame for enrollment again. To determine which application the person/LAR should submit, the LIDDA must know the person’s monthly income.

Note: There are monthly income limits that can affect Medicaid eligibility.

If the person’s monthly income does not exceed the monthly federal payment standard for SSI benefits by more than $20, the LIDDA must inform the person of the process for applying for SSI benefits and assist the person/LAR to apply. If the person’s SSI benefits are approved, SSI Medicaid is automatically approved, which is accepted for enrollment in the HCS or TxHmL program.

If the person’s monthly income exceeds the monthly federal payment standard for SSI benefits by more than $20, the LIDDA must assist the person/LAR with submitting Form H1200, Application for Assistance – Your Texas Benefits. The LIDDA can assist the person/LAR with creating an account and applying online at www.yourtexasbenefits.com. If the person/LAR applies online, the status of the application is available while under review. Also, if additional documentation is needed to complete the application process, the person/LAR will be informed of the needed documents through their online account. The LIDDA can assist the person/LAR with submitting documents through their online account. The online process is recommended; however, if preferred, the person/LAR or LIDDA may submit the application by fax.

When the application is submitted either online or by fax, the LIDDA must download Form H1746-A, MEPD Referral Cover Sheet, follow the form instructions to complete the form and fax it to the HHS Document Processing Center at 877-236-4123.

Note: Form H1746-A is a fillable “smart form” that must be downloaded each time and completed using Adobe Acrobat Reader DC. Each form has a unique bar code that captures the person’s information as the form is completed. This ensures the form is matched to the correct application upon submission. Form H1746-A is not to be photocopied.

If completed and when faxing Form H1746-A, the LIDDA should include a copy of the person’s Determination of Intellectual Disability (DID), Form 8578, Intellectual Disability/Related Condition Assessment, and Form 3608, Individual Plan of Care (IPC) – HCS/CFC, (for HCS), or Form 8582, Individual Plan of Care – TxHmL/CFC, (for TxHmL). Submission of these forms is encouraged before completion of Form H1200 and Form H1746-A.

Apply for SSI benefits if the person’s monthly income does not exceed the monthly federal payment standard for SSI benefits by more than $20. Medicaid should only be applied for if the person’s monthly income exceeds the monthly federal payment standard for SSI benefits by more than $20. The Medicaid application cannot be approved if the person may be eligible for SSI benefits.

A Medicaid application cannot be processed while the person has a pending application for SSI benefits or is appealing an SSI denial. If the person is denied SSI benefits and does not want to appeal, or the person appeals and is still denied, follow the process described above for submitting a Medicaid application.

 

15412 Qualified Medicare Beneficiary (QMB) or Specified Low-Income Medicare Beneficiary (SLMB)

Revision 20-4; Effective October 15, 2020

 

QMB and SLMB are not “full” Medicaid benefit programs. QMB only pays for a person’s Medicare premiums, deductibles and co-pays, while SLMB is an extension of QMB which only pays for Medicare Part B premiums. Persons receiving QMB or SLMB may also receive full Medicaid benefits. However, if the person’s Medicaid information in Client Assignment and Registration (CARE) System screen C63, Medicaid Eligibility Search, indicates the person only receives QMB (Q24) or SLMB (B23), the local intellectual and developmental disability authority (LIDDA) must follow the process described in Section 15411, No Medicaid.

The LIDDA can refer to the Medicaid for the Elderly and People with Disabilities Handbook for detailed information about Medicaid programs, timelines, procedures and forms.

 

15420 Persons Leaving an ICF/IID, State Hospital or SSLC to Enroll in HCS

Revision 20-4; Effective October 15, 2020

 

A person residing in an intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID), state hospital or state supported living center (SSLC) is certified for full Medicaid benefits under the institutional Medicaid program. If a person is leaving the facility and enrolling in the Home and Community-based Services (HCS) or Texas Home Living (TxHmL) program, when the LIDDA completes all Client Assignment and Registration (CARE) System data entry screens for enrollment, Program Eligibility and Support (PES) will request the Medicaid program for HCS or TxHmL enrollment. However, if the person loses full Medicaid benefits before the LIDDA enters the enrollment screens, the LIDDA must follow the process described above for submitting a new Medicaid application.

Note: PES cannot submit a request for the Medicaid program change until the person is discharged and the HCS or TxHmL services are scheduled to begin, and only if the LIDDA has entered all CARE System enrollment screens, which include L01, Consumer Enrollment; L23, IDRC Assessment; L02, Individual Plan of Care; L03, Enrollment Packet Checklist; L09, Register Client Update; and L05, Provider Choice.

A person receiving Supplemental Security Income (SSI) benefits is automatically certified for SSI Medicaid. CARE screen C63, Medicaid Eligibility Information, displays a Medicaid coverage code and program type of “D13” or “I13” for people who reside in a facility and receive SSI Medicaid. Before PES can request a Medicaid program change for HCS or TxHmL to “R13,” the person’s representative payee must contact the Social Security Administration (SSA) to update the person’s address and inform the SSA of the person’s facility discharge date. The facility must submit a discharge form to the SSA. If the SSA receives the discharge form from the facility before the representative payee notifies the SSA of the change, SSI benefits may be suspended, which will result in suspension of SSI Medicaid. When the representative payee contacts the SSA to update the information, SSI will be unsuspended, which will automatically reinstate SSI Medicaid. When SSI Medicaid is reinstated, PES can request the Medicaid program change.

For persons being discharged from an ICF/IID, state hospital, or SSLC who have lost SSI benefits or full Medicaid benefits before the HCS or TxHmL begin date, the LIDDA must follow the process described in Section 15411, No Medicaid.

 

15500 Chart of Acceptable Types of Medicaid for HCS and TxHmL

Revision 20-4; Effective October 15, 2020

 

The following chart indicates the acceptable Medicaid coverage codes and program types for enrollment in Home and Community-based Services (HCS) and Texas Home Living (TxHmL). If a person does not an acceptable Medicaid coverage/program, the local intellectual and developmental disability authority (LIDDA) must follow the process described in Section 15411, No Medicaid.

Required Medicaid Codes and Type Program
Coverage Code Type Program HCS TxHmL Coverage Code Type Program HCS TxHmL
R or P 01 Yes Yes R or P 47 Yes Yes
R or P 02 Yes Yes R or P 48 Yes Yes
R or P 03 Yes Yes R or P 51 Yes No
R or P 07 Yes Yes R or P 55 Yes Yes
R or P 08 Yes Yes R or P 61 Yes Yes
R or P 09 Yes Yes R or P 70 Yes Yes
R or P 10 Yes Yes R or P 79 Yes Yes
R or P 11 Yes Yes R or P 80 Yes Yes
R or P 12 Yes Yes R or P 81 Yes Yes
R or P 13 Yes Yes R or P 82 Yes Yes
R or P 14 Yes No R or P 87 Yes Yes
R or P 15 Yes Yes R or P 88 No Yes
R or P 18 Yes Yes R or P 91 Yes Yes
R or P 19 Yes Yes R or P 92 Yes Yes
R or P 20 Yes Yes R or P 93 Yes Yes
R or P 21 Yes Yes R or P 94 Yes Yes
R or P 22 Yes Yes R or P 95 Yes Yes
R or P 29 Yes Yes R or P 96 Yes Yes
R or P 37 Yes No R or P 97 Yes Yes
R or P 40 Yes Yes R or P 98 Yes Yes
R or P 43 Yes Yes        
R or P 44 Yes Yes        
R or P 45 Yes Yes        

 

15600 Appointment of an Authorized Representative

Revision 20-4; Effective October 15, 2020

 

A person may allow designate another person to act on his or her behalf as a Medicaid authorized representative by completing Form H1003, Appointment of an Authorized Representative. Only one authorized representative may be appointed. To change or end a designated authorized representative, the person can log in to his/her Your Texas Benefits account or call 2-1-1.

An authorized representative must be familiar with the person and knowledgeable of their finances; therefore, a person should only designate a LIDDA staff person as a last resort. However, the person or their designated authorized representative may submit Form H1826, Case Information Release,  to authorize HHSC to release information regarding the person’s Medicaid case to the LIDDA. To end this authorization, the person can log in to his/her Your Texas Benefits account or call 2-1-1. The LIDDA may also call 2-1-1 to end the authorization.

Form H1003 is submitted to HHSC with Form H1746-A, MEPD Referral Cover Sheet, and when submitting the required application and supporting documentation.

 

15700 Medicaid Forms

Revision 20-4; Effective October 15, 2020

 

Medicaid forms are found in the Medicaid for the Elderly and People with Disabilities Handbook.

 

15710 Form H1746-A, MEPD Referral Cover Sheet

Revision 20-4; Effective October 15, 2020

 

Form H1746-A, MEPD Referral Cover Sheet, is completed by the local intellectual and developmental disability authority (LIDDA) to share case information and provide supporting documentation with Access and Eligibility Services (AES) eligibility staff for applicants and recipients of Home and Community-based Services (HCS) and Texas Home Living (TxHmL) waiver services.

Form H1746-A is a fillable “smart form” that must be downloaded each time and completed using Adobe Acrobat Reader DC. Each form has a unique bar code that captures the person’s information as the form is completed. This ensures the form is matched to the correct application upon submission. This form should not be photocopied.

Form H1746-A must be included with all applications and other documents submitted for an HCS/TxHmL applicant.

Complete the additional information section to notify AES eligibility staff of the following:

Form H1746-A must be the first document in the packet when mailing or faxing documents. Two-sided faxing must be used when possible. By faxing and mailing documents, duplication in the system occurs and delays the process. If sending more than one application, fax each application individually with one Form H1746-A per application, or mail applications in a batch using Form H1746-B, Batch Cover Sheet.

Not submitting Form H1746-A may result in a Medicaid denial for HCS/TxHmL services.

 

15720 Completing Sections on Form H1746-A, MEPD Referral Cover Sheet

Revision 20-4; Effective October 15, 2020

 

Applicant/Person Information

Action

Program

Information for MEPD Worker

Sender

Additional Comments

Follow-up

 

15800 Financial Eligibility After Enrollment - HCS and TxHmL

Revision 20-4; Effective October 15, 2020

 

Persons must maintain financial eligibility to remain eligible for the waiver program.

Supplemental Security Income (SSI) Medicaid

If a person loses SSI benefits, the person also loses SSI Medicaid. It is the person’s representative payee’s responsibility to contact the Social Security Administration (SSA) for assistance. If SSI benefits are reinstated, SSI Medicaid will be automatically reinstated. If the program provider is the representative payee, the provider is responsible for taking action to reestablish SSI benefits and SSI Medicaid.

Medical Assistance Only (MAO)

If a person loses MAO, the person or their authorized representative must call 2-1-1 for assistance. However, the local intellectual and developmental disability authority (LIDDA) must assist if requested by the person or authorized representative.

 

15810 Medicaid Redetermination

Revision 20-4; Effective October 15, 2020

 

For Medical Assistance Only (MAO) recipients (i.e., not applicable for Supplemental Security Income (SSI) recipients), Texas Health and Human Services Commission (HHSC) requires persons to submit a Medicaid redetermination packet to HHSC at least annually. HHSC mails the redetermination packet to the person’s mailing address on file in the Texas Integrated Eligibility Redesign System (TIERS) 90 days in advance of the redetermination due date. It is important that the packet be completed and returned to HHSC before the due date; otherwise, Medicaid eligibility will be denied.

Local intellectual and developmental disability authorities (LIDDA) can review the Client Assignment and Registration (CARE) System screen C63, Medicaid Eligibility Search, to determine a person’s review date. This information is displayed in the “ME Annual Renewal Date” field in this screen. LIDDAs can also review the following CARE XPTR reports to assist people with maintaining and reestablishing Medicaid eligibility (ME).

Note: Persons who receive SSI Medicaid are not required to submit a redetermination packet because their eligibility is based on their SSI eligibility. The Social Security Administration (SSA) reports SSI recipient information directly to TIERS for these persons.

 

15820 Reestablishing Medicaid

Revision 20-4; Effective October 15, 2020

 

 

 

15821 Loss of Supplemental Security Income (SSI) Medicaid

Revision 20-4; Effective October 15, 2020

 

If a person loses SSI benefits, the person will also lose SSI Medicaid. It is the responsibility of the person or their representative payee to contact the Social Security Administration (SSA) to determine the necessary action to reinstate SSI benefits. Adults who lose SSI benefits because they became eligible for Retirement, Survivors and Disability Insurance (RSDI) benefits, and their income is now over the income limit for SSI benefits, may be eligible for Disabled Adult Children’s Medicaid. Therefore, if SSI benefits will not be reinstated due to receiving RSDI benefits, the person must submit a Medicaid application to Texas Health and Human Services Commission (HHSC).

If the provider is the representative payee, the provider is responsible for ensuring immediate action is taken to reestablish financial eligibility. If they are not the authorized representative, the provider is responsible for working with the person or authorized representative in assisting to maintain and reestablish the person’s financial eligibility. The local intellectual and developmental disability authority (LIDDA) must assist if requested by the person or authorized representative. If the LIDDA is assisting with the submission of the Medicaid application, they must include a completed Form H1746-A, MEPD Referral Cover Sheet.

 

15822 Loss of Medical Assistance Only (MAO) Medicaid

Revision 20-4; Effective October 15, 2020

 

If a person loses financial eligibility, it is the responsibility of the person, legally authorized representative (LAR) or authorized representative to reestablish financial eligibility as soon as possible. If the provider is the authorized representative, it is the provider’s responsibility to maintain and reestablish the person’s financial eligibility to prevent an interruption in services and payment. If they are not the authorized representative, the provider is responsible for working with the person or authorized representative in assisting to maintain and reestablish the person’s financial eligibility. The local intellectual and developmental disability authority (LIDDA) must assist if requested by the person or authorized representative.

 

15823 Loss of Department of Family and Protective Services (DFPS) Medicaid

Revision 20-4; Effective October 15, 2020

 

When a person “ages out” of DFPS conservatorship, the person may lose DFPS Medicaid. Typically, as the person reaches the age out date, DFPS submits a Supplemental Security Income (SSI) application to the Social Security Administration (SSA) on the person’s behalf. However, should a person lose DFPS Medicaid due to aging out of DFPS conservatorship, the person’s representative payee must submit an SSI application to the SSA.