County Indigent Health Care Program Handbook

Section 1000, Program Administration

Revision 20-0; Effective November 2019

 

1100 Handbook Purpose and Contact Information

Revision 20-0; Effective November 2019


The purpose of the County Indigent Health Care Program (CIHCP) Handbook is to:

Contact Information

Mailing Address
County Indigent Health Care Program
P.O. Box 149347, Mail Code 2831
Austin, TX 78714-9347

Physical Address for Courier Service
Texas Health and Human Services Commission
County Indigent Health Care Program
Office of Primary and Specialty Health, Mail Code 1938
Moreton Building
1100 W. 49th Street
Austin, TX 78756

Helpline
800-222-3986 Ext. 6467
8 a.m. to 5 p.m. Central Time
Monday through Friday
Austin Area Local Phone 512-776-6467

Fax number: 512-776-7162

Email: CIHCP@hhsc.state.tx.us

Website: https://hhs.texas.gov/services/health/county-indigent-health-care-program

 

1110 Rules

Revision 20-0; Effective November 2019

 

The Texas Administrative Code (TAC) is the compilation of all state agency rules in Texas.

The County Indigent Health Care Program (CIHCP) rules are in TAC, Title 25 (Health Services), Part 1 (HHSC), Chapter 14 (CIHCP), and the following Subchapters:

The CIHCP rules may be accessed at: https://texreg.sos.state.tx.us/public/readtac$ext.ViewTAC?tac_view=4&ti=25& pt=1&ch=14.

 

1120 Health and Safety Code

Revision 20-0; Effective November 2019

 

A law was passed by the First Called Special Session of the 69th Texas Legislature in 1985 that:

Chapter 61, Health and Safety Code, is intended to ensure that needy Texas residents, who do not qualify for other state or federal health care assistance programs, receive health care services.

Chapter 61, Health and Safety Code, may be accessed at: https://statutes.capitol.texas.gov/Docs/HS/htm/HS.61.htm.

 

1130 County Responsibility

Revision 20-0; Effective November 2019

 

A county not fully served by a public facility must:

Public Notice. Not later than the beginning of the state fiscal year (September 1), a county not covered by a public facility shall specify the procedure it will use during that fiscal year to verify eligibility and the documentation required to support a request for assistance and make reasonable effort to notify the public of the application procedure.

 

1140 Public Hospital and Hospital District

Revision 20-0; Effective November 2019

 

Public Notice. Not later than the beginning of a public hospital’s or hospital district’s operating year, the hospital or district shall specify the procedure it will use during the operating year to determine eligibility and the documentation required to support a request for assistance and shall make a reasonable effort to notify the public of the procedure.

 

1150 Options

Revision 20-0; Effective November 2019

 

A county not fully served by a public facility may file for Texas Medicaid reimbursement through the local provider or through Texas Health and Human Services Commission (HHSC) for eligible Supplemental Security Income (SSI) appellant CIHCP recipients who become eligible for retroactive Medicaid. For instructions regarding the filing process through HHSC, request the “CIHCP Medicaid Reimbursement Manual.”

An entity that chooses to establish an optional work registration procedure may contact its local Texas Workforce Commission (TWC) office to determine how to establish the county’s procedure and to negotiate what type of information can be provided. In addition, a county must follow the guidelines below.

  1. Notify all eligible residents and those with pending applications of the program requirements at least 30 days before the program begins.
  2. Allow an exemption from work registration if applicants or eligible residents meet one of the following criteria:
    • Receive food stamp benefits;
    • Receive unemployment insurance benefits or have applied but not yet been notified of eligibility;
    • Physically or mentally unfit for employment;
    • Undocumented alien;
    • Distance prohibits walking or transportation is not available;
    • Commuting time (not including taking a child to and from a child care facility) is greater than two hours a day;
    • Age 15 or younger;
    • Age 16 or 17 and not the head of household;
    • Age 16, 17 or 18 and attending school, including home school, or on an employment training program on at least a half-time basis;
    • Age 60 or older;
    • Parent or other household member who personally provides care for a child under age 6 or a disabled person of any age living with the household;
    • Employed or self-employed at least 30 hours per week;
    • Receive earnings equal to 30 hours per week multiplied by the federal minimum wage;
    • Migrant in the mainstream;
    • A regular participant or outpatient in a drug addiction or alcoholic treatment and rehabilitation program; or
    • Three to nine months pregnant.
  3. If a nonexempt applicant or CIHCP eligible resident fails without good cause to comply with work registration requirements, disqualify him from CIHCP benefits as follows:
    • For one month or until he agrees to comply, whichever is later, for the first noncompliance;
    • For three consecutive months or until he agrees to comply, whichever is later, for the second noncompliance; or
    • For six consecutive months or until he agrees to comply, whichever is later, for the third or subsequent noncompliance.

 

1200 Definitions

Revision 20-0; Effective November 2019

 

The following words and terms, when used in this manual, have the following meanings:

Approval Date – The date Form 3077, Notice of Eligibility, is issued to the household.

Claim – CMS-1500, UB-04 or pharmacy statement.

Claim Pay Date – The date the county writes a check to pay a claim.

Complete Application – Includes Form 3064, Application for Health Care Assistance, and:

The date that Form 3064 and all information necessary to make an eligibility determination is received is the application completion date.

County – A county not fully served by a public facility, namely a public hospital or hospital district; or a county that provides indigent health care services to its eligible residents through a hospital established by a board of managers jointly approved by a county and a municipality.

Days – All calendar days, except as specifically identified as workdays.

Denial Date – The date Form 3082, Notice of Ineligibility, is issues to the household.

Disqualified Member – A person receiving, or categorically eligible to receive, Medicaid.

Eligibility Effective Date – The date a household’s eligibility begins.

Eligibility End Date – The date a household’s eligibility ends.

Expenditure – Funds spent on basic or department-established optional health care services.

Expenditure Tracking – A county should track monthly basic and department-established optional health care expenditures.

General Revenue Tax Levy (GRTL) – Used by the county to determine eligibility for state assistance funds. For information on determining and reporting the GRTL, contact the Property Tax Division of the Texas State Comptroller of Public Accounts at 512-475-1826.

Governmental Entity – A county, municipality or other political subdivision of the state, excluding a hospital authority.

HHSC – Texas Health and Human Services Commission.

Hospital Authority – Created under Article 4437E, Section 3, City Created Hospital Authorities or Article 4494R, Section 3, County Created Hospital Authorities, a hospital authority has no obligation under Chapter 61, Health and Safety Code, to provide indigent health care assistance.

Hospital District – Created under the authority of the Texas Constitution, Article IX, Sections 4 – 11.

Identifiable Application – An application is identifiable if it includes the applicant’s name, applicant’s address, applicant’s signature and the date the applicant signed the application.

Mandated Provider – A health care provider, selected by the county, who agrees to provide health care services to eligible residents.

Medicaid – The Texas state-paid insurance program for recipients of Supplemental Security Income (SSI) and health care assistance programs for families and children.

Optional Services – Department-established optional health care services that a county may choose to provide.

Public Facility – A public hospital or a hospital owned, operated or leased by a hospital district.

Public Hospital – A hospital owned, operated or leased by a county, city, town or other political subdivision of the state, excluding a hospital district and a hospital authority. For additional information, refer to Chapter 61, Health and Safety Code, Subchapter C.

Reimbursement Expenditure – A health care expenditure that may be applied to state assistance funds eligibility/reimbursement and that is for a service provided to a person who is eligible under a monthly net income standard that is at least 21% of the Federal Poverty Guideline (FPG) or up to 50% of the FPG. For additional information, refer to Section 5, State Assistance Funds.

Service Area – The geographic region in which a governmental entity, public hospital or hospital district has a legal obligation to provide health care services.

State Fiscal Year – The 12-month period beginning September 1 of each calendar year and ending August 31 of the following calendar year.

Section 2000, Eligibility Criteria

Revision 20-1; Effective April 27, 2020

 

2100 Residence

Revision 20-0; Effective November 2019

 

 

 

2110 General Principles

Revision 20-0; Effective November 2019

 

A person must live in the Texas county in which he applies. There is no durational requirement for residency.

An inmate of a county correctional facility, who is a resident of another Texas county, would not be required to apply for assistance to their county of residence. They may apply for assistance to the county of where they are incarcerated.

A person lives in the county if the person’s home or fixed place of habitation is in the county and the person intends to return to the county after any temporary absences.

A person with no fixed residence, or a new resident in the county who declares intent to remain in the county, is also considered a county resident.

A person does not lose residency status because of a temporary absence from the county. No time limits are placed on a person’s absence from the county.

A person cannot qualify for CIHCP from more than one county simultaneously.

Persons Not Considered Residents:

 

2120 Verifying Residence

Revision 20-0; Effective November 2019

 

Residency may be verified, if it is questionable. Proof may include, but is not limited to:

 

2130 Documenting Residence

Revision 20-0; Effective November 2019

 

On Form 3065, Worksheet, document why information regarding residence is questionable and how questionable residence is verified.

 

2200 Household

Revision 20-0; Effective November 2019

 

 

 

2210 General Principles

Revision 20-0; Effective November 2019

 

A County Indigent Health Care Program (CIHCP) household is a person living alone, or two or more persons living together, where legal responsibility for support exists, excluding disqualified persons.

Legal responsibility for support exists between:

Medicaid is the only program that disqualifies a person from CIHCP.

 

2220 Definitions

Revision 20-0; Effective November 2019

 

Adult – A person at least age 18 or a younger person who is or has been married or had the disabilities of minority removed for general purposes.  

Common Law Marriage – A relationship in which the parties age 18 or older are free to marry, live together and hold out to the public that they are spouses. A minor child in Texas is not legally allowed to enter a common law marriage unless the claim of common law marriage began before Sept. 1, 1997.

Emancipated Minor – A person under age 18 who has been married. The marriage must not have been annulled.

Managing Conservator – A person designated by a court to have daily responsibility for a child.

Married Minor – An individual, age 14-17, who is married. These individuals must have parental consent or court permission. An individual under age 18 may not be a party to an informal (common law) marriage.

Minor Child – A person under age 18 who is not, or has not been, married and has not had the disabilities of minority removed for general purposes.

 

2230 CIHCP Household

Revision 20-0; Effective November 2019

 

The CIHCP household is a person living alone, or two or more persons living together, where legal responsibility for support exists, excluding disqualified persons.

Disqualified Persons

A disqualified person is not a CIHCP household member regardless of his legal responsibility for support.

CIHCP One-Person Household

CIHCP Group Households

Two or more persons who are living together and meet one of the following descriptions:

 

2240 Screening Tools

Revision 20-0; Effective November 2019

 

Your Texas Benefits at http://www.yourtexasbenefits.com screens for potential eligibility for Medicaid and other programs provided by Texas state agencies.

The Benefit Eligibility Screening Tool (BEST) at http://www.ssabest.benefits.gov screens for potential eligibility for benefits from any of the programs that Social Security administers.  

 

2250 Verifying Household

Revision 20-0; Effective November 2019

 

Verify household, if questionable. Proof may include, but is not limited to:

 

2260 Documenting Household

Revision 20-0; Effective November 2019

 

On Form 3065, Worksheet, document why information regarding household is questionable and how questionable household is verified.

 

2300 Resources

Revision 20-0; Effective November 2019

 

 

 

2310 General Principles

Revision 20-0; Effective November 2019

 

A household must pursue all resources to which the household is legally entitled unless it is unreasonable to pursue the resource. Reasonable time (at least three months) must be allowed for the household to pursue the resource, which is not considered accessible during this time.

 

2320 Definitions

Revision 20-0; Effective November 2019

 

Accessible Resources – Resources legally available to the household.

Aged Person – Someone age 60 or older as of the last day of the month for which benefits are being requested.

Alien Sponsor – A person who signed an affidavit of support (namely, INS Form I-864 or I-864-A) on or after Dec. 19, 1997, agreeing to support an alien as a condition of the alien’s entry into the United States.
 
Assets – All items of monetary value owned by an individual.

Equity – The amount of money that would be available to the owner after the sale of a resource. Determine this amount by subtracting from the fair market value any money owed on the item and the costs normally associated with the sale and transfer of the item.

Fair Market Value – The amount a resource would bring if sold on the current local market.

Inaccessible Resources – Resources not legally available to the household. Examples include, but are not limited to irrevocable trust funds, property in probate, security deposits on rental property and utilities.

Person with Disabilities – Someone who is physically or mentally unfit for employment.

Personal Possessions – Appliances, clothing, farm equipment, furniture, jewelry, livestock and other items if the household uses them to meet personal needs essential for daily living.

Real Property – Land and any improvements on it.

Reimbursement – Repayment for a specific item or service.

Relative – A person who has one of the following relationships biologically or by adoption:

Relationship also extends to:

 
Resources – Both liquid and non-liquid assets a person can convert to meet his needs. Examples include, but are not limited to bank accounts, boats, bonds, campers, cash, certificates of deposit, gas rights, livestock (unless the livestock is used to meet personal needs essential for daily living), mineral rights, notes, oil rights, real estate (including buildings and land, other than a homestead), stocks and vehicles.

Sponsored Alien – A person who has been lawfully admitted to the United States for permanent residence under the Immigration and Nationality Act (8 U.S.C. Section 1101 et seq.) and who, as a condition of admission, was sponsored by a person who executed an affidavit of support on behalf of the person.

 

2330 Countable Resources and Exemptions

Revision 20-0; Effective November 2019

 

Alien Sponsor’s Resources – If an entity chooses to include the resources of a person who executed an affidavit of support on behalf of a sponsored alien and the resources of the person’s spouse, the entity shall adopt written procedures for processing the resources of the sponsor and the sponsor’s spouse.

Bank Accounts – Count the cash value of checking and savings accounts unless exempt for another reason.

Burial Insurance (Prepaid) – Exempt up to $7,500 cash value of a prepaid burial insurance policy, funeral plan or funeral agreement for each certified household member. Count the cash value exceeding $7,500 as a liquid resource.

Burial Plots – Exempt all burial plots.

Crime Victim’s Compensation – Exempt.

Energy Assistance Payments – Exempt payments or allowances made under any federal law for energy assistance.

Exemption: Resources/Income Payments – If a payment or benefit counts as income for a particular month, do not count it as a resource in the same month. If you prorate a payment as income over several months, do not count any portion of the payment as a resource during that time. If the client combines this money with countable funds, such as a bank account, exempt the prorated amounts for the time you prorate it.

Homestead – Exempt the household’s usual residence and surrounding property not separated by property owned by others. The exemption remains in effect if public rights of way, such as roads, separate the surrounding property from the home. The homestead exemption applies to any structure the person uses as a primary residence, including additional buildings on contiguous land, a houseboat or a motor home, if the household lives in it. If the household does not live in the structure, count it as a resource.

Income-Producing Property – Exempt property that:

Insurance Settlement – Count, minus any amount spent or intended to be spent for the household's bills for burial, health care or damaged/lost possessions.

Lawsuit Settlement – Count, minus any amount spent or intended to be spent for the household's bills for burial, legal expenses, health care expenses or damaged/lost possessions.

Life Insurance – Exempt the cash value of life insurance policies.

Liquid Resources – Count, if readily available. Examples include, but are not limited to cash, checking accounts, savings accounts, certificates of deposit (CDs), notes, bonds and stocks.

Loans (Non-educational) – Exempt these loans from resources. Consider financial assistance as a loan if there is an understanding that the loan will be repaid and the person can reasonably explain how he will repay it. Count assistance not considered a loan as unearned income (contribution).

Lump-Sum Payments – Count lump-sum payments received once a year or less frequently as resources in the month received, unless specifically exempt. Countable lump-sum payments include, but are not limited to, retroactive lump-sum Retirement, Survivors and Disability Insurance (RSDI), public assistance, retirement benefits, lump-sum insurance settlements, refunds of security deposits on rental property or utilities, and lump-sum payments on child support. Effective January 1, 2013, exempt federal tax refunds permanently as income and resources for 12 months after receipt. Exempt the Earned Income Credit (EIC) for a period of 12 months after receipt through December 31, 2018. Count lump-sum payments received or anticipated to be received more often than once a year as unearned income in the month received. Exception: Count contributions, gifts and prizes as unearned income in the month received, regardless of the frequency of receipt.

Personal Possessions – Exempt.

Real Property – Count the equity value of real property unless it is otherwise exempt. Exempt any portion of real property directly related to the maintenance or use of a vehicle necessary for employment or to transport a physically disabled household member. Count the equity value of any remaining portion unless it is otherwise exempt.

Reimbursement – Exempt a reimbursement in the month received. Count as a resource in the month after receipt. Exempt a reimbursement earmarked and used for replacing and repairing an exempt resource. Exempt the reimbursement indefinitely.

Retirement Accounts – An account in which an employee and/or his employer contribute money for retirement. There are several types of retirement plans. Some of the most common plans authorized under Section 401(a) of the Internal Revenue Services (IRS) Code are the 401(k) plan, Keogh, Roth Individual Retirement Account (IRA) and a pension or traditional benefit plan. Common plans under Section 408 of the IRS Code are the IRA, Simple IRA and Simplified Employer Plan. A pension or traditional defined benefit plan is employed based and promises a certain benefit upon retirement regardless or investment performance.

Exclude all retirement accounts or plans established under:

Count any other retirement accounts not established under plans or codes listed above.

Trust Fund – Exempt a trust fund if all the following conditions are met:

Vehicles – Exempt a vehicle necessary to transport physically disabled household members, even if disqualified and regardless of the purpose of the trip. Exempt no more than one vehicle for each disabled member. There is no requirement that the vehicle be used primarily for the disabled person. Exempt vehicles if the equity value is less than $4,650, regardless of the number of vehicles owned by the household. Count the value in excess of $4,650 toward the household’s resource limit.

Examples:

$15,000 Fair Market Value
- 12,450 Amount Still Owed
$2,550 Equity Value
- 4,650  
$0 Countable Resource

 

$9,000 Fair Market Value
- 0 Amount Still Owed
$9,000 Equity Value
- 4,650  
$4,350 Countable Resource

2340 Penalty for Transferring

Revision 20-0; Effective November 2019

 

A household is ineligible if, within three months before application or any time after certification, they transfer a countable resource for less than its fair market value to qualify for county health care assistance. This penalty applies if the total of the transferred resource added to other resources affects eligibility.

Base the length of denial on the amount by which the transferred resource exceeds the resource maximum when added to other countable resources. Use the chart below to determine the length of denial.

Amount in Excess of Resource Limit Denial Period
$.01 to $249.99 1 month
$250.00 to $999.99 3 months
$1,000.00 to $2,999.99 6 months
$3,000.00 to $4,999.99 9 months
$5,000.00 to $5,000.00 and more 12 months

If spouses separate and one spouse transfers his property, it does not affect the eligibility of the other spouse.

 

2350 Verifying Resources

Revision 20-0; Effective November 2019

 

Verify countable resources. Proof may include, but is not limited to:

 

2360 Documenting Resources

Revision 20-0; Effective November 2019

 

On Form 3065, Worksheet, document whether a resource is countable or exempt and why resources are verified.

 

2400 Income

Revision 20-0; Effective November 2019

 

 

 

2410 General Principles

Revision 20-0; Effective November 2019

 

A household must pursue and accept all income to which the household is legally entitled, unless it is unreasonable to pursue the income. Reasonable time (at least three months) must be allowed for the household to pursue the income, which is not considered accessible during this time.

 

2420 Definitions

Revision 20-0; Effective November 2019

 

Alien Sponsor – A person who signed an affidavit of support (namely, INS Form I-864 or I-864-A) on or after Dec. 19, 1997, agreeing to support an alien as a condition of the alien’s entry into the United States.

Budgeting – The method used to determine eligibility by calculating income and deductions using the best estimate of the household’s current and future circumstances and income.

Earned Income – Income a person receives for a certain degree of activity or work. Earned income is related to employment and, therefore, entitles the person to work-related deductions not allowed for unearned income.

Gross Income – Income before deductions.

Income – Any type of payment that is of gain or benefit to a household.

Net Income – Gross income minus allowable deductions.

Real Property – Land and any improvements on it.

Sponsored Alien – A person who has been lawfully admitted to the United States for permanent residence under the Immigration and Nationality Act (8 U.S.C. Section 1101 et seq.) and who, as a condition of admission, was sponsored by a person who executed an affidavit of support on behalf of the person.

Tip Income – Income earned in addition to wages that is paid by patrons to people employed in service-related occupations, such as beauticians, waiters, valets, pizza delivery staff, etc.

Unearned Income – Payments received without performing work-related activities.

 

2430 Countable Income and Exemptions

Revision 20-0; Effective November 2019

 

Adoption Payments Adoption Payments – Exempt.

Alien Sponsor’s Income – If an entity chooses to include the income of a person who executed an affidavit of support on behalf of a sponsored alien and the income of the person’s spouse, the entity shall adopt written procedures for processing the income of the sponsor and the sponsor’s spouse.

Cash Gifts and Contributions – Count as unearned income unless they are made by a private, nonprofit organization on the basis of need and total $300 or less per household in a federal fiscal quarter. The federal fiscal quarters are January - March, April - June, July - September and October-December. If these contributions exceed $300 in a quarter, count the excess amount as income in the month received.

Exempt any cash contribution for common household expenses, such as food, rent, utilities, and items for home maintenance, if it is received from a non-certified household member who:

If a noncertified household member makes additional payments for use by a certified member, it is a contribution.

Child’s Earned Income – Exempt a child’s earned income if the child, who is under age 18 and not an emancipated minor, is a full-time student (including a home-schooled child) or a part-time student employed less than 30 hours a week.

Child Support Payments – Count as unearned income after deducting up to $75 from the total monthly child support payments the household receives. Count payments as child support if a court ordered the support or the child’s caretaker or the person making the payment states the purpose of the payment is to support the child. Count ongoing child support income as income to the child even if someone else living in the home receives it. Count child support arrears as income to the caretaker. Exempt child support payments as income if the child support is intended for a child who receives Medicaid, even though the parent actually receives the child support.

Crime Victim’s Compensation Payments – Exempt. These are payments from the funds authorized by state legislation to assist a person who has been a victim of a violent crime, was the spouse, parent, sibling or adult child of a victim who died as a result of a violent crime, or is the guardian of a victim of a violent crime. The payments are distributed by the Office of the Attorney General in monthly payments or in a lump sum.

Disability Insurance Payments – Count disability payments as unearned income, including Social Security Disability Insurance (SSDI) payments and disability insurance payments issued for non-medical expenses. Exception: Exempt Supplemental Security Income (SSI) payments.

Dividends and Royalties – Count dividends as unearned income. Exception: Exempt dividends from insurance policies as income. Count royalties as unearned income, minus any amount deducted for production expenses and severance taxes.

Educational Assistance – Exempt educational assistance, including educational loans, regardless of source.  Educational assistance also includes college work study.

Energy Assistance – Exempt the following types of energy assistance payments:

If an energy assistance payment is combined with other payments of assistance, exempt only the energy assistance portion from income (if applicable).

Foster Care Payments – Exempt.

Government Disaster Payments – Exempt federal disaster payments and comparable disaster assistance provided by states, local governments and disaster assistance organizations if the household is subject to legal penalties when the funds are not used as intended. Examples: Payments by the Individual and Family Grant Program, Small Business Administration and/or Federal Emergency Management Agency (FEMA).

In-Kind Income – Exempt. An in-kind contribution is any gain or benefit to a person that is not in the form of money or check, payable directly to the household, such as clothing, public housing or food.

Interest – Count as unearned income.

Job Training – Exempt all payments made under the Workforce Investment Act (WIA). Exempt portions of non-WIA job training payments earmarked as reimbursements for training-related expenses. Count any excess as earned income. Exempt on-the-job training (OJT) payments received by a child who is under age 19 and under parental control of another household member.

Loans (Non-educational) – Count as unearned income unless there is an understanding that the money will be repaid and the person can reasonably explain how he will repay it.

Lump-Sum Payments – Count as income in the month received if the person receives it or expects to receive it more often than once a year. Consider retroactive or restored payments to be lump-sum payments and count as a resource. Separate any portion that is ongoing income from a lump-sum amount and count it as income. Exempt lump sums received once a year or less, unless specifically listed as income. Count them as a resource in the month received. Effective Jan. 1, 2013, exempt federal tax refunds permanently as income and resources for 12 months after receipt. Exempt the Earned Income Credit (EIC) for a period of 12 months after receipt through Dec. 31, 2018. If a lump sum reimburses a household for burial, legal or health care bills, or damaged/lost possessions, reduce the countable amount of the lump sum by the amount earmarked for these items.

Military Pay – Count military pay and allowances for housing, food, base pay and flight pay as earned income, minus pay withheld to fund education under the G.I. Bill.

Mineral Rights – Count payments for mineral rights as unearned income.

Pensions – Count as unearned income. A pension is any benefit derived from former employment, such as retirement benefits or disability pensions.

Reimbursement – Exempt a reimbursement (not to exceed the individual's expense) provided specifically for a past or future expense. If the reimbursement exceeds the individual's expenses, count any excess as unearned income. Do not consider a reimbursement to exceed the individual's expenses unless the individual or provider indicates the amount is excessive. Exempt a reimbursement for future expenses only if the household plans to use it as intended.

Retirement, Survivors and Disability Insurance (RSDI) Payments – Count as unearned income the benefit amount including the deduction for the Medicare premium, minus any amount that is being recouped for a prior RSDI overpayment. If a person receives an RSDI check and a Supplemental Security Income (SSI) check, exempt both checks since the person is a disqualified household member. If an adult receives a Social Security survivor's benefit check for a child, this check is considered the child's income.

Self-Employment Income – Count as earned income, minus the allowable costs of producing the self- employment income. Self-employment income is earned or unearned income available from one’s own business, trade or profession rather than from an employer. However, some individuals may have an employer and receive a regular salary. If an employer does not withhold Federal Insurance Contributions Act (FICA) or income taxes, even if required to do so by law, the person is considered self-employed.

Types of self-employment include:

If the person sells the property on an installment plan, count the payments as income. Exempt the balance of the note as an inaccessible resource.

Supplemental Security Income (SSI) Payments – Exempt. A person receiving any amount of SSI benefits also receives Medicaid and is, therefore, a disqualified household member.

Temporary Assistance for Needy Families (TANF) Benefits – Exempt.

Terminated Income – Count terminated income in the month received. Use actual income and do not use conversion factors if terminated income is less than a full month’s income. Income is terminated if it will not be received in the next usual payment cycle.

Income is not terminated if:

Third-Party Payments – Exempt the money received that is intended and used for the maintenance of a person who is not a member of the household. If a single payment is received for more than one beneficiary, exclude the amount actually used for the nonmember up to the nonmember's identifiable portion or prorated portion, if the portion is not identifiable.

Tip Income – Count the actual (not taxable) gross amount of tips as earned income. Add tip income to wages before applying conversion factors. Tip income is income earned in addition to wages paid by patrons to people employed in service-related occupations, such as beauticians, waiters, valets, pizza delivery staff, etc. Do not consider tips as self-employment income unless related to a self-employment enterprise.

Trust Fund – Count as unearned income trust fund withdrawals or dividends that the household can receive from a trust fund that is exempt from resources.

Unemployment Compensation Payments – Count as unearned income the gross benefit less any amount being recouped for an Unemployment Insurance Benefits (UIB) overpayment. Count the cash value of UIB in a UIB debit account, less amounts deposited in the current month, as a resource. Account inquiry is accessible to a UIB recipient online at www.myaccount.chase.com or at any Chase Bank automated teller machine free of charge. Exception: Count the gross amount if the household agreed to repay a food stamp overpayment through voluntary garnishment.

Veterans Affairs (VA) Payments – Count the gross VA payment as unearned income, minus any amount being recouped for a VA overpayment. Exempt VA special needs payments, such as annual clothing allowances or monthly payments for an attendant for disabled veterans.

Vacation Pay – If an individual receives vacation pay:

Vendor Payments – Exempt vendor payments if made by a person or organization outside the household directly to the household's creditor or person providing the service. Exception: Count as income money that is legally obligated to the household, but which the payer makes to a third party for a household expense.

Wages, Salaries, Commissions – Count the actual (not taxable) gross amount as earned income. If a person asks his employer to hold his wages or the person’s wages are garnished, count this money as income in the month the person would otherwise have been paid. If, however, an employer holds his employee’s wages as a general practice, count this money as income in the month it is paid. Count an advance in the month the person receives it.

Workers’ Compensation Payments – Count the gross payment as unearned income, minus any amount being recouped for a prior worker’s compensation overpayment or paid for attorney’s fees. Note: The Texas Workforce Commission (TWC) or a court sets the amount of the attorney’s fee to be paid. Do not allow a deduction from the gross benefit for court-ordered child support payments. Exception: Exclude workers’ compensation benefits paid to the household for out-of-pocket health care expenses. Consider these payments as reimbursements.

Other Types of Benefits and Payments – Exempt benefits and payments from the following programs:

 


2440 Verifying Income

Revision 20-0; Effective November 2019

 

Verify countable income, including recently terminated income, at initial application and when changes are reported. Proof may include, but is not limited to:

 

2450 Documenting Income

Revision 20-0; Effective November 2019

 

On Form 3065, Worksheet, document exempt income and the reason it is exempt, and unearned income, including the following items:

For self-employment income, include the following items:

For earned income, include the following items:

 

2500 Budgeting Income

Revision 20-0; Effective November 2019

 

 

 

2510 General Principles

Revision 20-0; Effective November 2019

 

Count income already received and any income the household expects to receive. If the household is not sure about the amount expected or when the income will be received, use the best estimate.

 

2520 Steps for Budgeting Income

Revision 20-1; Effective April 27, 2020

 

There are 10 steps:

Step 1: Determine countable income, using CIHCP guidelines.

Step 2: Determine how often countable income is received, such as yearly, monthly, twice a month, every other week or weekly.

Step 3:  Convert countable income to monthly amounts, if income is not received monthly.

When converting countable income to monthly amounts, use the following conversion factors:

Step 4: Convert self-employment allowable costs to monthly amounts.

When converting the allowable costs for producing self-employment to monthly amounts, use the conversion factors in Step 3 above.

Step 5: Determine if countable income is earned or unearned.

For earned income, proceed with Step 6. For unearned income, skip to Step 8.

Step 6: Subtract converted monthly self-employment allowable costs, if any, from converted monthly self-employment income.

Step 7: Subtract earned income deductions, if any.

Subtract these deductions, if applicable, from the household’s monthly gross income, including monthly self-employment income after allowable costs are subtracted:

Exception: For self-employment income from property, when a person spends an average of less than 20 hours per week in management or maintenance activities, count the income as unearned and only allow deductions for allowable costs of producing self-employment income.

Step 8: Subtract the deduction for Medicaid individuals, if applicable.

This deduction applies when the household has a member who receives Medicaid and, therefore, is disqualified from the CIHCP household. Using the chart below, deduct an amount for the support of the Medicaid member(s) as follows: Subtract an amount equal to the deduction for the number of Medicaid-eligible individuals.

Deduction for Medicaid-Eligible Individuals

Number of Medicaid-Eligible Individuals Single Adult or Adult with Children Minor Children Only
1 $78 $64
2 $163 $92
3 $188 $130
4 $226 $154
5 $251 $198
6 $288 $214
7 $313 $267
8 $356 $293

 

Step 9: Subtract the deduction for child support, alimony and other payments to dependents outside the home, if applicable.

Allow the following deductions from members of the household group, including disqualified members:

Consider the remaining income as the monthly net income for the CIHCP household.

Step 10: Compare the household’s monthly net income to the 21% Federal Poverty Guideline (FPG) minimum income standard, using the CIHCP monthly income standard.

CIHCP Monthly Income Standard Based on the 2020 FPG
Number of Individuals in the CIHCP Household 21% FPG Minimum Income Standard 50% FPG Maximum Income Standard
1 $224 $532
2 $302 $719
3 $381 $905
4 $459 $1,092
5 $537 $1,279
6 $616 $1,465
7 $694 $1,652
8 $773 $1,839
9 $851 $2,025
10 $929 $2,212
11 $1,008 $2,399
12 $1,086 $2,585

A household is eligible if its monthly net income, after rounding down cents, does not exceed the monthly income standard for the CIHCP household’s size.

Section 3000, Case Processing

Revision 20-0; Effective November 2019

 

3100 General Principles

Revision 20-0; Effective November 2019

 

Use the application, documentation and verification procedures established by HHSC or a less restrictive application, documentation or verification procedure.

 

3200 Processing an Application

Revision 20-0; Effective November 2019

 

There are eight steps for processing an application:

Step 1: Accept the identifiable application.

On Form 3064, Application for Health Care Assistance, document the date that the identifiable Form 3064 is received. This is the application file date.

Step 2: Determine if an interview is needed.

Eligibility may be determined without interviewing the applicant if all questions on Form 3064 are answered and all additional information has been provided.

Step 3: Interview the applicant or his representative face-to-face or by telephone if an interview is necessary.

If an interview appointment is scheduled, issue Form 3067, Appointment Notice, including the date, time and place of the interview. If the applicant fails to keep the appointment, reschedule the appointment, if requested, or follow the Denial Decision procedure in Step 8.

Step 4: Check that all information is complete, consistent and sufficient to make an eligibility determination.

Step 5: Request needed information pertaining to the four eligibility criteria: residence, household, resources and income.

 
Step 6: Repeat Steps 4 and 5 as necessary.

Step 7: Determine eligibility based on the four eligibility criteria.

Document information in the case record to support the decision.

Step 8: Issue the appropriate form, either Form 3082 or Form 3077.

 

3300 Denial Decision Disputes

Revision 20-0; Effective November 2019

 

Responses Regarding a Denial Decision

If a denial decision is disputed by the household, the following may occur:

Eligibility Dispute

If a provider of assistance and a governmental entity or hospital district cannot agree on a household’s eligibility for assistance, the provider or the governmental entity or hospital district may submit Form 3073, Eligibility Dispute Resolution Request, within 90 days of the date that the eligibility determination is issued.

HHSC initiates the resolution process by notifying the appropriate entities and requesting any necessary information. HHSC will make a decision within 45 days. An appeal may be submitted in writing within 30 days. HHSC shall issue a final decision within 45 days after the date on which the appeal is filed.

Employment Services Program

Reference Section 1000, Program Administration.

 

3400 Case Record Maintenance

Revision 20-0; Effective November 2019

 

Case Record Review

Issue the household Form 3064, Application for Health Care Assistance. Follow the steps in Section 3200,  Processing an Application, beginning with Step 2, Determine if an interview is needed.

Case Filing Record

Documents relating to eligibility and claim payments may be kept in the same case record or in separate case records. Case record documents may be kept in the order of the chart below.

Left Side of Case Record or Claim Payment Record Right Side of Case Record or Eligibility Record
From top to bottom:
 
  • Form 3069, Health Care Services Record, for current state fiscal year
  • Claims for current fiscal year
  • Divider
  • Form 3081, Appellant – Provider Assignment, if applicable
  • Divider
  • Form 3069 for previous state fiscal years
  • Claims for previous state fiscal years
From top to bottom:
 
  • Current Form 3077, Notice of Eligibility, or Form 3082 , Notice of Ineligibility
  • Current Form 3064, Application for Health Care Assistance
  • Current Form 3065, Worksheet
  • Current Form 3067, Appointment Notice, if applicable
  • Current Form 3068, Request for Information
  • Current verifications
  • Current miscellaneous documents

Changes

Changes are situations that occur in a household that may affect the eligibility of the household.

Follow the steps in Section 3200, beginning with Step 4, Check that all information is complete, consistent and sufficient to make an eligibility determination, to determine the effect of the change on the household’s eligibility.

If a change results in the household’s ineligibility, the eligibility end date is the date that Form 3082 is issued to the household.

Section 4000, Service Delivery

Revision 20-0; Effective November 2019

 

4100 General Principles

Revision 20-0; Effective November 2019

 

A county shall provide the basic health care services established by HHSC in this handbook or less restrictive health care services. The basic health care services are:

In addition to providing basic health care services, a county may provide other department-established optional health care services that the county determines to be cost effective. The department-established optional health care services are:

Services or supplies must be reasonable and medically necessary for diagnosis and treatment.

For a listing of services, supplies and expenses that may not be CIHCP benefits, refer to the Texas Provider Procedures Medicaid Manual at Section 1 Provider Enrollment and Responsibilities “Texas Medicaid Limitations and Exclusions.”

Chapter 61, Health and Safety Code, Section 61.035, states, “The maximum county liability for each state fiscal year for health care services provided by all assistance providers, including hospital and skilled nursing facility, to each eligible county resident is:

Thirty days of hospitalization refers to inpatient hospitalization. Use the client’s actual dates-of-service when determining which fiscal year to apply the maximum county liability.

For the claim payment to be considered, a claim should be received:

The payment standard is determined by the date the claim is paid.

For additional information on claim payment, see Section 4400, User’s Guide to Fee Schedules.

 

4200 Basic Health Care Services

Revision 20-0; Effective November 2019

 

HHSC-established Basic Health Care Services Payment Method

Section 4210, Physician Services – Physician Fee Schedule

Section 4211, Annual Physical Examinations – Physician Fee Schedule

Section 4212, Immunizations – Physician Fee Schedule

Section 4213, Medical Screening Services – Physician Fee Schedule

Section 4214, Laboratory and X-Ray Services – Physician Fee Schedule

Section 4215, Family Planning Services – Physician Fee Schedule

Section 4216, Skilled Nursing Facility Services – Daily Rate

Section 4217, Prescription Drugs –  Formula

Section 4218, Rural Health Clinic (RHC) Services – Rate per Visit

Section 4219, Inpatient Hospital Services – Diagnosis Related Group (DRG) or Inpatient Percent Rate

Section 4220, Outpatient Hospital Services – Outpatient Percent Rate or ASC Rate

Negotiate rates with providers for basic service procedure codes not listed in the Fee Schedules. For additional information on claim payment, see Section 4400, User’s Guide to Fee Schedules.

 

4210 Physician Services

Revision 20-0; Effective November 2019

 

Physician services include services ordered and performed by a physician that are within the scope of practice of their profession as defined by state law. Physician services must be provided in the doctor's office, patient’s home, a hospital, a skilled nursing facility or elsewhere.

Payment Standard for Physicians. Use the Fee Schedule for Texas Medicaid Physician at www.tmhp.com and proceed as follows:

  1. Use the amount listed in the age appropriate Facility or Non-Facility Adjusted Fee for Report Date Column.
  2. If the Adjusted Fee for Report Date Column is blank and the Note Code is 5 or blank, HHSC does not have a payable amount; however, a payment amount may be negotiated with the provider.

Payment Standard for Anesthesia Services. Using the Fee Schedule for Texas Medicaid Physician at www.tmhp.com, use the number of Relative Value Units (RVUs) listed in the Total RVUs column, the conversion factor listed in the Conversion Factor column and the calculation instructions below.

  1. Calculate the anesthesia units of time by using the following formula.

    Total anesthesia time in minutes divided by 15 = Anesthesia units of time.
     
  2. Calculate the reimbursement for anesthesia services by using the following formula.

    Anesthesia units of time plus RVUs multiplied by conversion factor = Reimbursement amount.

Reduce the reimbursement amount by 2% for dates of services rendered on or after Feb. 1, 2011.

Payment Standard for Podiatrists. Use the Fee Schedule for Texas Medicaid Podiatrist at www.tmhp.com and proceed using the instructions for Payment Standard for Physicians.

Payment Standard for Injections. Use the Fee Schedule for Texas Medicaid Physician at www.tmph.com.

For additional information on claim payment, see Section 4400, User’s Guide to Fee Schedules.

 

4211 Annual Physical Examinations

Revision 20-0; Effective November 2019

 

Annual physicals are examinations provided once per calendar year by a physician, physician assistant (PA), or an Advance Practice Nurse (APN).

Associated testing, such as mammograms, can be covered with a physician’s referral.

These services may be provided by an APN if they are within the scope of practice of the APN in accordance with the standards established by the Board of Nurse Examiners and published in 22 Texas Administrative Code §221.13.

Payment Standard for a Physician. Use the Fee Schedule for Texas Medicaid Physician at www.tmhp.com and proceed as follows:

  1. Use the amount listed in the age appropriate Facility or Non-Facility Adjusted Fee for Report Date Column.
  2. If the Adjusted Fee for Report Date Column is blank and the Note Code is 5 or blank, HHSC does not have a payable amount; however, a payment amount may be negotiated with the provider.

For additional information on claim payment, see Section 4400, User’s Guide to Fee Schedules.

 

4212 Immunizations

Revision 20-0; Effective November 2019

 

Immunizations are given when appropriate.

Payment Standard. Use the Fee Schedule for Texas Medicaid Physician at www.tmhp.com and proceed as follows:

  1. Use the amount listed in the age appropriate Facility or Non-Facility Adjusted Fee for Report Date Column.
  2. If the Adjusted Fee for Report Date Column is blank and the Note Code is 5 or blank, HHSC does not have a payable amount; however, a payment amount may be negotiated with the provider.

For additional information on claim payment, see Section 4400, User’s Guide to Fee Schedules.

 

4213 Medical Screenings

Revision 20-0; Effective November 2019

 

Medical screenings include blood pressure, blood sugar and cholesterol screening.

Payment Standard. Use the Fee Schedule for Texas Medicaid Physician at www.tmhp.com and proceed as follows:

  1. Use the amount listed in the age appropriate Facility or Non-Facility Adjusted Fee for Report Date Column.
  2. If the Adjusted Fee for Report Date Column is blank and the Note Code is 5 or blank, HHSC does not have a payable amount; however, a payment amount may be negotiated with the provider.

For additional information on claim payment, see Section 4400, User’s Guide to Fee Schedules.

 

4214 Laboratory and X-ray Services

Revision 20-0; Effective November 2019

 

Laboratory and X-ray services are professional and technical services ordered by a physician and provided under the personal supervision of a physician in a setting other than a hospital (inpatient or outpatient).

Payment Standard. Use the Fee Schedule for Texas Medicaid Physician at www.tmhp.com and proceed as follows:

  1. Use the amount listed in the age appropriate Facility or Non-Facility Adjusted Fee for Report Date Column.
  2. If the Adjusted Fee for Report Date Column is blank and the Note Code is 5 or blank, HHSC does not have a payable amount; however, a payment amount may be negotiated with the provider.

For additional information on claim payment, see Section 4400, User’s Guide to Fee Schedules.

 

4215 Family Planning Services

Revision 20-0; Effective November 2019

 

Family planning services are preventive health care services that assist an individual in controlling fertility and achieving optimal reproductive and general health.

Payment Standard. Use the Fee Schedule for Texas Medicaid Physician Fee Schedule at www.tmhp.com and proceed as follows:

  1. Use the amount listed in the age appropriate Facility or Non-Facility Adjusted Fee for Report Date Column.
  2. If the Adjusted Fee for Report Date Column is blank and the Note Code is 5 or blank, HHSC does not have a payable amount; however, a payment amount may be negotiated with the provider.

For additional information on claim payment, see Section 4400, User’s Guide to Fee Schedules.

 

4216 Skilled Nursing Facility Services

Revision 20-0; Effective November 2019

 

Skilled nursing facility services must be:

Payment Standard. The skilled nursing facility rate is $118 per day.

This $118 daily rate does not include physician services or three prescription drugs per month. These additional services must be billed separately.

 

4217 Prescription Drugs

Revision 20-0; Effective November 2019

 

This service includes up to three prescription drugs per month. New and refilled prescriptions count equally toward the three prescription drugs per month total. Drugs must be prescribed by a physician or other practitioner within the scope of practice under law.

The quantity of each prescription depends on the prescribing practice of the physician and the needs of the patient.

Payment Standard. Use the following information and formula.

Using any pharmaceutical company’s database that provides average wholesale pricing, look up the drug’s 11-digit National Drug Code (NDC) number and the quantity dispensed to determine the average wholesale price (AWP).

The formula for computing the HHSC Payable is: Net cost plus drug dispensing fee = HHSC Payable.

Example: Prescription is written for 34 generic tablets

 

4218 Rural Health Clinic (RHC) Services

Revision 20-0; Effective November 2019

 

RHC services must be provided in a freestanding or hospital-based RHC and provided by a physician, physician assistant, advanced practice nurse (including a nurse practitioner, clinical nurse specialist and certified nurse midwife) or visiting nurse.

Payment Standard: Use the Rate per Visit at https://rad.hhs.texas.gov/hospitals-clinic/clinic-facility-services/rural-health-clinics.

 

4219 Inpatient Hospital Services

Revision 20-0; Effective November 2019

 

Inpatient hospital services must be medically necessary and provided:

Payment Standard. For the hospital in which the inpatient services were provided, use the Hospital Inpatient Payment lists that are located at https://rad.hhs.texas.gov/hospitals-clinic/hospital-services/inpatient-services. These lists will be used to calculate the payment rate using either the Percent Standard or the Diagnosis Related Group (DRG) Standard.

Note: If you are unable to locate payment information for a facility, complete Form 3079, Facility Payment Rate Request.

Percent Standard. This standard reimburses hospitals based on a percent of the hospital’s total billed amount.

DRG Standard. This standard reimburses hospitals at a predetermined rate for services based on the patient’s diagnosis. In some cases, the reimbursement will be more than the actual cost of providing services for that stay. In other cases, the reimbursement will be less than the hospital’s actual cost.  In either case, use the calculated DRG payment.

The DRG Standard incorporates the DRG code that is assigned to the hospital stay, the Relative Weight (Rel. Wt.) and the Mean Length of Stay that are assigned to the DRG code, and the SDA, which is the blended average dollar amount a hospital recovers for any given patient account.

To calculate a full or partial DRG payment, use the APR-DRG Version 29 of the Core Grouping Software™ along with the DRG Code, Relative Weight, Mean Length of Stay, and the SDA, which are located at https://rad.hhs.texas.gov/hospitals-clinic/hospital-services/inpatient-services.

Determine the type of DRG Payment based on the following information:

Full DRG Payment. To calculate, proceed as follows:

Partial DRG Payment. To calculate, proceed as follows:

DRG Software. 3M Health Information Systems Division is the supplier of the APR-DRG Version 29 Core Grouping Software™, which is used to assign a three-digit group or “code” based on the diagnosis code(s). For more information, contact: www.3mhis.com.

Gerry Tracy, Sales, 3M Health Information Systems Telephone: 800-367-2447
Email: gwtracy@mmm.com

Gregg Perfetto, Manager, 3M Health Information Systems Telephone: 800-367-2447
Email: gmperfetto@mmm.com

 

4220 Outpatient Hospital Services

Revision 20-0; Effective November 2019

 

Outpatient hospital services must be medically necessary and be:

Payment Standard. For the hospital in which the outpatient  services were provided, use the Outpatient RCC Rates list that is located on the Texas Health and Human Services website at https://rad.hhs.texas.gov/hospitals-clinic/hospital-services/outpatient-services. This list will be used to calculate the payment rate using the Percent Standard.

Outpatient RCC Rates List – Hospitals on this list are paid using the Percent Standard. The percent listed in the Outpatient Rate column reflects all applicable rate reductions.

Exception: If the outpatient service is for a scheduled surgery, the county may use the Fee Schedule for Texas Medicaid HASC Group Rate Amounts and HASC Group number at www.tmhp.com.

A hospital-based ambulatory surgical center (ASC) service should be billed as one inclusive charge on a UB-04.

 

4300 Optional Health Care

Revision 20-0; Effective November 2019

 

 

 

4310 HHSC-Established Optional Health Care Services

Revision 20-0; Effective November 2019

 

Service Payment Method
Advanced Practice Nurse (APN) Services Nurse Practitioner (NP) or Certified Nurse Specialist (CNS)
Ambulatory Surgical Center (ASC) Freestanding Services ASC Fee Schedule
Colostomy Medical Supplies and Equipment Durable Medical Equipment (DME) Fee Schedule
Counseling Services Psychologist Fee Schedule
Dental Care Dentist/Orthodontist Fee Schedule
Diabetic Medical Supplies and Equipment DME Fee Schedule
Durable Medical Equipment DME Fee Schedule
Emergency Medical Services Ambulance Fee Schedule
Federally Qualified Health Center (FQHC) Services Rate Per Visit
Home and Community Health Care Services Rate Per Visit
Occupational Therapy Services Occupational Therapist Fee Schedule
Physical Therapy Services Physical Therapist Fee Schedule
Physician Assistant Services Physician Assistant Fee Schedule
Vision Care, including Eyeglasses Optometrist and Optician Fee Schedule
Other Medically Necessary Services or Supplies Fee Schedule or Negotiable Rate

Note: For all but APN Services, negotiate rates with providers for optional service procedure codes not listed in the Fee Schedules. For additional information on claim payment, see Section 4400, User’s Guide to Fee Schedules.

 

4311 Advanced Practice Nurse (APN) Services

Revision 20-0; Effective November 2019

 

An APN must be licensed as a registered nurse (RN) within the categories of practice, specifically a nurse practitioner (NP), clinical nurse specialist (CNS), certified nurse midwife (CNM) and a certified registered nurse anesthetist (CRNA), as determined by the Board of Nurse Examiners. APN services must be medically necessary and provided within the scope of practice of the APN.

The Medicaid rate for NPs or CNSs reflect 92% of the rate paid to a physician for the same service and 100% of the rate paid to physicians for laboratory, X-ray and injections.

Payment Standard for an NP, CNS and CNM. Use the Fee Schedule for Texas Medicaid Nurse Practitioner and Clinical Nurse Specialist at www.tmhp.com and proceed as follows:

Payment Standard for a CRNA. Use the Fee Schedule for Texas Medicaid Certified Registered Nurse Anesthetist at www.tmhp.com.

Anesthesia. Use the number of Relative Value Units (RVUs) listed in the Total RVUs column, the conversion factor listed in the Conversion Factor column, and the calculation instructions below.

Medical, Surgery and Laboratory Services. Proceed as follows:

For additional information on claim payment, see Section 4400, User’s Guide to Fee Schedules.

 

4312 Ambulatory Surgical Center (ASC) Services

Revision 20-0; Effective November 2019

 

ASC services must be provided in a freestanding ASC and are limited to items and services provided in reference to an ambulatory surgical procedure. A freestanding ASC service should be billed as one inclusive charge on Form CMS-1500. If more than one procedure code is listed, only the code with the highest HHSC payable amount should be paid.

Payment Standard. Use the Fee Schedule for Texas Medicaid ASC Group Rate Amounts and ASC Group number at www.tmhp.com.

 

4313 Colostomy Medical Supplies and Equipment

Revision 20-0; Effective November 2019

 

Colostomy medical supplies and equipment must be medically necessary and prescribed by a physician or advanced practice nurse (APN) within the scope of their practice in accordance with the standards established by the Board of Nurse Examiners and published in 22 Texas Administrative Code §221.13. The county may require the supplier to receive prior authorization.

Items covered are cleansing irrigation kits, colostomy bags/pouches, paste or powder, and skin barriers with flange (wafers).

Payment Standard. For covered items listed above, use the Fee Schedule for Texas Medicaid Durable Medical Equipment/Medical Supplies at www.tmhp.com and proceed as follows:

For additional information on claim payment, see Section 4400, User’s Guide to Fee Schedules.

 

4314 Counseling Services

Revision 20-0; Effective November 2019

 

Behavioral health services must be medically necessary, based on a physician referral and provided by a licensed clinical social worker (LCSW, previously known as LMSW-ACP), licensed marriage family therapist (LMFT), licensed professional counselor (LPC) or psychologist with a Ph.D. These services may also be provided based on an advanced practice nurse (APN) referral if the referral is within the scope of their practice in accordance with the standards established by the Board of Nurse Examiners and published in 22 Texas Administrative Code §221.13.

Payment Standard for LCSW, LMFT and LPC. The following procedure codes are covered for Type of Service (TOS) 1 counseling services provided by these providers: 90806, 90847 and 90853 (Current Procedures Terminology (CPT) codes only, copyright 2004 American Medical Association. All Rights Reserved). The HHSC payable amounts may be accessed in the Texas Medicaid Physician Fee Schedule.

Payment Standard for Ph.D. Psychologist. Use the appropriate Texas Medicaid Outpatient Behavioral Health Fee Schedule at www.tmhp.com and proceed as follows:

For additional information on claim payment, see Section 4400, User’s Guide to Fee Schedules.

 

4315 Dental Care

Revision 20-0; Effective November 2019

 

Dental services must be medically necessary and provided by a Doctor of Dental Surgery (DDS), Doctor of Dental Medicine (DMD) or Doctor of Dental Medicine (DDM). The county may require prior authorization.

Items covered are an annual routine dental exam, annual routine cleaning, one set of annual X-rays and the least-costly service for emergency dental conditions for the removal or filling of a tooth due to abscess, infection or extreme pain.

Payment Standard. For covered items listed above, use the Fee Schedule for Texas Medicaid Dentist-Orthodontist at www.tmhp.com and proceed as follows:

For additional information on claim payment, see Section 4400, User’s Guide to Fee Schedules.

 

4316 Diabetic Medical Supplies and Equipment

Revision 20-0; Effective November 2019

 

Diabetic medical supplies and equipment must be medically necessary and prescribed by a physician. These supplies and equipment may also be prescribed by an advance practice nurse (APN) if this is within the scope of their practice in accordance with the standards established by the Board of Nurse Examiners and published in 22 Texas Administrative Code §221.13. The county may require the supplier to receive prior authorization.

Items covered are test strips, alcohol prep pads, lancets, glucometers, insulin syringes, humulin pens and needles required for the humulin pens.

Insulin syringes, humulin pens, and the needles required for humulin pens are dispensed with a National Dispensing Code (NDC) number and are paid as prescription drugs. They do not count toward the three prescription drugs per month limitation. Insulin and humulin pen refills are prescription drugs (not optional services) and count toward the three prescription drugs per month limitation.

Payment Standard. For covered items listed above, use the Fee Schedule for Texas Medicaid Durable Medical Equipment/Medical Supplies at www.tmhp.com and proceed as follows:

For additional information on claim payment, see Section 4400, User’s Guide to Fee Schedules.

 

4317 Durable Medical Equipment (DME)

Revision 20-0; Effective November 2019

 

DME must be medically necessary, meet the Medicare/Texas Title XIX Medicaid requirements and be provided under a physician’s prescription. These supplies and equipment may also be prescribed by an advanced practice nurse (APN) if this is within the scope of their practice in accordance with the standards established by the Board of Nurse Examiners and published in 22 Texas Administrative Code §221.13. Items can be rented or purchased, whichever is the least costly. The county may require the supplier to receive prior authorization.

Items covered are appliances for measuring blood pressure that are reasonable and appropriate, canes, crutches, home oxygen equipment (including masks, oxygen hose and nebulizers), hospital beds, standard wheelchairs and walkers.

Payment Standard. For covered items listed above, use the Fee Schedule for Texas Medicaid DME at www.tmhp.com and proceed as follows:

For additional information on claim payment, see Section 4400, User’s Guide to Fee Schedules.

 

4318 Emergency Medical Services

Revision 20-0; Effective November 2019

 

Emergency Medical Services (EMS) are ground ambulance transport services. When the person’s condition is life-threatening and requires the use of special equipment, life support systems and close monitoring by trained attendants while en route to the nearest appropriate facility, ground transport is an emergency service.

Payment Standard. Use the Fee Schedule for Texas Medicaid Ambulance at www.tmhp.com and proceed as follows:

 

4319 Home and Community Health Care Services

Revision 20-0; Effective November 2019

 

These services must be medically necessary, meet the Medicare/Medicaid requirements and are provided by a certified home health agency.

A plan of care must be recommended, signed and dated by the recipient’s attending physician prior to care being provided.

The county may require prior authorization.

Items covered are registered nurse (RN) visits for skilled nursing observation, assessment, evaluation and treatment, provided a physician specifically requests the RN visit for this purpose. A home health aide to assist with administering medication is also covered.

Visits made for performing household services are not covered.

The skilled nurse visit is also called an SNV, RN or LVN visit.    
The Current Procedural Terminology (CPT) code G0154 below includes $10 maximum for incidental supplies used during the visit.

The home health aide visit is also called an HHA visit. The CPT code G0156 below includes incidental supplies used during the visit.

Payment Standard. Use the HHSC Payable below.

Type of Service (TOS) Procedure Code
C G0154/Visit
C G0156/Visit

 

4320 Physician Assistant (PA) Services

Revision 20-0; Effective November 2019

 

PA services must be medically necessary and provided by a PA under the supervision of a physician, and billed by and paid to the supervising physician.

Payment Standard. Use the Fee Schedules for Texas Medicaid Nurse Practitioner, Clinical Nurse Specialist and Physician Assistant at www.tmhp.com.

The Medicaid rate for PAs reflects 92% of the rate paid to a physician for the same service and 100% of the rate paid to physicians for laboratory, X-rays and injections.

 

4321 Vision Care, Including Eyeglasses

Revision 20-0; Effective November 2019

 

Every 24 months, one examination of the eyes by refraction and one pair of prescribed eyeglasses may be covered. The county may require prior authorization.

Payment Standard for Examination of the Eyes by Refraction. Use the Fee Schedule for Texas Medicaid Optometrist at www.tmhp.com and proceed as follows:

Payment Standard for Prescribed Eyeglasses. Use the Fee Schedule for Texas Medicaid Optician at www.tmhp.com and proceed as follows:

For additional information on claim payment, see Section 4400, User’s Guide to Fee Schedules.

 

4322 Federally Qualified Health Center (FQHC)

Revision 20-0; Effective November 2019

 

FQHC services must be provided in an approved FQHC by a physician, physician assistant, advanced practice nurse, clinical psychologist or clinical social worker.

Payment Standard. Use the Rate per Visit at https://rad.hhs.texas.gov/hospitals-clinic/clinic-facility-services/federally-qualified-health-centers.

 

4323 Occupational Therapy Services

Revision 20-0; Effective November 2019

 

These services must be medically necessary and may be covered if provided in a physician’s office, therapist’s office, an outpatient rehabilitation or free-standing rehabilitation facility, or in a licensed hospital. Services must be within the provider’s scope of practice, as defined by Occupations Code, Chapter 454.

Payment Standard. Use the Fee Schedule for Texas Medicaid Occupational Therapist at www.tmhp.com.  Use the amount listed in the age appropriate Facility or Non-Facility Adjusted Fee for Report Date Column.

 

4324 Physical Therapy Services

Revision 20-0; Effective November 2019

 

These services must be medically necessary and may be covered if provided in a physician’s office, therapist’s office, an outpatient rehabilitation or free-standing rehabilitation facility, or in a licensed hospital. Services must be within the provider’s scope of practice, as defined by Occupations Code, Chapter 453.

Payment Standard. Use the Fee Schedule for Texas Medicaid Physical Therapist at www.tmhp.com. Use the amount listed in the age appropriate Facility or Non-Facility Adjusted Fee for Report Date Column.

 

 

4400 User’s Guide to Fee Schedules

Revision 20-0; Effective November 2019

 

 

 

4410 Fee Schedules

Revision 20-0; Effective November 2019

 

All Texas Medicaid Fee Schedules are available at www.tmhp.com.

The Texas Medicaid Fee Schedule is categorized by field descriptions. Type of Service (TOS) codes are listed in the first field. The TOS identifies the specific field or specialty of services provided. The TOS descriptions are listed below:

0 Blood Products 5 Laboratory 9 DME
1 Medical 6 Radiation E Eyeglasses
2 Surgery 7 Anesthesia I Interpretation
3 Consultation 8 Assistant T Technical
4 Radiology F ASC/HASC  

 

Procedure Code. The third field lists the current procedure codes. The Texas Medicaid physician, advanced practice nurse (APN), and certified registered nurse anesthetists (CRNA) fee schedules each contain a list of payment rates for Current Procedural Terminology (CPT) codes, including the TOS 7 American Society of Anesthesiologists (ASA) procedure codes. The five-character alphanumeric procedure codes follow the numeric procedure codes.

Modifier. The modifier is placed after the five-digit procedure code, if applicable. A modifier describes and qualifies services that are provided. However, not all procedures require a modifier. Modifiers may affect the CIHCP payment amount. A list of frequently used modifiers is located in the Texas Medicaid Providers Procedures Manual in Section 6, Claims Filing.

Child Age. The sixth and seventh fields list the age range for pricing determination.

Resource-Based Units. Texas Medicaid Reimbursement Methodology (TMRM). The eighth field lists the payable amount for the TOS and procedure code.

Total RVUs. The ninth field lists the relative value units (RVUs) for the procedure code.

Conv Factor. The tenth field lists the conversion factor used in the calculation formula for anesthesia services in determining the TMRM payable amount.

PPS Fee. The eleventh field lists the prospective payment system (PPS) fee. Not applicable for CIHCP.

Access-Based or Max Fee. The twelfth field lists the access-based fee amount or maximum fee.

Effective Date. The thirteenth field lists the effective date for total RVUs for Resource-Based Fees (RBFs). For fees other than RBFs, the effective date for the PPS, access-based, or max fee.

Note Code. The fourteenth field lists the note code indicator. For CIHCP, a payment amount may be negotiated with the provider when the Note Code is 5.

TOS. The CPT codes are divided into sections based on the type of service codes. The one-digit TOS code identifies the specific field or specialty of services provided. TOS 0 and TOS 9 are not basic health care services.

See Section 4420, Type of Services – Definition and Payment Information, below.

 

4420 Type of Services – Definition and Payment Information

Revision 20-0; Effective November 2019

 

1 Medical Services – Includes office, inpatient hospital and emergency room visits; allergy treatment; chemotherapy; injections; physical therapy; dialysis; psychotherapy; ophthalmology; dermatology; ventilation; etc. Excludes anesthesia, radiological interpretations and laboratory interpretations.

2 Surgery – Includes invasive diagnostic procedures.

If you are unable to make this determination, contact the provider for further clarification. The payment standard for paying multiple surgical procedures that are not components of one comprehensive procedure is to allow the full HHSC physician payment standard for the primary procedure and half of the HHSC physician payment standard for the other procedure(s).

3 Consultations – Used when the attending physician consults with another physician concerning some non-surgical aspect of the patient’s treatment.

4 Radiology (total component, i.e., technical and interpretation) – Includes radiological exams (X-rays), computerized axial tomography (CAT) scans, magnetic resonance imaging (MRI), mammography, echography (ultrasound), and other types of internal organ and vascular X-rays. Procedure codes with a type of service (TOS) 4 include radiology services that are both the technical component and the interpretation (professional) component of X-ray services.

In summary:

5 Laboratory (total component, i.e., technical and interpretation) – Includes most types of blood, urine, feces, and sputum tests and tests on other bodily fluids or by-products; tissue studies and analysis; various hearing and speech tests; electrocardiograms (EKGs) and cardiovascular stress tests; respiratory (pulmonary) function tests; electroencephalograms (EEGs) and other brain activity tests. Procedure codes with a TOS 5 include laboratory services that are both the technical component and the interpretation (professional) component of laboratory services.

Use the following information for processing bills for TOS 5 (Laboratory), TOS T (Technical) and TOS I (Interpretation).

In summary:

6 Radiation Therapy (total component, i.e., technical and interpretation) – Includes radiology treatment planning, radiological dosimetry, teletherapy, megavoltage treatment and radioelement application. Procedure codes with a TOS 6 include radiation therapy services that are both the technical component and the interpretation (professional) component of radiology treatment planning, radiological dosimetry, teletherapy, megavoltage treatment and radioelement application services.

Use the following information for processing bills for TOS 6 (Radiation Therapy), TOS T (Technical), and TOS I (Interpretation).

In summary:

•    If a TOS 6 is paid first, then the total component has been met.
•    If a TOS T is paid first, then a TOS I may be payable.
•    If a TOS I is paid first, then a TOS T may be payable.

7 Anesthesia – Usually provided by or under the supervision of a physician in a hospital setting.

8 Assistant Surgery – A surgical procedure that requires the assistance of another surgeon. Procedure codes with a TOS 8 include assistant surgical services. In addition, use of a modifier code of 80, 81 and 82 with a surgical procedure code results in TOS 8 being assigned to the procedure.

Although certain surgical procedures require the service of an assistant surgeon, not all surgical procedures require this service.

If you are unable to make this determination, contact the provider for further clarification. The payment standard for paying multiple surgical procedures that are not components of one comprehensive procedure is to allow the full HHSC physician payment standard for the primary procedure and pay half of the HHSC physician payment standard for the other procedure(s).    
 
I Interpretation – Professional component for radiology, laboratory or radiation therapy services. Only one provider is entitled to reimbursement for interpreting a radiology, laboratory or radiation therapy procedure.

In summary:

T Technical – Technical component for radiology, laboratory or radiation therapy services.

Only one provider is entitled to reimbursement for performing the technical component of a radiology, laboratory or radiation therapy procedure.

In summary:

Section 5000, State Assistance Funds

Revision 20-0; Effective November 2019

 

5100 General Principles

Revision 20-0; Effective November 2019

 

Based on an annual allocation, subject to funding, HHSC distributes state assistance funds to counties not fully served by a public hospital or hospital district. To receive state assistance funds, a county must comply with the HHSC-established standards and procedures contained in this handbook.

Expenditures are reimbursable if they are paid:

Reimbursable expenditures must be paid in the state fiscal year for which state assistance funds are being requested.

The county is eligible for state assistance funds when it exceeds the 8% General Revenue Tax Levy (GRTL) expenditure level.

 

5200 Steps for Applying

Revision 20-0; Effective November 2019

 

 

 

5210 Steps for Applying for State Assistance Funds

Revision 20-0; Effective November 2019

 

Step 1 – Submit Form 3072, Monthly Financial Report, to be received by the HHSC County Indigent Health Care Program (CIHCP) by the 10th day of the month following the report month. Form 3072 must have been submitted for each of the 12 months prior to the month state assistance funds are requested. Submit Form 3086, End of Year Report, to HHSC CIHCG in Austin by September 30.

Step 2 – Report the county’s General Revenue Tax Levy (GRTL) to the Texas State Comptroller of Public Accounts.

Step 3 – Notify Texas Health and Human Services Commission (HHSC) CIHCP by email within seven days after the date that the county will expend 6% of its GRTL and follow up with a written notification.

6% Program Review. Upon receiving written notification that a county has expended 6% of its GRTL, HHSC may complete a review of the county's eligibility system and billing and provide the county with a written report on the findings of the review. If deficiencies are identified, the county must correct them within five workdays from the date the deficiencies are identified. The county must subtract any uncorrectable deficiencies from reimbursable expenditures.

Step 4 – Request state assistance funds when the county exceeds the 8% GRTL expenditure level. Compute the dollar amount that will be paid when the court authorizes payment. Request 90% of that amount from HHSC.

Contact HHSC by telephone or email to request state assistance funds prior to the Commissioner’s Court authorizing payment of the health care claims. HHSC will provide the county with a State Assistance Request number. Complete and submit to HHSC Form 3088, Request for State Assistance Funds (90 Percent), and supporting documentation within 30 days after the request.

Section 6000, Supplemental Security Income (SSI) Reimbursement

Revision 20-0; Effective November 2019

 

6100 General Principles

Revision 20-0; Effective November 2019

 

To receive retroactive Medicaid reimbursement for Supplemental Security Income (SSI) appellants, a county must comply with the HHSC established standards and procedures contained in this handbook.

Effective Oct. 1, 2008, HHSC can only file Medicaid claims for reimbursement if they are:

In addition, due to changes in the Texas Administrative Code, all Medicaid claims processed through HHSC must meet the 365-day federal filing deadline.

 

6200 Steps for Applying

Revision 20-0; Effective November 2019

 

 

 

6210 Steps for Requesting Medicaid Reimbursement for SSI Appellants

Revision 20-0; Effective November 2019

 

Step 1 – County staff must sign and submit Form 3087, TMHP Confidentiality Agreement, to HHSC.

Step 2 – County staff must have a potential Supplemental Security Income (SSI) appellant sign Form 3081, Appellant – Provider Assignment. The form must also be signed by the provider. Note: Claims paid before signatures are obtained will not be eligible for reimbursement.

Step 3 – Submit Form 3080, SSI Appellant Notification, with the requested reimbursement costs and Medicaid approved claim forms (Form CMS-1500, UB-04 or pharmacy statement).

The full Medicaid Reimbursement Manual may be accessed at Medicaid Reimbursement Manual (PDF).

Forms

ES = Spanish version available.

Form Title  
3064 Application for Health Care Assistance ES
3065 Worksheet  
3066 Report of Changes  
3067 Appointment Notice ES
3068 Request for Information ES
3069 Health Care Services Record  
3072 Monthly Financial Report  
3073 Eligibility Dispute Resolution Request  
3076 Case Record Information Release ES 
3077 Notice of Eligibility ES 
3078 Claim Processing Notification  
3079 Facility Payment Rate Request  
3080 SSI Appellant Notification  
3081 Appellant – Provider Assignment ES 
3082 Notice of Ineligibility ES 
3083 Optional Health Care Services Notification  
3084 Employment Verification ES 
3085 Statement of Self-Employment Income ES
3086 End of Year Report  
3087 TMHP Confidentiality Agreement  
3088 Request for State Assistance Funds (90 Percent)  

Policy Revisions

20-1, Monthly Income Standard Changes

Revision 20-1; Effective April 27, 2020

 

The following change(s) were made:

Revised Title Change
2520 Steps for Budgeting Income Updates the table in Step 10 for CIHCP Monthly Income Standard Based on the 2020 Federal Poverty Guideline.

 

20-0, Handbook Revised with New Format

Effective November 2019

 

The County Indigent Health Care Program Handbook is revised with a new format. Forms have been renumbered and linked directly to the handbook.

Contact Us

For questions about the County Indigent Health Care Program Handbook, email CIHCP@hhsc.state.tx.us.

For technical or accessibility issues with this handbook, email Editorial_Services@hhsc.state.tx.us.