Revision 12-3; Effective July 1, 2012

Medicaid for Breast and Cervical Cancer (MBCC) follows the Medical Programs citizenship policy in A-300, Citizenship.

Applicants who are U.S. citizens and certain legally admitted alien residents are eligible for MBCC if they meet all other eligibility criteria.

Note: MBCC-Presumptive or MBCC recipients who are qualified immigrant or non-immigrant who meet the eligibility criteria in A-342, TANF and Medical Programs Alien Status Eligibility Charts, Chart D, who applied before their 19th birthday, remain eligible for MBCC through the duration of their cancer treatment or until they no longer meet all the other eligibility criteria, whichever is earlier.

Revision 12-3; Effective July 1, 2012  

To establish identity, follow policy for Medical Programs in A-600, Identity.

Revision 15-4; Effective October 1, 2015

Medicaid for Breast and Cervical Cancer (MBCC)-Presumptive and MBCC follow Children’s Medicaid (TP 33, TP 34, TP 35, TP 43, TP 44, TP 45 and TP 48) policy in A-700, Residence.

Revision 12-3; Effective July 1, 2012

To qualify for Medicaid for Breast and Cervical Cancer (MBCC)-Presumptive or MBCC, applicants must have been screened and found to need active treatment for either breast or cervical cancer.

Related Policy

Screening, X-911

At each periodic review, MBCC recipients must provide verification that they continue to receive treatment for breast or cervical cancer.

Related Policy

Active Treatment, X-912

 

X—911 Screening

Revision 15-4; Effective October 1, 2015

A woman must be screened for breast and cervical cancer under the Centers for Disease Control and Prevention’s (CDC’s) National Breast and Cervical Cancer Early Detection Program (NBCCEDP). The Breast and Cervical Cancer Services (BCCS) contractor or provider, through the Texas Department of State Health Services (DSHS), is responsible for providing the Texas Health and Human Services Commission (HHSC) with verification that a woman has been screened and diagnosed using the NBCCEDP criteria.

A woman is considered screened under the NBCCEDP if:

• CDC Title XV funds paid for all or part of the cost of her screening services; or
• her particular clinical service has not been paid for by CDC NBCCEDP Title XV funds, but the:
  • service was provided by a provider and/or an entity funded at least in part by CDC Title XV funds;
  • service was within the scope of a grant, sub-grant or contract under that state program; and
  • state CDC Title XV grantee has elected to include such screening activities provided by the provider as screening activities pursuant to CDC Title XV.

The 80th Texas Legislature passed Senate Bill 10, the Medicaid Reform Act, which authorized any health care provider to refer eligible women in need of treatment for breast or cervical cancer to Medicaid. Beginning September 1, 2007, any woman diagnosed with breast or cervical cancer may receive MBCC if they meet all eligibility requirements. The diagnosing provider refers the woman to a BCCS contractor who assists the woman in applying for MBCC.

If Form H1034, Medicaid for Breast and Cervical Cancer, is received and the woman does not have a qualifying medical diagnosis, deny the application due to the woman not having a diagnosis for breast or cervical cancer.

 

X—912 Active Treatment

Revision 15-4; Effective October 1, 2015

At reapplication and at each redetermination, the MBCC applicant or recipient must provide Form H1551, Treatment Verification, completed by her treating health professional verifying that she needs active treatment services for breast or cervical cancer. Active cancer treatment includes services related to the individual's condition as documented in her plan of care, such as:

• surgery,
• chemotherapy,
• radiation,
• reconstructive surgery, and
• medication (ongoing hormonal treatment).

These services also may include diagnostic services that are necessary to determine the extent and proper course of treatment and active disease surveillance for triple negative receptor breast cancer.

Women who are determined to require only routine health screening services for a breast or cervical condition (for example, annual clinical breast examinations, mammograms and pap tests as recommended by the American Cancer Society and the U.S. Preventative Services Task Force) are not considered to need treatment and are not eligible for MBCC. A woman may reapply for MBCC if she is later diagnosed with a new breast or cervical cancer, pre-cancerous condition or a metastatic or recurrent breast or cervical cancer.

If the woman’s treating health professional indicates on Form H1551 that she is not actively receiving treatment, deny the MBCC Eligibility Determination Group (EDG) due to the woman not actively receiving treatment.

Revision 22-3; Effective July 1, 2022

Women who are eligible for MBCC-Presumptive or MBCC receive full regular Medicaid benefits.

Before certifying a woman for MBCC-Presumptive or MBCC, Centralized Benefit Services (CBS) staff complete inquiry into the Texas Integrated Eligibility Redesign System (TIERS) to determine if the applicant currently receives Medicaid or Children's Health Insurance Program (CHIP) benefits. Deny the MBCC application if the woman receives other Medicaid coverage. 

Exceptions: Do not deny the application if the woman’s Medicaid coverage is ending.

Note: If a woman certified for Healthy Texas Women (HTW) becomes eligible for MBCC, there may be an overlap in coverage for the month in which she applies for MBCC. MBCC eligibility begins the date an applicant meets all eligibility criteria and cannot precede the day after the diagnosis date. After the woman is determined eligible for MBCC, terminate HTW prospectively. 

Related Policy

Medicaid Effective Date (MED), X-921
Other Medical Assistance, X-932
Current Medicaid, Medicare (Part A or B) and Children's Health Insurance Program (CHIP) Recipients, W-911

X—921 Medical Effective Date (MED)

Revision 12-3; Effective July 1, 2012

Medicaid eligibility begins the date an applicant meets all eligibility criteria. The MED cannot precede the day after the diagnosis date.

For MBCC-Presumptive, the MED is the date the BCCS contractor determines the woman is presumptively eligible for MBCC, but no earlier than the date after the woman was diagnosed with breast or cervical cancer. If the woman provides information needed for MBCC eligibility, provide MBCC coverage for dates that precede the MBCC-Presumptive MED.

Related Policy

Prior Coverage, X-922

X—922 Prior Coverage

Revision 15-4; Effective October 1, 2015

A woman may be eligible for up to three months of prior coverage under MBCC if all other eligibility requirements are met. MBCC only covers unpaid medical bills for services received after the individual's breast and cervical cancer diagnosis date. If a woman indicates on Form H1034, Medicaid for Breast and Cervical Cancer, that she has unpaid medical bills that occurred during the three months before she applied for MBCC, assign an MED of the day after her diagnosis date. Do not require the woman to provide proof of the unpaid medical bills or a completed Form H1113, Application for Prior Medicaid Coverage.

For medical expenses incurred before or on her date of diagnosis, the client must apply for prior Medicaid coverage using Form H1010, Texas Works Application for Assistance — Your Texas Benefits; Form H1205, Texas Streamlined Application; or online at YourTexasBenefits.com. Refer the client to an HHSC eligibility office for the appropriate application or have the client call 2-1-1 to locate the nearest HHSC eligibility office.

Example One: The applicant was diagnosed on August 15 and applied for MBCC on November 21 indicating that she has unpaid medical bills for August, September, October and November. Assign an MED of August 16.

Example Two: The applicant was diagnosed on July 7 and applied for MBCC on July 21 indicating that she has unpaid medical bills for May and June. The individual is not eligible for prior coverage under MBCC since the unpaid medical bills were before her diagnosis date. Assign an MED of July 8.

Example Three: The applicant was diagnosed on January 31 and applied for MBCC on June 4 indicating she has unpaid bills for February. The woman is not eligible for prior coverage since her unpaid medical bills occurred prior to the three-month period before she applied for MBCC.

Note: If the applicant had creditable coverage before applying for MBCC and indicates she has unpaid medical bills for the months she was covered by insurance, the client is not eligible for prior coverage under MBCC. The client must apply for prior Medicaid coverage using Form H1010, Form H1205, or online at YourTexasBenefits.com to determine whether she meets all eligibility requirements for prior Medicaid. See A-831, Three Months Prior Coverage.

X—923 Medicaid Termination

Revision 20-4; Effective October 1, 2020

MBCC eligibility ends when the recipient first meets any of the following conditions. The recipient:

• becomes 65;
• obtains creditable coverage;
• is no longer receiving active treatment for breast or cervical cancer;
• no longer resides in Texas;
• is confined in a public institution; or
• dies.

Related Policy

Termination of Medical Coverage for People Confined in a Public Institution, B-510

X—924 Types of Coverage

Revision 18-1; Effective January 1, 2018

People certified for MBCC-Presumptive receive their medical care via fee-for-service.

People certified for MBCC are enrolled in the STAR+PLUS managed care program.

Related Policy

Managed Care, A-821.2
Managed Care Plans, C-1116

X—931 General Overview

Revision 17-2; Effective April 1, 2017

A woman is ineligible to receive MBCC if she has creditable coverage. Deny an MBCC application if her plan covers breast or cervical cancer treatment.

Creditable coverage is defined as:

• group health insurance;
• health insurance coverage;
• Medicare (Part A or B);
• Medicaid;
• CHIP;
• armed forces insurance; or
• a state health risk pool.

Do not consider a plan with a limited scope of coverage such as dental, vision, long-term care, etc., or for only a specific illness/disease, such as drug/substance abuse, as creditable coverage. Note: Healthy Texas Women (TA 41) is not considered creditable coverage.

Consider a woman as having creditable coverage even if it has limits on benefits, such as limited drug coverage or limits on the number of outpatient visits, or high deductibles. A woman is considered to no longer have creditable coverage if she:

• is in a period of exclusion (such as pre-existing condition exclusions or a health maintenance organization [HMO] affiliation period) for treatment of breast or cervical cancer; or
• exhausts her lifetime limit on all benefits under the plan or coverage or her yearly benefits for breast or cervical cancer treatment. When the new plan year begins, determine if the woman has creditable coverage.

Note: Set a special review if it is known that the exclusion period of the creditable coverage will expire (pre-existing period has expired) or the woman’s yearly benefits for breast or cervical cancer treatment will be reinstated before the next periodic review. See X-1930, Setting Special Reviews.

Women screened under BCCS are not subject to a waiting period if they had prior creditable coverage.

As long as the termination of the creditable coverage occurs before disposition, a woman is eligible to receive benefits under the MBCC program.

A woman is required to report when she has obtained creditable coverage.

If an MBCC applicant indicates she has health insurance but does not know whether it provides coverage for breast or cervical cancer, certify the woman for MBCC-Presumptive. Contact the insurance provider to verify whether the policy provides coverage for breast or cervical cancer.

X—932 Other Medical Assistance

Revision 17-2; Effective April 1, 2017

An MBCC applicant is not eligible to receive benefits if she is currently receiving Medicaid, Medicare Part A or B, or coverage through CHIP. If an application is received for a woman who receives Medicaid, Medicare (Part A or B) or CHIP, or if a Medicaid or CHIP application is certified before the MBCC application, deny the MBCC application.

Staff must verify via TIERS, the State Online Query (SOLQ) or the Wire Third-Party Query (WTPY) system that an applicant is not currently enrolled in Medicaid, Medicare Part A or B, CHIP, or Healthy Texas Women (HTW) before disposition. If a woman is eligible for MBCC and is currently receiving HTW, the HTW EDG must be denied.

X—932.1 Currently Receiving MBCC and Applies for Other Benefits

Revision 16-3; Effective July 1, 2016

A woman receiving MBCC-Presumptive or MBCC who is found eligible for another type of Medicaid program is ineligible to continue to receive MBCC-Presumptive or MBCC. The MBCC advisor receives a task to prospectively deny the MBCC-Presumptive/MBCC EDG so that the advisor processing the application can certify the woman for the other type of Medicaid. The MED for the other Medicaid type begins the first of the month following the MBCC-Presumptive/MBCC EDG denial.

When the other Medicaid type of assistance is denied, the woman may be eligible for MBCC if she continues to be in need of active treatment for breast or cervical cancer and she meets all other eligibility criteria. When the other type of Medicaid is denied (unless the denial is due to death, unable to locate or a move out of state), TIERS generates a reapplication packet if  the woman is under age 65 and less than 12 months has passed since her diagnosis date or the date her active treatment was last verified, whichever is later.  The reapplication packet contains:

• Form H1833, Cover Letter — Other Medicaid Ending or Form H1834, Cover Letter — Other Medicaid Denied;
• Form H2340, Medicaid for Breast and Cervical Cancer Renewal;
• Form H1551, Treatment Verification;
• a self-addressed envelope; and
• Form H0025, HHSC Application for Voter Registration.

The woman must return the completed Form H2340 and Form H1551 for her eligibility for MBCC to be reconsidered.

If more than 12 months have passed since the woman's diagnosis date or her active treatment was last verified, the woman must be screened and reapply for MBCC through a Breast or Cervical Cancer Services (BCCS) contractor using Form H1034, Medicaid for Breast and Cervical Cancer.  TIERS generates either Form H1833-L, Other Medicaid Ending, or Form H1834-L, Other Medicaid Denied, informing the woman how to reapply for MBCC and provides the web address (www.healthytexaswomen.org/healthcare-programs/breast-cervical-cancer-services/bccs-how-apply) where the woman can locate a BCCS contractor in her area.

Revision 13-4; Effective October 1, 2013

If a woman is screened in another state through the CDC’s National Breast and Cervical Cancer Early Detection Program (NBCCEDP) and moves to Texas, she may be eligible for MBCC in Texas. If a woman meets the MBCC eligibility criteria in Texas, her screening in another state does not prohibit her from receiving MBCC in Texas.

A new state resident requests MBCC in Texas by contacting 2-1-1. Form H2340-OS, Medicaid for Breast and Cervical Cancer, is mailed to the woman for her to complete and return.

Upon receipt of Form H2340-OS, CBS determines the woman’s eligibility for MBCC. Staff must verify with the losing state the woman’s screening under NBCCEDP and termination of any Medicaid benefits received in that state, if any, before certification. Use Form H1550, Out of State NBCCEDP Verification, to verify the applicants screening and diagnosis.

Related Policy

New Texas Residents, A-720
Medicaid Coverage for New State Residents, A-822

Revision 12-3; Effective July 1, 2012

Resources do not apply to Medicaid for Breast and Cervical Cancer (MBCC)-Presumptive or MBCC.

Revision 15-4; Effective October 1, 2015

Before certifying applicants and processing reviews, complete the following:

• Ensure the applicant completes each item and signs and dates Form H1034, Medicaid for Breast and Cervical Cancer, the application for assistance.
• During processing, note if the applicant indicates changes on Form H1034 or during the interview, if an interview is requested. Document the nature of the change and when the individual expects the change to occur. If other programs exist for the individual, report the change to the appropriate office.
• Give or mail the applicant Form H1019, Report of Change. Explain that she must report changes involving her address or creditable coverage within 10 days after knowing about the change. Indicate the appropriate reporting requirement on Page 1.
• Refer the applicant to other programs for which she might be eligible such as Family Planning; Supplemental Security Income or other benefits from the Social Security Administration; and Women, Infants and Children (WIC). Refer aged and individuals with disabilities who are ineligible for Medical Programs for children and families to the Texas Health and Human Services Commission's (HHSC's) Medicaid for the Elderly and People with Disabilities (MEPD) programs.
• Inform the applicant of her right to appeal any HHSC action that affects her eligibility.
• Inform the applicant that the information she provided is subject to verification by third parties.
• Instruct individuals to report any accident-related injuries requiring medical care or accident-related unsettled legal claims within 60 days.
• Mail Form H0025, HHSC Application for Voter Registration, with all applications and renewals. If the individual contacts the local office to decline the opportunity to register based on receipt of Form H0025, use Form H1350, Opportunity to Register to Vote, to acknowledge the declination. Mail Form H1350 to the individual for her signature and, upon receipt, file a copy in the case record.

Revision 15-4; Effective October 1, 2015

Document that the application was mailed along with Form H0025, HHSC Application for Voter Registration, and Form H1350, Opportunity to Register to Vote.

Revision 15-4; Effective October 1, 2015

Case disposition is the result of processing a request for assistance. Advisors must produce a notice of eligibility status. At the end of the interview, if one was requested by the client, or once Form H1034, Medicaid for Breast and Cervical Cancer; Form H2340, Medicaid for Breast and Cervical Cancer Renewal; or Form H2340-OS, Medicaid for Breast and Cervical Cancer, has been processed, mail the client one of the following notices to inform the individual that the case is pended, certified, sustained or denied.

Form H1020, Request for Information or Action

Form H1020 informs the individual the:

• reason the case is pending;
• action the individual or advisor must take;
• date by which the individual or advisor must take action; and
• date the advisor must deny the application/case if the individual does not take action, if applicable.

If all required proof/verification is not available when processing the application, the advisor allows the household at least 10 days to provide it. The due date must be a workday. Advisors determine what sources of proof/verification are readily available to the household and request those sources first if the advisor expects them to be sufficient proof/verification. If the applicant has an active or inactive Eligibility Determination Group (EDG) in the Texas Integrated Eligibility Redesign System (TIERS), the advisor checks to see whether any proof/verification previously provided on any other EDG can be used to determine eligibility for Medicaid for Breast and Cervical Cancer (MBCC).

Note: Verification previously provided on another case/EDG is only acceptable if it was provided within the 90 days preceding the file date.

Form TF0001, Notice of Case Action

If eligible for MBCC-Presumptive or MBCC, Form TF0001 informs the client of:

• the date benefits begin,
• her right to appeal, and
• the address and phone number of free legal services available in the area.

If the woman is certified for MBCC-Presumptive, a separate Form H1020 is sent informing her of the additional information needed to determine her eligibility for MBCC.

If ineligible for MBCC-Presumptive or MBCC, Form TF0001 informs the client of:

• the date of denial,
• her right to appeal, and
• the address and phone number of free legal services available in the area.

 

X—1911 Summary of Due Dates for Form H1020, Request for Information or Action

Revision 10-2; Effective April 1, 2010

Case Action	Due Date	Final Due Date
Application	10 days from the date issued	30 days, or 10th day if 10 days end after 30th day
Renewal	10 days from the date issued	By cutoff of review month
Incomplete review	10 days from the date issued	10 days

Revision 13-2; Effective April 1, 2013

MBCC EDGS do not have a certification period.

TIERS calculates a review date from the date the advisor disposes the case action as follows:

• Applications – five months from the date of disposition.
• Renewals – six months from the date of disposition.

Revision 13-1; Effective January 1, 2013

When processing an application or renewal, set a special review if it is known that before the next periodic review the exclusion period of the creditable coverage will expire (pre-existing condition period has expired) or the woman’s yearly benefits for breast or cervical cancer treatment will be reinstated.

Revision 10-2; Effective April 1, 2010

Any household receiving a notice of adverse action has the right to request a fair hearing. In some situations, households may continue receiving benefits pending an appeal. After certification, give households advance notice of adverse action to deny benefits except for reasons listed in A-2344.1, Form TF0001 Required (Adequate Notice), and A-2344.2, No Form TF0001 Required.

For adverse action, use current policy found in A-2340, Adverse Action.

Revision 20-4; Effective October 1, 2020

Process the application within two business days of receipt, but no later than 15 business days from the application file date.

Re-open an application denied for failure to provide information or verification if the missing information is provided. Use the date all of the missing information was provided as the new file date. The original Form H1034, Medicaid for Breast and Cervical Cancer, is valid for up to 60 days. If the information on Form H1034 has changed or is more than 45 days old, the person and staff must update the form.

Revision 12-3; Effective July 1, 2012

Provide Form TF0001, Notice of Case Action, the same day eligibility is determined. Determine eligibility no later than 15 days from the file date.

Revision 12-3; Effective July 1, 2012

No appointment is required to process an application or renewal unless requested by the applicant or recipient. If requested, provide a telephone interview. If she fails to keep her appointment, do not deny the application or renewal; continue to process the application/renewal.

Revision 15-4; Effective October 1, 2015

Advisors may not request additional information or documentation from clients unless such information is not available electronically or the information obtained electronically is not consistent with the information provided by the client.

Advisors must request documents that are readily available to the household if the advisor anticipates them to be sufficient verification. Each Texas Works Handbook section lists potential verification sources. C-900, Verification and Documentation, provides information on verification procedures.

In determining eligibility, the advisor must consider any information the individual reports between the application date and the decision date. Include any information the individual reports during the application decision process.

Note: Verification previously provided on another Eligibility Determination Group (EDG) is only acceptable if it was provided within the 90 days preceding the file date.

Revision 15-4; Effective October 1, 2015

The Texas Integrated Eligibility Redesign System (TIERS) generates a renewal packet to a recipient two months before the periodic review due date.

The renewal packet includes:

• Form H1830, Application/Review/Expiration/Appointment Notice;
• Form H2340, Medicaid for Breast and Cervical Cancer Renewal;
• Form H1551, Treatment Verification, to verify if the recipient is currently receiving treatment for breast or cervical cancer; and
• a self-addressed stamped envelope.

Revision 15-4; Effective October 1, 2015

The file date is the date the Texas Health and Human Services Commission (HHSC) receives the renewal application. Process the renewal by mail or telephone.

Note: Send the individual Form H1020, Request for Information or Action, if the individual did not provide Form H1551, Treatment Verification, with Form H2340, Medicaid for Breast and Cervical Cancer Renewal.

A woman remains eligible for Medicaid for Breast and Cervical Cancer (MBCC) when it is verified that she:

• has not turned age 65;
• is actively receiving treatment, as defined in X-912, Active Treatment; and
• does not have creditable coverage as defined in X-930, Creditable Coverage.

Deny a recipient if it is verified that she has creditable coverage, is not actively receiving treatment or is age 65 or older.

 

Revision 16-3; Effective July 1, 2016

Advisors must process periodic reviews before cutoff in the month:

• the review date falls, if the review is due on or before cutoff; or
• after the review date, if the review is due after cutoff.

If the household must provide verification to complete the review, allow the household at least 10 days to provide it.

Advisors must reopen a renewal form denied for failing to furnish information or verification if the missing information is provided by the 60th day from the file date. The date the missing information/verification was provided is the new file date.

The original Form H2340, Medicaid for Breast and Cervical Cancer Renewal, can be used until it is 60 days old, following the policy explained in B-111, Reuse of an Application Form After Denial.

Advisors must consider a Form H2340 received after the last day of the certification period as an application using application processing time frames in X-2010, Applications, if it is received 12 months or less after the woman's breast or cervical cancer diagnosis date or the date active treatment was last verified, whichever is later.

Revision 12-3; Effective July 1, 2012

Recipients must report the following changes:

• moving out of state,
• obtaining creditable coverage,
• turning age 65,
• discontinuing treatment, or
• death.

Note: If a change for a Medicaid for Breast and Cervical Cancer (MBCC)-Presumptive or MBCC recipient is received in an eligibility office:

• without verification, staff take the change and enter it into the State Portal-Report A TIERS Change portlet and the system automatically creates and routes the change task appropriately.
• with verification, staff must complete an MI/Change Routing cover sheet and fax it to the vendor at 1-877-236-4123. The system creates and routes the change task appropriately.

 

Revision 10-2; Effective April 1, 2010

Centralized Benefit Services staff follow change processing procedures and time frames in B-631, Actions on Changes, under All Programs.

Revision 12-3; Effective July 1, 2012

Medicaid for Breast and Cervical Cancer (MBCC)-Presumptive or MBCC applicants/recipients receiving a notice of adverse action are entitled to continued benefits if the recipient requests them and appeals the decision within the advance adverse action time frame.

All renewal denials must receive advance notice of adverse action.

Refer to B-1000, Fair Hearings, for specific appeals policy and procedures.

Revision 12-3; Effective July 1, 2012

Medicaid for Breast and Cervical Cancer (MBCC)-Presumptive or MBCC follows policy in B-1200, Confidentiality, for confidentiality policy and procedures.