Revision 18-1, Effective March 1, 2018
The Medicaid program provides medical benefits to groups of low-income people, some of whom may have no medical insurance or inadequate medical insurance. Medicaid is a jointly funded cooperative venture between the federal and state governments to assist states in providing adequate medical care to eligible needy persons.
Although the federal government establishes general guidelines for the program, the Medicaid program requirements are established by each state. States are required to include certain types of individuals or eligibility groups under their Medicaid plans and they may include others.
HHSC is responsible for determining eligibility for the MEPD Medicaid programs for persons who are aged, blind or disabled. Medicaid matching federal funding provides for medical care and supportive services (for example, vendor drugs, nursing facility and institutional care) to persons who qualify for Medicaid under one of the MEPD programs in this chapter.
HHSC administers long-term services and supports in the community. See Form 2121, Long Term Services and Supports, for more information.
For a list of HHSC’s type programs and types of assistance, refer to the TIERS Policy and Procedures Guide, Section A-6, Type Program Lists in the Texas Integrated Eligibility Redesign System (TIERS).
Revision 11-2; Effective June 1, 2011
(a) General. This section describes the groups of people who are categorically eligible for a Medicaid-funded program for the elderly and people with disabilities (MEPD) under the Texas State Plan for Medical Assistance.
(b) Mandatory coverage groups. In accordance with 42 CFR Part 435, Subpart B, the Texas Health and Human Services Commission (HHSC) determines eligibility for MEPD for a person who falls into at least one of the following mandatory coverage groups:
(1) Supplemental Security Income (SSI) eligible. In accordance with 42 CFR §435.120, this mandatory coverage group covers a person who is aged, blind, or disabled and is receiving SSI or deemed to be receiving SSI. The Social Security Administration (SSA) determines eligibility for SSI under Title XVI of the Social Security Act. If SSA determines that a person is eligible for SSI, HHSC accepts SSA's determination as an automatic determination of eligibility for Medicaid.
(2) Coverage for certain aliens. In accordance with 42 CFR §435.139, an alien, as defined in 42 CFR §435.406, is provided services necessary for the treatment of an emergency medical condition, as defined in 42 CFR §440.255.
(3) Disabled adult child. In accordance with §1634(c) of the Social Security Act (42 U.S.C. §1383c), this mandatory coverage group covers a person who:
(A) is at least 18 years of age;
(B) became disabled before 22 years of age;
(C) is denied SSI because of receipt of or an increase in Retirement, Survivors, and Disability Insurance (RSDI) disabled children's benefits received on or after July 1, 1987, and any subsequent increase; and
(D) meets current SSI criteria, excluding the RSDI benefit described in subparagraph (C) of this paragraph.
(4) Historical 1972 income disregard. In accordance with 42 CFR §435.134, this mandatory coverage group covers a person who:
(A) was receiving both public assistance and Social Security benefits in August 1972; and
(B) meets current SSI eligibility criteria, excluding from income the October 1972 cost-of-living adjustment (COLA) increase in Social Security benefits but not excluding subsequent COLA increases in Social Security benefits.
(5) Title II COLA disregard (Pickle). In accordance with 42 CFR §435.135(a) - (b), this mandatory coverage group covers a person who:
(A) has been denied SSI for any reason since April 1977; and
(B) meets current SSI eligibility criteria, excluding from countable income any Social Security COLA increases received after the person last received both SSI and Social Security benefits in the same month.
(6) Disabled widow's or widower's COLA disregard. In accordance with 42 CFR §435.137, this mandatory coverage group covers a person who:
(A) is 50 to 60 years of age;
(B) is ineligible for Medicare;
(C) was denied SSI due to an increase in a disabled widow's or widower's and surviving divorced spouse's RSDI; and
(D) meets SSI eligibility criteria, excluding from countable income the RSDI benefit and any subsequent COLA increases in RSDI.
(7) Early age widow's or widower's COLA disregard. In accordance with 42 CFR §435.138, this mandatory coverage group covers a disabled person who was denied SSI due to early receipt of Social Security widow's or widower's benefits and:
(A) is at least 60 years of age;
(B) is not eligible for Medicare; and
(C) meets current SSI eligibility criteria, excluding from countable income the RSDI benefit and any subsequent COLA increases in RSDI.
(8) SSI denied children. In accordance with §1902(a)(10)(A)(i)(II) of the Social Security Act (42 U.S.C. §1396a(a)(10)(A)(i)(II)), this mandatory coverage group covers a person who:
(A) is under 18 years of age;
(B) was receiving SSI on August 22, 1996;
(C) was subsequently denied SSI because of the change in disability criteria implemented by the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (Public Law 104-193); and
(D) meets SSI eligibility criteria, including the disability criteria in effect before August 22, 1996.
(c) Optional coverage groups. In accordance with 42 CFR Part 435, Subpart C, HHSC determines Medicaid eligibility for MEPD for a person who falls into an optional coverage group described in this subsection. Although federal regulations may allow other optional coverage groups, HHSC does not provide benefits to a member of an optional coverage group unless the group is included in the Texas State Plan for Medical Assistance.
(1) Institutional. In accordance with 42 CFR §435.211, this optional coverage group covers a person who would be eligible for SSI, as specified in 42 CFR §435.230, if the person were not in an institutional setting.
(2) Institutional special income limit. In accordance with 42 CFR §435.236, this optional coverage group covers a person who has lived in an institutional setting for at least 30 consecutive days, as described in §358.433 of this chapter (relating to Special Income Limit), and is eligible under the special income limit.
(3) §1915(c) waiver program. In accordance with 42 CFR §435.217, this optional coverage group covers a person who would be eligible for Medicaid if institutionalized, but is living in the community and receiving services under a §1915(c) waiver program.
(d) Other. In accordance with the Texas State Plan for Medical Assistance, HHSC determines Medicaid eligibility for MEPD for a person who meets the criteria for one of the following services:
(1) Primary home care services. This is a person who needs primary home care services and meets the criteria established in §1929(b)(2)(B) of the Social Security Act (42 U.S.C. §1396t(b)(2)(B)) but is not otherwise eligible for Medicaid.
(2) Program of All-Inclusive Care for the Elderly (PACE). In accordance with 42 CFR Part 460, this is a person who is enrolled in a PACE program under a PACE program agreement.
(3) Susan Walker v. Bayer Corporation services. A person who has received payments from the class action settlement of Susan Walker v. Bayer Corporation may be eligible for Medicaid as a result of excluding from countable resources the payments from the settlement.
(e) Retroactive coverage. In accordance with 42 CFR §435.914, HHSC may determine eligibility for retroactive coverage:
(1) for up to three months before the date of application for:
(A) an applicant;
(B) a person who has been denied SSI;
(C) a deceased person, if a representative for the deceased person requests that HHSC determine eligibility for retroactive coverage; and
(D) a person eligible under the SSI-denied-children coverage group in subsection (b)(8) of this section; and
(2) for up to two months before the month in which an SSI recipient's Medicaid coverage automatically begins.
(f) Medicare Savings Program. In accordance with 42 U.S.C. §1396a(a)(10)(E) for this mandatory coverage group, HHSC may determine eligibility for a person who meets the criteria in Chapter 359 of this title (relating to Medicare Savings Program) for a Medicare Savings Program, which uses Medicaid funds to help the person pay for all or some of the person's out-of-pocket Medicare expenses, such as premiums, deductibles, or coinsurance.
(g) Medicaid Buy-In Program. In accordance with §1902(a)(10)A)(ii)(XIII) of the Social Security Act (42 U.S.C. §1396a(a)(10)(A)(ii)(XIII)) for this optional coverage group, HHSC may determine eligibility for a person with a disability who is working and earning income and meets the criteria established in Chapter 360 of this title (relating to Medicaid Buy-In Program).
(h) Medicaid Buy-In for Children. In accordance with §1902(cc) of the Social Security Act (42 U.S.C. §1396a(cc)) for this optional coverage group, HHSC may determine eligibility for a child with a disability who meets the criteria established in Chapter 361 of this title (relating to Medicaid Buy-In for Children Program).
Revision 13-4; Effective December 1, 2013
HHSC determines eligibility for MEPD for a person who falls into at least one of the following mandatory coverage groups:
Revision 11-4; Effective December 1, 2011
The Social Security Administration (SSA) administers the SSI program. Texas entered into an agreement with SSA under Section 1634 of the Social Security Act for SSA to make Medicaid eligibility determinations. Persons found eligible for SSI cash payment are automatically determined eligible for Medicaid. SSA notifies the state through a computer network called the State Data Exchange System (SDX). HHSC sends a Your Texas Benefits Medicaid card to the person based on the computer file information from SSA. Either SSA or the state in which a person resides determines eligibility for SSI. Medicaid is administered by each state in which a person resides. See the following items for residence related issues and eligibility for Medicaid services.
Section D-3600, Interstate Issues
Section D-3610, Interstate Requests for Assistance
Section D-3620, Out-of-State Medicaid and Texas Medicaid Recipients
Section D-3630, Texas Applicant Outside the State of Texas
Section D-3640, Applicant from Another State
Section D-3650, Out-of-State Recipient Visiting Texas
Section D-3660, SSI Recipient Visiting in Texas
Note:
Automated System Program Identifier
TIERS – ME-SSI
Revision 12-3; Effective September 1, 2012
Certain aliens with an emergency medical condition who meet all SSI criteria, except citizenship, may be eligible for Medicaid coverage for the medical emergency. Coverage is for the duration of the emergency period. It is not considered as a "prior" medical, though prior months may be covered.
Automated System Program Identifier
TIERS – ME-A and D Emergency
Revision 09-4; Effective December 1, 2009
Medicaid eligibility for the aged, blind and disabled is directly related to receipt of SSI in most states. Loss of SSI payments can result in loss of Medicaid coverage. To preserve Medicaid coverage for certain groups of persons who lose SSI payments, Congress enacted special Medicaid continuation provisions. Persons denied SSI due to certain increases in Social Security benefits may continue to be eligible for Medicaid coverage. SSA informs HHSC through automated files to help locate potential eligible persons who may apply for continued Medicaid.
Revision 11-4; Effective December 1, 2011
This applies to persons denied SSI after July 1, 1987, and who meet SSI eligibility criteria when qualifying RSDI disabled adult children's benefits are excluded from countable income (OBRA 1986). These persons were denied SSI benefits because of an increase in or receipt of RSDI disabled children's benefits. These persons may continue to be eligible for Medicaid if they:
Automated System Program Identifier
TIERS – ME-Disabled Adult Child
Note: Based on SSA information, adult disabled child benefits generally end if the person gets married. There are exceptions such as marriage to another adult disabled child. This is an SSA requirement and not part of MEPD policy.
Revision 11-4; Effective December 1, 2011
This applies to persons who were receiving both public assistance and Social Security benefits in August 1972. These persons must meet current SSI or MEPD eligibility criteria, with the exclusion from income of the amount of the October 1972, 20% Social Security cost of living adjustment (COLA) increase.
Automated System Program Identifier
TIERS – ME-Pickle
Revision 11-4; Effective December 1, 2011
This applies to persons denied SSI cash benefits for any reason since April 1977. They must meet all current SSI eligibility criteria, with the exclusion of any Social Security COLA increases received since they were eligible for and entitled to both SSI and Social Security benefits in the same month. The earliest COLA increase that can be excluded is the increase received in July 1977. There are two files received from SSA for Title II COLA denials. The 503 file identifies "Pickle" potentials and is received late November of each year. The Lynch vs. Rank file is usually received mid-December.
Automated System Program Identifier
TIERS – ME-Pickle
Revision 11-4; Effective December 1, 2011
This applies to persons age 60 to 65 who are ineligible for Medicare and who are denied SSI due to excess widow/widower's RSDI benefits. They must meet SSI eligibility criteria, with the exclusion of their RSDI benefit and any subsequent COLA increases from countable income (OBRA 1987).
Automated System Program Identifier
TIERS – ME-Early Age Widow(er)
This applies to persons age 50 to 60 who are ineligible for Medicare and who are denied SSI due to excess disabled widow/widower's and surviving divorced spouse's RSDI benefits. They must meet SSI eligibility criteria, with the exclusion of their RSDI benefit and any subsequent COLA increases from countable income (OBRA 1990).
Historically this also applies to persons denied SSI due to a recomputation of their Social Security disabled widows/widowers benefits for January 1984. They must meet SSI eligibility criteria, with the exclusion of the recomputation increase and any subsequent Social Security COLA increases from countable income. Persons had to have filed an application before July 1, 1998, to be eligible under this program. Enrollment for this program ended June 30, 1998 (OBRA 1985).
Automated System Program Identifier
TIERS – ME-Disabled Widow(er)
Revision 13-4; Effective December 1, 2013
Note: This program is retired.
This program continues Medicaid benefits for children who were receiving SSI and were denied on or after July 1, 1997, because of the change in disability criteria. To be eligible for SSI Denied Children, the person must continue to meet all SSI criteria, including the disability criteria in effect before Aug. 22, 1996, and must be under age 18. SSA informs HHSC through automated files to assist with continued Medicaid for these persons (Public Law 104-193).
Automated System Program Identifier
TIERS – ME-SSI Denied Children
Revision 18-1; Effective March 1, 2018
HHSC also determines Medicaid eligibility for MEPD for persons who fall into an optional coverage group. Although federal regulations may allow other optional coverage groups, HHSC only provides benefits to a member of an optional coverage group if the group is included in the Texas Medicaid State Plan.
Revision 09-4; Effective December 1, 2009
This optional coverage group covers a person who would be eligible for SSI, if the person were not in an institutional setting.
Revision 16-1; Effective March 1, 2016
The special income limit applies to persons who will reside in a Medicaid-approved long-term care facility or who apply for certain Home and Community-Based Services (HCBS) waiver programs. Countable income must be equal to or less than the special income limit established by HHSC (see Appendix XXXI, Budget Reference Chart). A person must live in one or more Medicaid-certified long-term facilities at least 30 consecutive days to be eligible under the special income limit. The following are included in this group:
Automated System Program Identifier
TIERS – ME-Nursing Facility; ME-State School; ME-Non-State Group Home; ME-State Group Home; ME-State Hospital; ME-Waivers
Revision 16-1; Effective March 1, 2016
Home and Community-Based Services (HCBS) waiver programs may have limited enrollment and are an alternative to institutionalization. A person can enroll in only one HCBS waiver at a time, but may be on the interest list for multiple HCBS waivers. Persons applying for certain HCBS waiver programs who are not already Medicaid eligible under another coverage group covered by the waiver and who meet the waiver eligibility criteria may be Medicaid eligible using the special income limit.
For additional information about HCBS waiver programs, including interest lists, go to http://hhs.texas.gov/services/disability/intellectual-or-developmental-disabilities-idd-long-term-care.
Descriptions for some of the Home and Community-Based Services waiver programs follow in this section.
Revision 16-1; Effective March 1, 2016
A person may be eligible for services through CLASS if the person:
Automated System Program Identifier
TIERS – ME-Waivers
Revision 16-1; Effective March 1, 2016
A person may be eligible for services through DBMD if the person:
Automated System Program Identifier
TIERS – ME-Waivers
Revision 16-1; Effective March 1, 2016
A person may be eligible for services through HCS if the person:
Automated System Program Identifier
TIERS – ME-Waivers
Revision 16-1; Effective March 1, 2016
A person may be eligible for services through YES if the person:
Note: This program is administered by the Department of State Health Services. For additional information, go to www.dshs.state.tx.us/mhsa/yes.
Automated System Program Identifier
TIERS – ME-Waivers
Revision 16-1; Effective March 1, 2016
A person may be eligible for services through MDCP if the person:
Automated System Program Identifier
TIERS – ME-Waivers
Revision 16-1; Effective March 1, 2016
Revision 18-1; Effective March 1, 2018
A person may be eligible for services through TxHmL if the person:
Eligibility is not determined using the special income limit.
Automated System Program Identifier
TIERS shows this as ME-Pickle, ME-Disabled Adult Child, etc. HHSC puts the person on TxHmL.
Revision 16-1; Effective March 1, 2016
The SPW provides for the managed care delivery of home and community-based Medicaid services in addition to all other services provided through STAR+PLUS.
Revision 16-1; Effective March 1, 2016
This program covers children with disabilities up to the age of 19 with family income up to 300 percent of the federal poverty level. A family may have to pay a monthly premium as a condition of eligibility. The MBIC program began Jan. 1, 2011. For more information, see Chapter N, Medicaid Buy-In for Children.
Automated System Program Identifier
TIERS – ME-MBIC
TA 88
Revision 16-1; Effective March 1, 2016
Texans with disabilities who work can apply for health insurance benefits even if their income exceeds traditional Medicaid limits. A person may have to pay a monthly premium as a condition of eligibility. For more information on the Medicaid Buy-In Program, see Chapter M, Medicaid Buy-In Program.
Automated System Program Identifier
TIERS – ME-MBI
TA 87
Revision 18-1; Effective March 1, 2018
HHSC also determines Medicaid eligibility for MEPD for a person who meets the criteria for one of the following services.
Revision 11-4; Effective December 1, 2011
Those who may be eligible for CAS services are persons who are not eligible under a Medicaid program and have a functional need for Medicaid Primary Home Care (PHC) services. The intent of the program is to delay or prevent the need for institutional care; therefore, countable income must be equal to or less than HHSC's special income limit. Eligible persons do not receive regular Medicaid benefits; they receive only PHC services. The program has its statutory basis in §1929(b) of the Social Security Act. This program historically was called Waiver Five and later 1929(b).
Automated System Program Identifier
TIERS – ME-Community Attendant and CC-CCAD-Community Attendant
Revision 18-1; Effective March 1, 2018
The PACE program serves the frail elderly and features a comprehensive service delivery system and integrated Medicare and Medicaid financing. Those who may be eligible for PACE services are persons age 55 and older with chronic medical problems and functional impairments who meet criteria for MN (only required for program entry) and are eligible for Medicaid (see §1905(a)(26) of the Social Security Act (enacted in Section 4802 of the Balanced Budget Act of 1997)).
Automated System Program Identifier
TIERS – ME-Waivers and CC-PACE
Revision 09-4; Effective December 1, 2009
Revision 12-4; Effective December 1, 2012
In addition to the creation of the SSI program, Public Law 92-603 extended Medicaid benefits to cover the three-month time period before the month an application is filed with the Social Security Administration for SSI, if unpaid or reimbursable medical bills are incurred during the prior months.
Medicaid coverage also is extended to cover the three-month time period before the month an application is filed with MEPD for an ongoing MEPD program. For example, if an individual applies for ME – Nursing Facility, the eligibility specialist explores three months prior coverage.
People are potentially eligible for coverage in the prior months, regardless of their eligibility for the month of application and ongoing is approved or denied.
Note: This provision does not provide prior coverage for an application for which no MEPD program is available.
For specific program coverage, see Section G-7100, Prior Coverage for SSI Applicants, Section G-7200, Prior Coverage for Medical Assistance Only (MAO) Applicants, Section G-7210, Prior Coverage for Deceased Applicants, and Section G-7300, Prior Coverage for Aliens.
Revision 11-4; Effective December 1, 2011
Public Law 104-193, Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA), Section 3502.4, changed policy for retroactive Medicaid coverage for persons found eligible for SSI. Effective July 1997, HHSC automatically adds Medicaid coverage for the month prior to the first month of SSI cash payment due (20 CFR §416.501). The person may apply with HHSC for coverage for the two preceding months if there are unpaid or reimbursable medical bills and the person meets all Medicaid eligibility requirements in those months.
Automated System Program Identifier
TIERS – ME-SSI Prior
Revision 12-4; Effective December 1, 2012
Medicaid coverage is extended to a deceased person, if a bona fide agent files an application with MEPD on behalf of a deceased person. The three-month time period is the three months prior to the month the application is received by MEPD.
Revision 18-1; Effective March 1, 2018
Persons eligible for full Medicaid benefits may elect to participate in the Texas Medicaid Hospice Program if they have a medical prognosis of six months or less to live. In order to enroll in the Texas Medicaid Hospice Program, the person or authorized representative signs and dates Form 3071, Individual Election/Cancellation/Update. This election remains in effect until another Form 3071 is completed canceling hospice election. Recipients electing hospice waive their rights to other Medicaid services related to treatment of the terminal illness(es). They do not waive their rights to Medicaid services that are not related to treatment of the terminal illness(es). Hospice services may be received at home, in a hospital or in a Medicaid-contracted long-term care facility.
Revision 11-4; Effective December 1, 2011
Persons residing in a community-based living arrangement, such as their home or a hospital, may elect to participate in the Texas Medicaid Hospice Program if they are eligible for full Medicaid benefits. This means that they qualify as an SSI recipient (ME-Temp Manual SSI or ME-SSI) or an MEPD recipient in the community (certified under ME-Pickle, ME-Disabled Adult Child or ME-Early Aged Widow(er)).
Persons whose only eligibility is MC-SLMB, MC-QMB and MC-QDWI may not participate in the Texas Medicaid Hospice Program because they receive only limited Medicaid coverage. However, they may be entitled to receive Medicare hospice services.
For a list of programs, see the TIERS Policy and Procedures Guide, Section A-6, Type Program Lists in the Texas Integrated Eligibility Redesign System (TIERS) in the Texas Works Handbook.
Revision 18-1; Effective March 1, 2018
A Medicaid recipient may elect to receive hospice services in a Medicaid-certified nursing facility (NF) or intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID). In order to receive Medicaid hospice services, the person must meet all eligibility criteria for MEPD in a long-term care facility, including confinement in one or more Medicaid-certified long-term care facilities for 30 consecutive days. Form 3071, Individual Election/Cancellation/Update, substitutes for the medical necessity determination when hospice is elected.
The hospice provider informs the eligibility specialist of the possibility of hospice election by a recipient. When the recipient (or authorized representative) signs and dates Form 3071, the hospice provider contacts the eligibility specialist, providing the effective date that the recipient is starting/electing hospice services. The hospice provider follows up this contact by sending Form 3071 to the contractor for Medicaid claims, with a copy to the eligibility specialist.
For Medicaid hospice residents in long-term care facilities, the hospice provider is responsible for collecting the applied income, and the nursing facility manages the patient trust fund. The hospice provider is responsible for completing Form 3071 in the event of any change in the hospice provider, cancellation of the hospice election, and death. There is normally no need for the eligibility specialist to take any action in response to any of these changes. The automated system receives this information through interfacing with the Service Authorization System Online (SASO) and communication with HHSC. If the eligibility worker becomes aware of the death of the recipient, manual denial of the case should be taken.
Revision 12-3; Effective September 1, 2012
Coverage for persons age 65 and older in IMDs is part of the Medicaid program. These persons must meet all eligibility criteria for institutional care. The medical necessity determination is met by a letter from the institution stating that in-patient care is necessary. The personal needs allowance is $60 for a person and $120 for a couple. There is no protected earned income allowance.
For TIERS, persons in IMDs (ME-State Hospital or ME-Non-State Group Home) receive a Your Texas Benefits Medicaid card. Although these cases are Title XIX community-based ICF/IID facilities and state hospitals, the co-payment is calculated as appropriate for institutional cases.
Revision 14-2; Effective June 1, 2014
Revision 11-4; Effective December 1, 2011
QMBs are entitled to Medicare Part A (either with or without payment of premiums) with income usually counted according to the SSI rules at or below the federal poverty guidelines. States determine QMB eligibility, and Medicaid pays all Medicare-related expenses for QMBs (premiums, deductibles and coinsurance). Many SSI beneficiaries meet the QMB eligibility factors. Persons may be eligible under both a Medicaid or Community Attendant Services program and the QMB program (Public Law 100-360). For more information on the QMB program, see Section Q-2000, Qualified Medicare Beneficiaries (QMB) – MC-QMB.
Automated System Program Identifier
TIERS – MC-QMB
Revision 13-4; Effective December 1, 2013
Persons eligible for this program do not receive regular Medicaid benefits. Medicaid will pay the Medicare Part B premiums for SLMB. The person must be entitled to enroll in Medicare Part A and must meet all of the eligibility requirements for QMB status, except for income less than 120 percent of the federal poverty level. Persons may be eligible under both a Medicaid or Community Attendant Services program and the SLMB program (see Section 4501(b) of the OBRA, 1990). For more information on the SLMB program, see Section Q-3000, Specified Low-Income Medicare Beneficiaries (SLMB) – MC-SLMB.
Automated System Program Identifier
TIERS – MC-SLMB
Note: For TIERS, the following programs cannot be dually eligible for SLMB: ME-Pickle; ME-SSI Prior; ME-Temp Manual SSI; ME-SSI; ME-Disabled Adult Child (DAC); MC-SLMB; MC-QMB; and ME-A and D Emergency. Even though ME-Pickle and ME-DAC recipients may meet SLMB eligibility requirements, the Medicare Part B premium is already paid by the state of Texas based on their prior SSI eligibility and the continuation of that Medicaid coverage. The only requirement to test for SLMB is if the Pickle or DAC eligibility will be denied.
Revision 14-2; Effective June 1, 2014
Persons eligible for this program do not receive regular Medicaid benefits. QIs must meet the eligibility criteria for the Qualified Medicare Beneficiary (QMB) Program, except the income limits are higher. Medicaid will pay the Medicare Part B premiums for QIs. These persons must be entitled to be enrolled in Medicare Part A and have countable income of at least 120 percent but less than 135 percent of the current federal poverty level. Eligibility is determined for each calendar year.QI recipients cannot be certified under any other Medicaid-funded program and receive QI benefits simultaneously (Public Law 105-33, Balanced Budget Act of 1997). For more information on the QI program, see Section Q-5000, Qualifying Individuals (QIs).
Automated System Program Identifier
TIERS – MC-QI-1
Note: Even though ME-Pickle and ME-Disabled Adult Child (DAC) recipients may meet QI-1 eligibility requirements, the Medicare Part B premium is already paid by the state of Texas through the Pickle or DAC Medicaid program eligibility. The only requirement to test for QI-1 is if the Pickle or DAC eligibility will be denied.
Revision 14-2; Effective June 1, 2014
Persons eligible for this program do not receive regular Medicaid benefits and must be disabled working individuals entitled to Medicare Part A (hospital coverage). Medicaid will pay the Medicare Part A premiums for QDWIs. These persons must be entitled to enroll in Medicare Part A, not otherwise certified under any other Medicaid-funded program, have countable income of no more than 200% of the federal poverty guidelines, have countable resources of no more than twice the SSI resource limit and be referred by SSA (Public Law 101-239, OBRA 1989). For more information on the QDWI program, see Section Q-6000, Qualified Disabled and Working Individuals (QDWI) – MC-QDWI.
Automated System Program Identifier
TIERS – MC-QDWI
Revision 18-1; Effective March 1, 2018
Medicare beneficiaries who have low incomes and limited resources may also receive help from the Medicaid program. For persons who are eligible for full Medicaid coverage, Medicare health coverage is supplemented by services that are available under the Medicaid program, according to eligibility category. For persons enrolled in both programs, any services that are covered by Medicare are paid for by the Medicare program before any payments are made by the Medicaid program, since Medicaid is always the "payer of last resort." Certain other Medicare beneficiaries may receive help with Medicare premium and cost-sharing payments through the Medicaid program.
Revision 18-1; Effective March 1, 2018
Medicare is a federal program under Title XVIII of the Social Security Act and is administered by the Social Security Administration (SSA). Medicare provides health care benefits for individuals age 65 or older, under age 65 with certain disabilities, and any age with permanent kidney failure (called end-stage renal disease).
Those younger than 65 will receive Medicare after getting Social Security disability benefits for at least two years.
There are exceptions to the two-year waiting period, including:
Medicare is available to an individual who has paid into the Medicare trust account through payroll taxes sometimes called the Federal Income Contributions Act (FICA). Most employers are required to withhold FICA taxes, but there are some exceptions. Federal government employees have been eligible to participate in Social Security only since 1984. As a result, some older employees have opted to remain with the former Civil Service Retirement System. Some state and local government employee retirement plans also are not covered by Social Security.
If an individual receives Medicare, they are either:
Medicare is divided into four parts:
In most cases, the Part B and Part D premiums are deducted from the Social Security or Railroad Retirement check. The recipient is responsible for calendar-year deductibles and co-pay liabilities for both Parts A and B.
The Part C premium is handled by the private company that offers the benefit as a Medicare Advantage Plan. The Medicare Advantage Plan has its own benefits and coverage that differs from the traditional Medicare benefits. Medicare pays a fixed amount every month to the companies offering Medicare Advantage Plans. These companies must follow rules set by Medicare. However, each Medicare Advantage Plan can charge different out-of-pocket costs and have different rules for how one gets services.
Extra help for Part D (Medicare Prescription Drug Coverage) is available for people with Medicare who have limited income and resources. If eligible for extra help, Medicare will pay for almost all prescription drug costs. Extra help provides a subsidy based on the amount of income and resources an individual has.
Full Subsidy Benefits from Extra Help:
Other Low Income Subsidy Benefits from Extra Help:
Individuals who have Medicare and Medicaid or who are eligible for the Medicare Savings Program (MSP) do not need to apply for extra help through the SSA.
Individuals can apply for extra help or get more information about extra help subsidy by calling Social Security at 800-772-1213 (TTY 800-325-0778) or visiting www.socialsecurity.gov.
Revision 11-4; Effective December 1, 2011
To ensure that Medicaid recipients who are entitled to Medicare receive maximum health care protection, the state pays for certain recipients' Medicare Part B premiums. This process is called buy-in. For those persons who have dual entitlement, Medicare becomes the payer of first resort, with Medicaid paying deductibles and co-insurance for Medicaid-covered services.
If recipients in ME-Nursing Facility, ME-State School, ME-Waivers and ME-Community Attendant are not eligible for QMB or SLMB, they are not eligible for buy-in.
Revision 11-4; Effective December 1, 2011
Recipients are eligible for buy-in if they are:
If recipients in ME-Nursing Facility, ME-State School, ME-Waivers and ME-Community Attendant are not eligible for QMB or SLMB, they are not eligible for buy-in.
Revision 13-4; Effective December 1, 2013
Persons who have Medicare Part B coverage at the time they are certified for Medicaid are enrolled as follows:
When a recipient is enrolled in buy-in, SSA stops charging for Part B premiums. Usually this occurs the month after SSA has acknowledged receiving the recipient's name as an addition to the buy-in rolls. If premiums have been withheld from the monthly benefit, the recipient's check should reflect an upward adjustment by the third month after the month of certification.
Address questions about the buy-in status of a recipient who has been certified for at least three months to:
CCC_Data_Integrity_Program@hhsc.state.tx.us
Revision 09-4; Effective December 1, 2009
This chapter contains processes for applications and redeterminations for all MEPD coverage groups.
See Chapter A, General Information and MEPD Groups, for descriptions.
Revision 09-4; Effective December 1, 2009
(a) The Texas Health and Human Services Commission (HHSC) gives anyone the opportunity to apply for a Medicaid-funded program for the elderly and people with disabilities (MEPD), in accordance with 42 CFR §435.906. A person can apply for MEPD by submitting:
(1) an application for assistance to HHSC; or
(2) an application for Supplemental Security Income (SSI) to the Social Security Administration.
(b) Under the application submittal process described in subsection (a)(1) of this section, a person must follow the requirements in §358.515 of this subchapter (relating to Application Requirements) to obtain an eligibility determination from HHSC.
(c) In accordance with 42 CFR §435.120 and §435.909(b)(1), an application for SSI as described in subsection (a)(2) of this section serves as an application for MEPD. A person receiving or deemed to be receiving SSI derives eligibility for MEPD from the person's SSI eligibility and does not require an eligibility determination from HHSC.
In accordance with 42 CFR §435.908, an authorized representative may accompany, assist, and represent an applicant or recipient in the application or eligibility redetermination process.
(a) To apply for a Medicaid-funded program for the elderly and people with disabilities (MEPD) under the application submittal process described in §358.505(a)(1) and (b) of this subchapter (relating to Application Process Overview), and in accordance with 42 CFR §435.907, an applicant, authorized representative, or someone acting responsibly for the applicant (if the applicant is incompetent or incapacitated) must:
(1) use the application prescribed by the Texas Health and Human Services Commission (HHSC) and complete it according to HHSC instructions:
(A) in writing, using a paper application obtained via telephone, Internet request, or other means;
(B) online, using the application process available over the Internet;
(C) over the telephone, through the State's toll-free telephone number; or
(D) in person, by visiting an HHSC benefits office;
(2) provide all requested information according to HHSC instructions; and
(3) sign the application for assistance under penalty of perjury.
(b) If someone helps an applicant or authorized representative complete the application for assistance, the name of the person completing the form must appear as requested on the application.
(c) If HHSC sends an applicant or authorized representative a request for missing information or verification documents, or both, the applicant or authorized representative must provide the requested information to HHSC by the due date given in the request, or eligibility may be denied.
(a) The date of application is the date on which:
(1)the Texas Health and Human Services Commission receives an application for assistance in accordance with subsection (c) of this section; or
(2) an application for Supplemental Security Income is filed with the Social Security Administration.
(b) If an application for assistance is received after the close of business, the date of application is the next working day.
(c) For purposes of determining the date of application for an application for assistance received under subsection (a)(1) of this section:
(1) an application received via fax or mail must contain, at a minimum, the applicant's name, address, and valid signature; and
(2) an application received via telephone or the Internet:
(A) must contain, at a minimum, the applicant's name and address; and
(B) the applicant must provide a valid signature within 45 days after the date of application.
An application for assistance remains valid for 90 days after a date of denial, if the Texas Health and Human Services Commission denies eligibility. An applicant may use his or her previously completed application to reapply during the 90-day period, in accordance with HHSC instructions.
(a) Time frame for determination. After an applicant or authorized representative provides all information and verification documents requested, the Texas Health and Human Services Commission (HHSC) makes an eligibility determination within the following time frames, in accordance with 42 CFR §435.911:
(1) by the 90th day after the date of application if the applicant is applying on the basis of a disability;
(2) by the 45th day after the date of application for all other applicants; or
(3) beyond the time frames established in paragraphs (1) and (2) of this subsection under unusual circumstances, such as those set forth in 42 CFR §435.911.
(b) Basis for determination. HHSC decides whether an applicant meets the eligibility criteria for a Medicaid-funded program for the elderly and people with disabilities based on:
(1) a complete, signed, and dated application for assistance;
(2) information obtained from an interview, if an interview occurred; and
(3) required verification documents.
(a) In accordance with 42 CFR §435.916, the Texas Health and Human Services Commission (HHSC) redetermines a person's eligibility for a Medicaid-funded program for the elderly and people with disabilities (MEPD):
(1) at least every 12 months;
(2) after HHSC receives information about a change in the person's circumstances, such as living arrangement, income, or resources, that may affect MEPD eligibility; and
(3) at the appropriate time based on an anticipated change in the person's circumstances.
(b) If the result of an eligibility redetermination causes an adverse action, HHSC:
(1) gives timely and adequate notice of the proposed action to terminate, discontinue, or suspend MEPD eligibility;
(2) gives timely and adequate notice to reduce or discontinue MEPD services; and
(3) informs the person of the right to request a hearing to appeal the adverse action in accordance with 42 CFR Part 431, Subpart E and HHSC's fair hearing rules in Chapter 357 of this title (relating to Hearings).
Revision 18-1; Effective March 1, 2018
Revision 09-4; Effective December 1, 2009
HHSC staff are mandated to report abuse or neglect that threatens the health or welfare of a child or an elderly or disabled adult. Staff must report instances of:
Report such instances to the Department of Family and Protective Services. The toll-free number to report abuse is 1-800-252-5400.
For reports of domestic violence, abuse or neglect of adults, inform the person or his or her authorized representative of the report unless you believe informing them would place the person at risk of serious harm.
Revision 09-4; Effective December 1, 2009
An eligibility specialist has an obligation to avoid even the appearance of impropriety or conflict of interest when determining Medicaid eligibility. The eligibility specialist must not work on or review an ongoing case nor assist an applicant or recipient to receive benefits if the applicant or recipient is a relative (by blood or marriage), roommate, dating companion, supervisor or someone under the specialist's supervision. The specialist may not determine their eligibility for Medicaid. The specialist may provide anyone with an application for Medicaid and may inform anyone how and where to apply. The specialist may help anyone gather documents to verify eligibility and need for Medicaid, but must not take any other role in determining eligibility.
The specialist must consult with the supervisor if the applicant or recipient is a friend or acquaintance. Generally, the specialist should not work on cases or applications involving these individuals, but the degree and nature of the relationship should be taken into account.
Revision 09-4; Effective December 1, 2009
Verify all eligibility factors according to the verification and documentation requirements for each factor.
Document all factors of eligibility in the case record to substantiate the decisions made on all applications and redeterminations before certifying, recertifying, denying or taking any other action on a person's eligibility and/or co-payment.
Revision 11-4; Effective December 1, 2011
Documentation standards are contained in this handbook. Specific documentation and verification standards can be found in Appendix XVI, Documentation and Verification Guide. Appendix XVI provides documentation expectations and suggested sources for obtaining information that have proven to result in quality, accurate cases.
When supervisor approval is suggested, written or documented, verbal contact is acceptable. Requirements for documenting telephone contacts are contained in Appendix XVI.
Documentation standards include the date and name/signature of the MEPD eligibility specialist on all recording documents and case actions.
See Section B-8440, Streamlining Methods.
Revision 09-4; Effective December 1, 2009
Explaining policy is appropriate. The law requires that Medicaid rules, policies and procedures be freely available to the public. The rules governing MEPD are contained in the Texas Administrative Code (TAC), Title 1, Part 15, Chapters 358, 359 and 360. This handbook also contains the MEPD rules, as well as policies, procedures and examples. Both the TAC and MEPD Handbook are available online. MEPD eligibility specialists act properly in explaining the rule or policy that applies to an applicant's or recipient’s situation, and in referencing the applicable rule or handbook sections.
Giving advice is contrary to HHSC policy. Giving advice includes suggesting options for how to become eligible or how to avoid Medicaid estate recovery, as well as expressing any opinion of what is preferable or more advantageous to the applicant or recipient. Giving advice is contrary to HHSC policy because it:
The approach taken by MEPD eligibility specialists should be to explain policy but not to make recommendations. If an MEPD eligibility specialist is asked for advice, an appropriate response would be to provide the policy that applies to the situation, and to otherwise decline the request. The MEPD eligibility specialist should explain that agency policy prohibits giving advice, and may suggest that the applicant or recipient seek the assistance of an attorney or other estate planning professional of their own choosing.
See Appendix XVI, Documentation and Verification Guide, and Appendix XXXVI, Qualified Income Trusts (QITs) and Medicaid for the Elderly and People with Disabilities (MEPD).
If an applicant is income ineligible in an institutional living arrangement, Appendix XXXVI may be shared with applicants and their representatives to assist them in understanding the purpose of and requirements for a QIT.
To prevent allegations that MEPD staff are engaging in the unauthorized practice of law, the following instructions are provided. Use the instructions on the chart regarding the appropriate actions to take and the actions to avoid.
| May | May Not |
|---|---|
| Provide applicants or their representatives with a copy of Appendix XXXVI for informational purposes only. | Tell applicants or their representatives that they need a QIT. |
| Provide applicants or their representatives with applicable policy and procedures. | Recommend specific actions applicants or their representatives should take to become eligible for Medicaid. |
Refer applicants or their representatives to the following allowable referral list:
|
Tell applicants or their representatives whether or not they must have an attorney to establish a QIT.
Recommend that an applicant or representative consult with a specific attorney or organization. (See allowable referral list.) |
| Speak with their supervisor or regional services attorney about any questions they have regarding the use of Appendix XXXVI. | Recommend that an applicant or representative call an HHSC attorney for legal advice. |
See Appendix XVI, Documentation and Verification Guide.
If excess resources can be designated as burial funds, allow the individual the opportunity to do so. See Section F-4227, Burial Funds.
If a person is determined ineligible because of excess funds in a joint account, allow an opportunity to disprove the presumed ownership of all or part of the funds. The person also must be allowed to disprove ownership of joint accounts that currently do not affect eligibility but may in the future. See Section F-4121, Joint Bank Accounts.
Revision 18-1; Effective March 1, 2018
Medicaid Estate Recovery Program (MERP) is not part of the eligibility determination process for Medicaid.
MERP recovers from a Medicaid recipient’s estate the cost of Medicaid assistance paid for an individual who:
1) was age 55 or older at the time Medicaid services were received; and
2) initially applied for certain types of long-term care (LTC) services on or after March 1, 2005.
Individuals whose estate may be subject to MERP recovery include:
Individuals applying for or receiving these LTC services must be informed about MERP.
A signed Form 8001, Medicaid Estate Recovery Program Receipt Acknowledgement, or documentation the Form 8001 was provided, must be in the case record of each applicant whose estate is subject to MERP recovery.
Revision 18-1; Effective March 1, 2018
On March 1, 2005, Texas implemented MERP in compliance with federal Medicaid and state laws. The program is managed by HHSC. Under this program, the state may file a claim against the estate of a deceased Medicaid recipient who: 1) was age 55 or older when Medicaid services were received; and 2) first applied for certain long-term care services and supports on or after March 1, 2005. The most complete, current and accurate source of information regarding MERP is the HHS website: Medicaid Estate Recovery Program. MERP Claims include the cost of Medicaid assistance paid for the following services:
Notes:
Revision 18-1; Effective March 1, 2018
HHSC staff must inform anyone requesting Medicaid assistance for long-term services and supports that may be subject to MERP recovery. Complete the following to document this requirement:
If a Form H1746-A, MEPD Referral Cover Sheet, has a mark in the box "MERP shared," do not send MERP notifications to the individual. The agency making the referral has shared MERP information with the individual.
The MERP notification requirement applies to any individual, age 55 or older, who is applying for Medicaid assistance for long-term care services and supports that are subject to MERP on or after March 1, 2005, either through an application or program transfer. Individuals transferring to long-term care services and supports subject to MERP must have documentation of Form 8001 in the case record. If there is no documentation in the case record, send Form 8001 and follow documentation guidelines outlined in this section.
Example: Mr. Andy Allen applied for a Medicare Savings Program (MSP) before Nov. 1, 2004, and was certified, but did not receive Form 8001 since Mr. Allen was on an MSP before March 1, 2005. Mr. Allen entered a nursing facility this month and requested a program transfer. Based on Section B-7450, Medicaid Certified Person Enters Nursing Facility or Home and Community-Based Services Waiver Program, the program transfer is complete, and Form 8001 is sent to Mr. Allen. Staff document in case comments the date the Form H8001 was mailed.
Revision 14-4; Effective December 1, 2014
Revision 14-4; Effective December 1, 2014
For Medicaid for the Elderly and People with Disabilities (MEPD), the application for assistance is based on one of the following versions of Form H1200:
If requested, give the applicant a receipt (Form H1800, Receipt for Application/Medicaid Report/Verification/Report of Change) to verify the applicant provided an application. An applicant may request Form H1800 by fax or mail. Mail the receipt to the applicant’s listed address.
The United States Postal Service (USPS) is phasing out the use of rural route addresses as a result of local 9-1-1 systems that are converting business and residential rural route addresses to street-style addresses. Ask household members for an updated address if they have a rural route address. A rural route address may contain any of the following to denote a rural route:
If the household members state they do not have a new address, continue to use the address provided. Take no action if the street-style address is not provided, but ask the household members to report if USPS notifies them of a new address.
Revision 09-4; Effective December 1, 2009
Federal law requires that anyone who wishes to apply for a Medicaid program be allowed to file an application without delay, regardless of the person's ultimate eligibility for assistance.
An application form must be mailed within two working days from the receipt of the request for an application.
Use an application form to test eligibility for all Medicaid programs for which a person meets the criteria. A separate application form is not required for each of the different Medicaid programs for the elderly and persons with disabilities.
Consider the application complete with a name, address and signature.
Revision 16-3; Effective September 1, 2016
An individual who may complete or sign an application for an applicant may possibly not be on the list of individuals to whom the Texas Health and Human Services Commission (HHSC) can release the applicant’s individually identifiable health information. See Section C-5000, Personal Representatives, for individuals who may receive or authorize the release of an applicant's individually identifiable health information under Health Insurance Portability and Accountability Act (HIPAA) privacy regulations.
An authorized representative may accompany, assist and represent an applicant or recipient in the application or eligibility redetermination process.
Anyone may assist the applicant, guardian, power of attorney or authorized representative in completing an application form. If someone helps complete the application for assistance, the name of the individual completing the form must appear as requested on the application.
See Section B-3220, Who May Sign an Application for Assistance, to determine who may sign an application for assistance form. The requirements for signing a redetermination form are the same as the requirements for signing an application.
See Section C-1100, Responsibility of Applying.
Most applicants in an institutional setting such as a nursing facility are signed into the facility by someone else. An application and information from the applicant and/or the individual(s) having knowledge of the applicant's fina al circumstances are required.
Revision 16-3; Effective September 1, 2016
An individual who may complete or sign an application for an applicant may not be on the list of people to whom HHSC can release the applicant’s individually identifiable health information. See Section C-5000, Personal Representatives, for individuals who may receive or authorize the release of an applicant’s individually identifiable health information under HIPAA privacy regulations.
An applicant, authorized representative or someone acting responsibly for the applicant (if the applicant is incompetent or incapacitated) may sign an application for assistance. The application for assistance must be signed under penalty of perjury.
If an applicant has a guardian, the guardian must:
If an application is signed by someone other than the applicant or the applicant’s guardian, power of attorney, family member, or a friend who is knowledgeable of the applicant’s finances, the individual must provide a Form H1003, Appointment of an Authorized Representative, signed by the applicant, or evidence of:
If an applicant makes an "X" on the signature line for applicant/recipient, a witness must sign on the witness signature line.
Revision 13-3; Effective September 1, 2013
A valid signature on the application is required. Effective Jan. 20, 2006, a faxed "signed" signature is acceptable. Unsigned applications that are not data entered are returned to the applicant for signature and the file date is not protected.
Exceptions:
If an unsigned application is received via fax or mail and is not identified as such before data entry and the data entry date is more than one business day after the receipt date of the application, the date of application is protected and is the receipt date of the application. The missing signature is treated as missing information. Use the following time frames:
In the following situations, notify the applicant of the requirement for a signature and treat the signature as missing information. Allow the applicant until the final due date to provide the signature.
See Section B-6400, Processing Deadlines, related to the final eligibility determination due date.
Revision 11-4; Effective December 1, 2011
An authorized representative or bona fide agent is a person who is familiar with the applicant and knowledgeable of the applicant’s financial affairs.
An authorized representative may accompany, assist and represent an applicant or recipient in the application or eligibility redetermination process.
Form H1003, Appointment of an Authorized Representative, allows the applicant/recipient to assign an authorized representative.
Revision 10-3; Effective September 1, 2010
If an applicant or authorized representative contacts HHSC to initiate an application and appears to be eligible for SSI, refer the person or authorized representative to the Social Security Administration. If the person or authorized representative wishes to file an application with HHSC, give the person or authorized representative the appropriate form letter, an application for assistance and Form H0025, HHSC Application for Voter Registration.
Explain that eligibility is determined on the basis of:
When eligibility is based on the special income limit, finalization of the person's eligibility cannot be processed or disposed in the system of record until the 30 days in an institutional setting have been met. A determination that a person requires the services of a licensed nurse in an institutional setting to carry out a physician's planned regimen for total care is also required.
See Section B-6300, Institutional Living Arrangement. Use the special income limit for the month of entry to the Medicaid-certified facility (Medicare-SNF, NF or ICF/MR) if it is anticipated that the person will remain in a Medicaid-certified facility for at least 30 days. The person cannot be determined eligible based on the special income limit until the 30 consecutive days have been met.
See Section J-4000, Assessment and SPRA. When determining the 30-day stay requirement, consider both the days in a medical facility and the days in the Home and Community-Based Services waiver setting.
See Section C-7000, National Voter Registration Act of 1993, for information regarding voter registration.
Note: Explain the availability and benefits of Texas Health Steps (formerly EPSDT) programs for applications for children under age 21.
Revision 17-4; Effective December 1, 2017
The file date of an application is the date the Texas Health and Human Services Commission (HHSC) receives an application form containing the applicant’s name, address and appropriate signature. This is day zero in the application process.
For electronically filed applications, the file date is the date the applicant clicks the “Submit Application” button in YourTexasBenefits.com.
For applications received after the close of business for the day, or on days when HHSC is closed (including weekends and holidays), the file date is the next business day.
If an application is denied in error, the original file date of the application must be protected no matter how old the application for assistance.
Within 10 calendar days from receipt of an application, send Form H1236, Notification of Receipt of Application, to the nursing facility or ICF/IID where a person resides or intends to reside. If requested, provide the applicant a receipt (Form H1800, Receipt for Application/Medicaid Report/Verification/Report of Change) to verify an application was received. An applicant may request Form H1800 by fax or mail. Mail the receipt to the applicant’s listed address.
Revision 15-4; Effective December 1, 2015
A previously completed application for assistance may be used in the following situations:
See Section B-6400, Processing Deadlines, for application due dates.
Revision 18-3; Effective September 1, 2018
As a result of the initiative to integrate application and eligibility determination processes, a face-to-face interview or a telephone interview is not required in determining eligibility for Medicaid programs within this handbook.
At the request of the person or the person's authorized representative, conduct a face-to-face interview or an interview by telephone based on the request. Form H1246, Medicaid Eligibility Interview Guide, is optional for staff to use to record information during the interview.
Information to consider for the case documentation:
Interviews are not required for Medicaid applicants or recipients. If an appointment is scheduled and the person does not keep the appointment, do not deny based on the missed appointment.
If a person does not report a bank account, trust fund or similar account on Form H1200, Application for Assistance – Your Texas Benefits, or other application for assistance, ask the person or the authorized representative to explain how the person's financial affairs are handled. This includes determining who:
If the person reveals previously unreported liquid resources, request verification to determine the value, ownership and accessibility according to the requirements for the resource involved.
Sources for verifying financial management are as follows:
Use Appendix XVI, Documentation and Verification Guide, for sources of needed verifications.
Include the following information in the case record documentation:
Note: If the person's bank account is dormant, financial management must be verified and documented. For applications, explore financial management if there has been no activity in a reported account during the month of application and the month before.
Determine the first day the applicant’s eligibility can be established under the special income limit. Form 3618, Resident Transaction Notice; Form 3619, Medicare/SNF Patient Transaction Notice; and Form H0090-I, Notice of Admission, Departure, Readmission or Death of an Applicant/Recipient of Supplemental Security Income and/or Assistance Only in a State Institution, are adequate verification of dates of admission to a Medicaid facility. In absence of the above-listed forms, eligibility staff may contact the administrator, bookkeeper or office manager for the date of admission.
See Section G-6000, Institutional Eligibility Budget Types. The 30-day requirement begins with confinement to one or more Medicaid-certified facilities (Medicare-SNF, NF or ICF/IID) for at least 30 consecutive days.
Eligibility under the special income limit cannot be processed or disposed in the system of record until the 30 consecutive days in an institutional setting have been met.
The date of entry to an institution is day zero. For the institution to be paid, the individual must stay overnight. This is due to the days being defined on a 24-hours basis – midnight to midnight which is explained in the DADS nursing facility requirements and licensure handbooks.
Example 1: Individual entered the nursing facility on March 27. He stayed there for 30 consecutive days – not going home, to the hospital or to another nursing facility. The earliest the specialist can certify the case is the 31st day, which is April 27.
Example 2: Individual entered the hospital on Feb. 10 and entered the nursing facility on Feb. 19. He stayed there for 30 consecutive days – not going home, to the hospital or to another nursing facility. The start of the 30 consecutive days started on Feb. 19, not Feb. 10. The earliest the specialist can certify the case is the 31st day, which is March 22.
Example 3: Individual entered the nursing facility on March 1. He went to the hospital on March 5. He returned to the nursing facility on March 10. The 30 consecutive days started on March 1 and was not interrupted by the hospital stay. The earliest the specialist can certify the case is the 31st day, which is April 1.
Example 4: Individual entered the nursing facility on May 10. The 31st day is June 10. He went home on June 1. He did not stay the required 30 consecutive days. The specialist cannot certify the case.
Example 5: Individual entered the nursing facility on April 20. The 31st day is May 21. He died on May 10. He did not stay the required 30 consecutive days; however, the specialist can certify the case if the individual meets all other eligibility requirements.
Example 6: Mr. Smith entered the hospital on Feb. 15 and then went to the nursing home on March 10. His wife continues to live in their home in the community. The 30 consecutive days starts on March 10, not Feb. 15. The earliest the specialist can certify the case is the 31st day, which is April 10th.
Note: The hospital stay in February is start date for the continuous period in an institution for the spousal resource assessment – which is different than the 30 consecutive day’s requirement.
See Chapter J, Spousal Impoverishment, regarding the resource assessment and spousal protected resource amount (SPRA). When determining the 30-day stay requirement, consider both the days in a medical facility and the days in the Home and Community-Based Services waiver setting.
Use the special income limit for the month of entry to a Medicaid-certified long-term care facility (Medicare-SNF, NF or ICF/IID) if it is anticipated that the person will remain in a Medicaid-certified facility for at least 30 days. When eligibility is based on the special income limit, finalization of the person’s eligibility cannot be processed or disposed in the system of record until the 30 consecutive days in an institutional setting have been met. See Appendix XIX, Earliest Certification Application Due Dates Chart, to determine the 31st day.
See Section G-7000, Prior Coverage.
It may be necessary to verify the living arrangement for prior months by contacting the person or authorized representative to ensure the appropriate income limit is used for determining eligibility for prior months. It may also be necessary to contact the facility, the Home and Community-Based Services waiver provider or the hospital, if a person has been discharged to a hospital, to ensure that the 30-consecutive-day requirement is met.
The following verification and documentation must be included in the case record:
See Appendix XXX, Medical Effective Dates (MEDs). Use the information under the Institutional Based area to determine the appropriate income limit for the month of application and the prior months.
The 30 consecutive day in an institutional setting requirement does not apply to a regular Medicaid recipient who:
The COLA disregard programs are:
See Section B-7450, Medicaid Certified Person Enters Nursing Facility or Home and Community-Based Services Waiver Program.
Make and document an eligibility decision on an application as soon as all required verification is received.
Time frame for eligibility determination:
References:
In Section B-4000, Date of Application, several dates of application are outlined. However, for timeliness and processing purposes:
If an applicant applies for multiple programs and all requested information is provided for one program and not the other(s), make an eligibility determination for the program in which all the information has been received. Continue to collect the missing information for the other program(s) until the final due date for missing information.
Reminders:
Applications
Use Form H1020, Request for Information or Action, to request missing information or verifications. The final due date for missing information for applications on Form H1020 is the:
Do not send a second request for missing information. Take appropriate case action based on the original request for missing information.
Delay in Certification
When there is an approved delay in certification, the 39th and 84th days are extended 90 days.
Always send notification to the applicant/authorized representative and nursing facility, using Form H1020 and Form H1247, Notice of Delay in Certification.
Use Form H1020 to indicate the needed information and the re-established due dates during the delay in certification. See Section B-6510, Failure to Furnish Missing Information.
Re-established due dates are based on the reason for the delay in certification and reasonable MEPD specialist judgment. For example, if the delay is due to the 30-day consecutive requirement not being met, the re-established due date would not automatically need to be the full 90-day extension. However, if the delay is due to the facility pending certification, the full 90-day extension may be necessary. When unsure of the re-established due dates based on the reason for the delay in certification, consult the supervisor to determine the re-established pending period. Do not send a second request for missing information during the re-established due dates based on the delay in certification. Take appropriate case action based on the Form H1247 and Form H1020 used to notify the applicant of the delay in certification and the needed verification.
Redeterminations
Use Form H1020 to request missing information or verifications. The due date for missing information or verifications for redeterminations should be 10 days from the date on Form H1020.
Before a person is denied for any reason during application, eligibility for QMB/SLMB must also be tested.
Examples:
Revision 18-3; Effective September 1, 2018
Applications
An individual or authorized representative must furnish verification needed to make an eligibility decision. For applications, the initial written request for verification must be initiated within 30 calendar days from the date the application is received by the Texas Health and Human Services Commission (HHSC).
Do not deny the application for failure to furnish missing information before doing the following:
Do not send a second request for missing information for applications.
Deny the application if the procedures described above are followed and the individual or authorized representative does not provide the requested information by the close of business on the final due date. See Section B-6420.
Delay in Certification
Delay in certification procedures may be necessary if the applicant or the authorized representative is attempting to obtain the information but cannot meet the deadline. For specific delay information, follow the guidelines in Section R-3100, Establish Processing Deadlines, and in Section B-6420.
Use Failure to Furnish Information when the application is denied because of failure to provide missing information.
References:
Redeterminations
A person or authorized representative must furnish verification needed to make an eligibility redetermination decision.
Do not deny the redetermination for failure to furnish missing information before doing the following:
Do not send a second request for missing information for redeterminations.
Deny the redetermination if the procedures described are followed and the information/verification is not provided by the close of business on the due date. See Section B-6420.
Revision 13-4; Effective December 1, 2013
The Social Security Administration (SSA) determines Medicaid eligibility for all persons who apply for SSI cash benefits. When SSA makes a determination on an application for SSI cash benefits (either approved or denied), HHSC is notified by means of the SSA/State Data Exchange System (SDX).
SSA is responsible for redetermination of SSI Medicaid eligibility. See Section H-6000, Co-Payment for SSI Cases, for other special handling of SSI eligible individuals.
When an SSI recipient enters a Medicaid facility and the SSI cash benefit will be denied because the income is greater than the reduced federal benefit rate, and:
TIERS is notified by the State Data Exchange (SDX) system when SSI cash benefits have been denied because of income that is greater than the reduced SSI federal benefit rate. Once the SDX denial notice is received by TIERS, the SSI Medicaid will be denied by the system.
There is no overlay option in TIERS. Certification for MEPD benefits cannot occur until the SSI is denied. This may require delay in certification, closing and re-opening applications until the SSI is denied.
When SSI has been denied and an MEPD application has not been filed, and:
Reference: See Section B-7210, Ensuring Continuous Medicaid Coverage.
After receipt of Form H1200, determine the recipient's financial eligibility for MEPD using the special income limit beginning with the first month after SSI denial. Also determine whether the recipient has an approved medical necessity or level of care and meets all other eligibility requirements. If the recipient has been denied a medical necessity or level of care but remains in the Medicaid facility (Medicare-SNF, NF or ICF/IID), or if the recipient does not remain in a Medicaid facility (Medicare-SNF, NF or ICF/IID) for 30 consecutive days, deny the MEPD application and refer the recipient back to SSI for reinstatement of full SSI benefits. If the recipient will not be reinstated for full SSI benefits, test eligibility for other Medicaid-funded programs, such as QMB, ME-Pickle, etc.
Notes:
Reference: See Chapter H, Co-Payment, for exceptions to reduced SSI payment standard.
When a recipient is eligible for institutional Medicaid coverage, the medical effective date (MED) is the day after the date of SSI denial, when the SSI denial is due to entry into an institution. This ensures continuous Medicaid coverage.
Note: To ensure continuous Medicaid coverage for SSI recipients who enter institutions, the coverage may be more than three months from the application file date. For example, SSI was denied March 31, 2013. The individual applied for ME-Nursing Facility on Sept. 10, 2013. The MED can go back to April 1, 2013, which is more than three months prior.
Persons who have applied for SSI and who appear to be SSI-eligible, but for whom processing of the SSI claim has been delayed, may be certified under the appropriate MEPD program pending adjudication of the SSI claim. In order to certify MEPD eligibility, however, all eligibility criteria must be met. This expedited procedure does not negate the requirement that disability be established, or the utilization of benefits, or 30 consecutive days of institutionalization, if applicable.
Consider the age of the person when temporarily certifying the person.
Once an MEPD eligibility recipient becomes eligible for SSI, SSA will report the SSI eligibility to HHSC via the SDX system. Once the SDX information is received, TIERS will automatically deny MEPD coverage and activate the SSI coverage. This is not adverse action, since the recipient loses no benefit, so notification is not required unless co-payment is being changed. For Community Living Assistance and Support Services and Home and Community-based Services cases, notify DADS of the MEPD denial using Form H2067, Case Information, or automated communication tool.
The above is not intended as a routine procedure, but should be used only in situations where there has been a delay in an SSI claim already filed. (The eligibility specialist must verify and document that an SSI application has been filed.) The procedure also applies only to applicants who are eligible under an existing MEPD coverage group.
HHSC is responsible for processing Medicaid applications for certain residents of Medicaid facilities (Medicare SNF, NF, ICF/IID and institutions for mental diseases (IMD)). To qualify for medical assistance for institutional care, a person must:
Reference: Section B-6300, Institutional Living Arrangement.
HHSC processes:
State law (Chapter 242, Health and Safety Code) requires that community resource coordination groups (CRCG) be notified when a recipient under age 22 with a developmental disability enters an institutional setting. HHSC must notify the CRCG in the county of residence of the recipient's parent or guardian within three days of the recipient's admission.
The name and telephone number of the appropriate CRCG can be obtained by calling the CRCG state office at 1-866-772-2724. A CRCG list is available on the Internet at: /services/service-coordination/community-resources-...
Documentation of the notification to the CRCG should be filed in the case record.
To qualify for Medicaid facility vendor payments, a recipient must have a medical necessity for nursing facility care. The state Medicaid claims administrator (currently TMHP) is responsible for determining medical necessity for recipients in Medicaid facilities. DADS makes level of care determinations for residents in Medicaid ICF/IID facilities.
Do not approve a person for medical assistance for institutional care unless the person is (or has been) in a Medicaid facility and a level of care is assigned or medical necessity has been determined. (In a Medicare SNF, the Medicare determination of need for care is accepted as a medical necessity determination.) Form 3071, Recipient Election/Cancellation/Discharge Notice, substitutes for the medical necessity determination when hospice is elected as referenced in Section A-5200, Hospice in a Long-Term Care Facility.
Use the previous level of care or medical necessity determination if:
Use the level of care/medical necessity determination for Home and Community-Based Services waiver eligibility to transfer a Home and Community-Based Services waiver recipient admitted to an institution to the appropriate institutional care program.
If a recipient has a permanent medical necessity determination before being denied Medicaid and is not discharged from a Medicaid facility for more than 30 days, then the permanent medical necessity determination may still be used if a reapplication for assistance is filed.
If a level of care/medical necessity determination is not approved, deny the application.See Appendix XVI, Documentation and Verification Guide.
Under the utilization review procedures, facilities are required to submit medical information to the state Medicaid claims administrator (currently, TMHP) on the Minimum Data Set (MDS) assessment or to DADS on Form 8578, Intellectual Disability/Related Condition Assessment, so that medical necessity/level of care may be determined. As a part of these procedures, facilities must comply with time limits for submitting the form.
If a level of care/medical necessity determination is denied for an MEPD recipient, initiate denial procedures immediately.
A recipient may continue to be Medicaid-eligible as long as the recipient meets all eligibility criteria and:
If the recipient has not been in the facility for 30 months, regular Medicaid denial procedures apply.
If an MEPD recipient in a private Medicaid facility is denied solely because of no level of care/medical necessity determination, refer the person to SSA if available income is less than the SSI full federal benefit rate. Refer SSI recipients who are denied a level of care/medical necessity determination to SSA for rebudgeting to the full federal benefit rate.
Federal regulations require that an evaluation be made of resources available to the applicant in the home, family and community. This requirement is met by sending Form H1204, Long Term Care Options, as an information cover letter for all MEPD Medicaid applications, except for state supported living centers, state hospitals and state centers. State law requires that information about all long-term services and supports be provided to applicants, authorized representatives and at least one family member so they can make an informed choice about service options.
Explain alternate care services available in the area if the applicant, authorized representative or family member(s) has questions. If the applicant or authorized representative expresses an interest in alternate care, refer the applicant to DADS staff via Form H2067, Case Information, or automated communication tool.
If a Form H1746-A, MEPD Referral Cover Sheet, has a mark in the box "LTSS Information Shared," do not send Form H1204 to the person. The agency making the referral has shared the Long Term Care Options with the person.
Eligibility Systems and Payment Systems
When an active recipient with coverage Code R (either Long Term Care or Texas Works) enters a nursing facility and has a valid medical necessity and facility admission, DADS Claims Management Services/Service Authorization System Online (CMS/SASO) identifies the recipient as Service Group 1 and allows vendor payment. It also automatically assigns the recipient a Code 60 (authorization for unlimited medications), which allows all medications to be paid through the vendor drug benefit.
If a recipient has only a temporary nursing facility stay and returns home before being transferred to institutional Medicaid, there is no action required by the eligibility specialist. No retroactive coverage changes are needed. The client history can remain as it is.
Texas Works Medicaid to MEPD
If a person is on a Texas Works (Category 2) program and enters the facility for a long-term stay, the nursing facility admission information will be received by TIERS from DADS via an interface. TIERS will automatically deny the Texas Works Eligibility Determination Group (EDG) and create the MEPD EDG. The eligibility specialist then coordinates the disposition of the EDGs with Texas Works staff. There is no need for retroactive changes because vendor payment and medications are authorized through the DADS payment systems CMS/SASO).
If the eligibility specialist is notified by a facility, then the eligibility specialist should process as any other application and coordinate with Texas Works.
Community to Nursing Facility or Home and Community-Based Services Waiver Eligibility Considerations
When a Medicaid (MEPD or Texas Works) or Medicare Savings Program recipient enters a facility for a long-term stay, review information for transfer of assets, substantial home equity and other factors affecting eligibility and co-payment for services in a nursing facility or waiver. Other considerations are notification requirements regarding annuities, estate recovery and long-term care options. See Appendix XI, Reference for Client Notification Forms.
Revision 15-4; Effective December 1, 2015
The certificate of insurance coverage is proof of a Medicaid recipient's most recent period of Medicaid coverage. The Department of State Health Services sends the certificate, a requirement of the Health Insurance Portability and Accountability Act (HIPAA) of 1996, to denied recipients. HIPAA mandates that prior health insurance coverage must be counted toward reducing or eliminating any applicable pre-existing condition exclusion period when a person enrolls in a new health insurance plan. Former Medicaid recipients may request a certificate within 24 months after their Medicaid is denied by calling 1-800-723-4789.
A recipient’s eligibility is redetermined:
For more information on redeterminations, see Section B-8430, Special Reviews, and Section B-8440, Streamlined Redetermination (Passive Redetermination).
Note: For couple cases, including cases with spouses who may be certified under different type programs, redeterminations should be synchronized to minimize the redetermination process for the recipients and the workload for the eligibility specialist. A complete redetermination of each person's eligibility must be completed at least once every 12 months.
It is a recommended practice to review community-based cases at least every three months if the recipient's countable resources are within $100 of the resources limit.
Monitor eligibility at least every three months if the person's:
The following information must be included in the case record documentation:
Clearly document:
Example: If someone has a private pension and the pension amount is anticipated to increase in the future, a special review must be set for the anticipated change. The eligibility area will be income. Documentation must specify pension information that will need to be verified at the special review, including:
Use Form H1020, Request for Information or Action, and Form H1020-A, Sources of Proof, to request information from the person or authorized representative. When requesting missing information on a redetermination, allow 10 calendar days from the date the notice is mailed for the individual to provide the information. Do not deny the case for failure to furnish information before the due date listed on Form H1020.
Note: Monitor special reviews for resource or income elements through entry of the special review due date in the applicable TIERS screen.
Data Broker is not required on redeterminations, including the streamlined versions.
Note: A person who may complete or sign a redetermination form for a recipient may possibly not be on the list of people to whom HHSC can release the recipient’s individually identifiable health information. See Section C-5000, Personal Representatives, for persons who may receive or authorize the release of a recipient’s individually identifiable health information under HIPAA privacy regulations.
See Section B-3220, Who May Sign an Application for Assistance, to determine who may sign a redetermination form. The requirements for signing a redetermination form are the same as the requirements for signing an application.
Note: A signature is not needed when the redetermination is passive or simplified. See Section B-8440, Streamlined Redetermination (Passive Redetermination).
When reports based on the system of record indicate a redetermination or review of eligibility is due for a recipient, the automated system will send Form H1233, Redetermination Cover Letter, a Form H1200 application series form, and Form H0025, HHSC Application for Voter Registration, to the recipient or authorized representative requesting that the application form be completed and returned along with required verification documents.
Reference: Policy and procedures found in Section B-3210, Who May Complete an Application for Assistance, and Section B-3220, Who May Sign an Application for Assistance, apply to all H1200 series application forms.
Note: Document any actions taken regarding voter registration in the Agency Use Only section of any of the H1200 series. If the recipient contacts the office declining to complete Form H0025, mail Form H1350, Opportunity to Register to Vote, to the person. See Section C-7000, National Voter Registration Act of 1993.
For redetermination involving stable institutional or community-based cases, Form H1200/H1200-A may be accepted without verifications, if information is consistent with what previously has been reported and eligibility and/or co-payment are not affected.
For redeterminations completed by the eligibility specialist because the recipient does not have an authorized representative, a contact with the recipient, facility staff or other appropriate verification sources must be made to verify all applicable eligibility points.
A minimum of one annual review, using Form H1200/H1200-A, must be made before streamlined options in Section B-8440, Streamlined Redetermination (Passive Redetermination), can be used to complete the redetermination process. This option applies to both institutional cases (except spousal impoverishment cases) and community-based cases.
Data Broker is not required on annual reviews, including the streamlined versions.
For redeterminations, explore financial management if there has been no activity in the person’s bank account, other than interest credited, since the last redetermination.
If a person does not report a bank account, trust fund or similar account on the application for assistance, ask the person or the authorized representative to explain how the person’s financial affairs are handled. This includes determining who cashes his checks and where, who pays his bills and how, and who keeps his money and how the funds are kept.
If the person reveals previously unreported liquid resources, determine the value, ownership and accessibility according to the requirements for the resource involved.
Sources for verifying financial management are as follows:
Include the following information in the case record documentation:
On receipt of the completed, signed and dated H1200 series form, redetermine eligibility for MEPD. A review may result in no changes being made or one of the following situations:
Note: Complete Form H1259 manually for notification if co-payment involves averaged income (raised or lowered) or incurred medical expenses. If all amounts are lower in the reconciliation shown on Form H1259, then adverse action is not required. In the above situations, ensure that if Form TF0001 and/or Form TF0001P is not sent automatically, a manual Form TF0001 and/or Form TF0001P is sent.
If there is no change in eligibility or co-payment, there is no mandate to send a notification to the recipient.
A special review occurs between the annual review cycles to evaluate one or more eligibility elements without completing the annual review. The annual review (redetermination) packet is not required for a special review.
The need for a special review is based on policy, a reported change or the eligibility specialist's judgment.
Examples of when special reviews are needed for follow-up:
For special reviews, document clearly the detailed reason(s) for the special review. Documentation must include:
Include this information on correspondence sent to the person to request information concerning the special review. No redetermination packet is required.
For example, if someone has a private pension and the pension amount is anticipated to increase in the future, set a special review for the anticipated change. The eligibility area will be income. Documentation must specify pension information that will need to be verified at the special review. Include the:
Form H1020, Request for Information or Action, and Form H1020-A, Sources of Proof, are used to request information from the person or authorized representative. Include the due date on Form H1020 or H1020-A. If the recipient calls with questions, follow Appendix XVI, Documentation and Verification Guide, for acceptable verification sources.
Example:
George Black called this morning saying he received a letter requesting verification that he had applied for Veterans Affairs (VA) benefits. He stated that he had applied and was told that it would take at least six months to hear anything.
Document what Mr. Black said. Recipient declaration is acceptable verification that he has applied for additional benefits. Be sure to tell Mr. Black to call and report if he hears anything about his eligibility from the VA.
A minimum of one annual redetermination based on procedures in Section B-8400, Procedures for Redetermining Eligibility, and using Form H1200/H1200-A, must be made before this streamlined option can be used to complete the redetermination process.
Do not use the streamlining method for the Medicaid Buy-In for Children (MBIC) program or the Medicaid Buy-In (MBI) program.
For redeterminations after the first annual redetermination, the eligibility specialist determines if Form H1200/H1200-A or Form H1200-EZ is needed based on the case criteria and this option is marked in TIERS. If it is determined the H1200-H1200-A/H1200-EZ is not needed, then the H1200-SR is sent.
The recipient is sent the H1200-SR and informed on the cover sheet that if the income and resources are the same and no changes have occurred, the redetermination form does not need to be returned. If the review packet is not returned, the redetermination will be automatically renewed using existing information in TIERS.
Use the case criteria given below to determine if Form H1200/H1200-A/H1200-EZ is needed. This option applies to both institutional cases (except spousal impoverishment cases) and community-based cases.
If the case criteria exhibits no more than the following case characteristics, the redetermination process may be streamlined:
In addition to cases meeting the above case criteria, other stable cases (including those with variable income) may be streamlined. Regional management determines when supervisory approval is needed.
Regional management will ensure all streamlined cases meet the established criteria.
Data Broker is not required on redeterminations, including the streamlined versions.
If an action by DADS against a facility results in the loss of a Medicaid contract, and the eligibility specialist has been notified by DADS or has discovered the loss of Medicaid certification, the eligibility worker begins denial procedures by sending Form TF0001, Notice of Case Action.
Ensure that the local SSA office is aware of the loss of the Medicaid contract for that facility since SSA determines SSI eligibility. See Section B-6300, Institutional Living Arrangements.
The following procedures are followed whenever a facility's contract with DADS is cancelled or the facility closes.
| Step | Procedure |
|---|---|
| 1 | HHSC receives official written notice from DADS. The eligibility specialist sends Form TF0001 within 10 workdays after receipt of a report indicating changes that may affect eligibility or co-payment or verified discovery of the loss of Medicaid certification. See Section B-8200, Redetermination Cycles. |
| 2 | The eligibility specialist sends Form TF0001 to all Medical Assistance Only (MAO) recipients who continue to live in the uncontracted facility. See Section B-9100, Administrative Denials, and Appendix XI, Reference for Client Notification Forms. |
| 3 | If the recipient relocates to a contracted facility, or if the facility in which the recipient is living is reinstated as a contracted provider before the effective date of Medicaid denial, the denial action is cancelled and a new application is not required. |
| 4 |
Ensure that the local SSA office is aware of the loss of the Medicaid contract for that facility since SSA determines SSI eligibility for the residents of the facility. |
Revision 13-2; Effective June 1, 2013
Before a person is denied for any reason during redetermination, eligibility for QMB/SLMB must also be tested.
If the redetermination is denied in error, protect the date of receipt of redetermination no matter how old the redetermination.
The automated system provides a DG0001 report, which indicates all pending and overdue reviews. Each region uses this as a tracking tool to ensure all reviews are completed by their due date. If a redetermination packet other than a Form H1200-SR has been mailed and the individual/authorized representative (AR) has not responded, the eligibility worker may contact the individual/AR or DADS to determine why the packet was not returned prior to denial; however, this is not a requirement. If no response is received and it has been 13 calendar days after the form was mailed and the case record indicates the recipient or AR is capable of completing the redetermination form:
Note: The MES can re-instate DADS coverage without Form H1746-A, MEPD Referral Cover Sheet, if:
Example: Case due Feb. 10, 2013. Denial disposed Feb. 11, 2013. Denial is effective March 31, 2013.
The review packet was received on or before March 31, 2013. No new Form H1746-A is required, if the additional requirements listed above are met.
See Appendix XI, Reference for Client Notification Forms.
When reviewing an MEPD case, verify medical necessity/level of care determination if:
If the medical necessity/level of care determination has been denied, do not sustain the review.
Reference: See Section B-7431, Denial of Level of Care/Medical Necessity Determination, for procedures when medical necessity/level of care is denied.
Revision 10-2; Effective June 1, 2010
An applicant or recipient has the right to:
(1) be treated fairly and equally regardless of race, color, religion, national origin, gender, political beliefs, or disability;
(2) have information collected for determining his or her eligibility to be treated as confidential;
(3) request a review of an action;
(4) have his or her eligibility tested for other programs before HHSC denies eligibility;
(5) review all information that contributed to an eligibility decision; and
(6) request a fair hearing to appeal an action by HHSC.
The Texas Health and Human Services Commission follows 20 CFR §§401-403 concerning disclosure of information about a person, both with and without the person's consent; the maintenance of records; and the general guidelines in deciding whether to make a disclosure.
A person requesting assistance on the basis of disability must complete a medical information release form.
(a) An applicant or recipient must provide the Texas Health and Human Services Commission (HHSC) the necessary documentation and information to determine eligibility for Medicaid.
(b) An applicant or recipient must report to HHSC certain events that affect benefits in accordance with 20 CFR Subpart G.
(a) The Texas Health and Human Services Commission (HHSC) follows 42 CFR §§455.13-455.16 for issues governing fraud referral and restitution.
(b) HHSC evaluates a person's willful withholding of information for fraud, including:
(1) willful misstatements, oral or written, made by the person or the person's authorized representative in response to oral or written questions from HHSC concerning the person's income, resources, or other circumstances that may affect the amounts of benefits, including understatements or omission of information about income and resources; and
(2) willful failure by the person or the person's authorized representative to report changes in income, resources, or other circumstances that may affect the amount of benefits, if HHSC has clearly notified the person or the person's authorized representative of the person's obligation to report these changes.
Revision 10-2; Effective June 1, 2010
Federal law requires that anyone who wishes to apply for Medicaid be allowed to file an application, regardless of the person's ultimate eligibility for services. See Chapter B, Applications and Redeterminations, for more information.
In addition to meeting other requirements, a person must file an application to become eligible to receive benefits. An authorized representative may accompany, assist and represent an applicant or recipient in the application or eligibility redetermination process.
Someone who is Supplemental Security Income (SSI) eligible automatically receives Medicaid and does not have to file a separate application unless coverage for unpaid or reimbursable bills during prior months to the SSI application is requested. See Section A-4300, Retroactive Coverage.
To apply for an MEPD program, an application for assistance must be received that is:
An applicant or authorized representative must also provide all requested information according to HHSC instructions. See Section C-8000, Responsibility to Provide Information and Report Changes.
If someone helps an applicant or authorized representative complete the application for assistance, the name of the person completing the form must appear as requested on the application.
Filing an application will:
Revision 14-2; Effective June 1, 2014
Information that is collected in determining initial or continuing eligibility is confidential. The restriction on disclosing information is limited to information about individual applicants/recipients. HHSC may disclose general information, including financial or statistical reports; information about policies, procedures or methods of determining eligibility; and any other information that is not about or does not specifically identify an applicant/recipient.
An applicant/recipient may review all information in the case record and in HHSC handbooks that contributed to the decision about his eligibility.
Applicants/recipients have a right to correct any information that HHSC has about the applicant/recipient and any other individual on the applicant's/recipient's case.
A request for correction must be in writing and must:
If HHSC agrees to change individually identifiable health information, the corrected information is added to the case record, but the incorrect information remains in the file with a note that the information was amended per the applicant's/recipient's request.
Notify the applicant/recipient in writing within 60 days (using current HHSC letterhead) that the information is corrected or will not be corrected and the reason. Inform the applicant/recipient if HHSC needs to extend the 60-day period by an additional 30 days to complete the correction process or obtain additional information.
If HHSC makes a correction to individually identifiable health information, ask the applicant/recipient for permission before sharing with third parties. HHSC will make a reasonable effort to share the correct information with persons who received the incorrect information from HHSC if they may have relied or could rely on it to the disadvantage of the applicant/recipient. Follow regional procedures to contact HHSC's privacy officer for a record of disclosures.
Note: Do not follow procedures above if the accuracy of information provided by a applicant/recipient is determined by another review process, such as:
The decision in that review process is the decision on the request to correct information.
Keep all information HHSC has about an applicant/recipient or any individual on the applicant's/recipient's case confidential. Confidential information includes, but is not limited to, individually identifiable health information.
Before discussing or releasing information about an applicant/recipient or any individual on the applicant's/recipient's case, take steps to be reasonably sure the individual receiving the confidential information is either the applicant/recipient or an individual the applicant/recipient authorized to receive confidential information (for example, an attorney or personal representative).
Establish the identity of an individual who identifies himself/herself as an applicant/recipient using his/her knowledge of the applicant's/recipient's:
Establish the identity of a personal representative by using the individual's knowledge of the applicant's/recipient's:
Establish the identity of attorneys or legal representatives by asking the individual to provide Form H1003, Appointment of an Authorized Representative, completed and signed by the applicant/recipient.
Establish the identity of legislators or their staff by following regional procedures.
Establish the identity of the individual who presents himself/herself as an applicant/recipient or applicant's/recipient's representative at an HHSC office by:
Establish the identity of other HHSC staff, federal agency staff, researchers or contractors by:
Identify the need for other HHSC staff, federal staff, research staff or contractors to access confidential information through:
Contact appropriate regional or state office staff when federal agency staff, contractors, researchers or other HHSC staff, etc., come to the office without prior notification or adequate identification and request permission to access HHSC records.
Note: Contractors cannot have access to IRS Federal Tax Information (FTI).
If disclosing individually identifiable health information, document how you verified the identity of the person if contact is outside the interview.
Verify the identity of the person who contacts you with a request to disclose individually identifiable health information using sources such as:
As a condition for receiving federal taxpayer returns and return information from the IRS, HHSC is required pursuant to IRC 6103(p)(4) to establish and maintain, to the satisfaction of the IRS, safeguards designed to prevent unauthorized access, disclosure, and use of all returns and return information and to maintain the confidentiality of that information. The IRS security requirements for safeguarding IRS FTI are outlined in Publication 1075, Tax Information Security Guidelines for Federal, State and Local Agencies, Safeguards for Protecting Federal Tax Returns and Return Information.
MEPD Income Eligibility and Verification System (IEVS) specialists must independently verify the income and resource information from any of the data matches to ensure continuous financial eligibility for the MEPD programs.
For all case actions regarding the clearance of the IEVS match of IRS FTI, MEPD staff must not enter any IRS FTI into TIERS (including comments). Documentation on the TIERS income/resource screen is limited to the approved language indicated in the centralized process available on the Social Services Intranet on the Medicaid Eligibility for the Elderly and People with Disabilities home page at hhs.texas.gov/laws-regulations/handbooks/medicaid-elderly-people-disabilities-handbook.
HHSC must accommodate an applicant's/recipient's reasonable request to receive communications by alternative means or at alternate locations.
The applicant/recipient must specify in writing the alternate mailing address or means of contact and include a statement that using the home mailing address or normal means of contact could endanger the applicant/recipient.
Records must be safeguarded. Use reasonable diligence to protect and preserve records and to prevent disclosure of the information they contain except as provided by HHSC regulations.
"Reasonable diligence" for employees responsible for records includes keeping records:
Upon discovery of an actual or possible compromise of an unauthorized inspection or disclosure of IRS FTI including breaches and security incidents, the individual making the observation or receiving the information must immediately contact the HHSC IRS Coordinator at 512-206-5681. If you are unable to personally reach the HHSC IRS Coordinator by phone, send a secure email to HHSC IRS_FTI_Safeguards@hhsc.state.tx.us.
The HHSC IRS Coordinator will report the incident by contacting the office of the appropriate Special Agent-in-Charge, Treasury Inspector General for Tax Administration (TIGTA) and the IRS Office of Safeguards as directed in Section 10.2 of Publication 1075.
Staff who become aware of an incident of unauthorized access to, or disclosure of, restricted (IRS FTI and verified SSA information) or confidential information must immediately contact the HHSC IRS Coordinator at 512-206-5681. If you are unable to personally reach the HHSC IRS Coordinator by phone, send a secure email to: HHSC IRS_FTI_Safeguards@hhsc.state.tx.us.
The HHSC IRS Coordinator will report the incident by contacting the Information Security Officer (ISO).
If a person is responsible for a security breach or an employee's employment is terminated, the user's access to all information resources will be removed. Supervisors must follow agency procedures for removing access for employees, contractors, vendors or trainees.
In addition to the measures in Section C-2300, Custody of Records, use the following to safeguard tape match data obtained through the Income Eligibility and Verification System (IEVS):
References: See Appendix XVII, System Generated IEVS Worksheet Legends for IRS Tax Data. See Appendix XVIII, IRS Tax Code, Sections 7213, 7213A and 7431.
To dispose of documents with applicant/recipient-specific information, staff follow procedures for destruction of confidential data according to Health and Human Services records management policies.
The approved method of destruction of IRS FTI is shredding. The IRS requires the following safeguards:
Reference: See Appendix XVIII, IRS Tax Code, Sections 7213, 7213A and 7431.
If subpoenaed to appear in court with an applicant's/recipient's record, notify the supervisor immediately. Give the supervisor all the facts about the case and the date and time of the court hearing. The supervisor should contact the lawyer who is requesting the record and determine whether the requested information is confidential. If a problem exists, the supervisor should inform the regional attorney about all relevant facts. Usually, the subpoenaed employee must take the record and appear in court as directed by the summons. When requested to disclose information from the record, ask the judge to be excused from disclosing the information because of the statutory prohibitions stated previously in this section. Abide by the ruling of the judge.
For individually identifiable health information, refer the requestor to 45 CFR Sections 164.102-164.534.
Revision 11-4; Effective December 1, 2011
Notes:
Certain information about applicants/recipients may be disclosed provided that no indication exists that the information can be used against the applicant/recipient:
Give applicant/recipient addresses or other case information only to a person who has written permission from the applicant/recipient to obtain the information. The applicant/recipient authorizes the release of information by completing and signing:
Note: If the case information to be released includes individually identifiable health information, the document also must tell the applicant or recipient that information released under the document may no longer be private and may be released further by the person receiving the information.
Occasionally requests for information from the case records of deceased applicants/recipients are received. In these instances, also protect the confidentiality of the former applicants/recipients and their survivors. See Section C-5300, Deceased Individuals, for information about who can act on behalf of a deceased applicant/recipient regarding individually identifiable health information.
HHSC's Office of the General Counsel handles questions about the release of information under the Open Records Act. All questions and problems encountered by individuals concerning release of information should be referred to the Office of the General Counsel.
Revision 15-2; Effective June 1, 2015
Applicants/recipients requesting assistance on the basis of disability must complete a medical information release form.
The Health Insurance Portability and Accountability Act (HIPAA) is a federal law that sets additional standards to protect the confidentiality of individually identifiable health information. Individually identifiable health information is information that identifies or could be used to identify an individual and that relates to the:
The MEPD eligibility specialist must send each applicant/recipient a copy of the HIPAA — Notice of Privacy Practices or HIPAA — Notice of Privacy Practices (Spanish) upon certification. The privacy notice tells the applicant/recipient about:
The applicant/recipient may authorize the release of his or her health information from HHSC records by using a valid authorization form. Form H1003, Appointment of an Authorized Representative, includes all the authorization elements required by HIPAA privacy regulations. See Section C-3000, When and What Information May Be Disclosed, for the elements necessary for a valid authorization.
Reasonable efforts must be made to limit the use, request or disclosure of individually identifiable health information to the minimum necessary to determine eligibility and operate the program. The disclosure of individual medical information from HHSC records must be limited to the minimum necessary to accomplish the requested disclosure. For example, if an applicant/recipient authorizes release of income verification, including disability income, do not release related case medical information unless specifically authorized by the applicant/recipient.
Revision 09-4; Effective December 1, 2009
Only an applicant's/recipient's personal representative can exercise the applicant's/recipient's rights with respect to individually identifiable health information. Therefore, only a applicant's/recipient's personal representative may authorize the use or disclosure of individually identifiable health information or obtain individually identifiable health information on behalf of an applicant/recipient. Exception: HHSC is not required to disclose the information to the personal representative if the applicant/recipient is subjected to domestic violence, abuse or neglect by the personal representative. Consult the regional attorney if you believe that health information should not be released to the personal representative.
Note: A responsible party is not automatically a personal representative.
If the applicant/recipient is an adult or emancipated minor, including married minors, the applicant/recipient's personal representative is a person who has the authority to make health care decisions about the applicant/recipient and includes a:
A parent is the personal representative for a minor child except when:
The personal representative for a deceased applicant/recipient is an executor, administrator or other person with authority to act on behalf of the applicant/recipient or the applicant's/recipient's estate. These individuals include:
Consult the regional attorney if you have questions about whether a particular person is the personal representative of an applicant or recipient.
Revision 18-1; Effective March 1, 2018
If an individual is dissatisfied with HHSC's decision concerning his eligibility for any MEPD program, including Medicaid Savings Programs, the individual has the right to appeal through the appeal process established by HHSC. In certain circumstances, the individual is entitled to receive continued benefits or services until a hearing decision is issued. Whether an individual is entitled to continued assistance is based on requirements set forth in appropriate state or federal law or regulation of the affected program. See the Fair and Fraud Hearings Handbook.
Individuals whose medical assistance is denied because of an SSA decision should file an appeal with the appropriate SSA office.
Note: If an individual submits an application during the time the continued benefits are being processed, the application must be processed as normal. See Chapters B-2300, Eligibility Determination, B-3200, Application Process, and B-6400, Processing Deadlines.
If an applicant/recipient requests a fair hearing, the burden of proof to uphold HHSC's decision rests with HHSC. The hearing officer is a neutral party and is restricted by law from presenting HHSC's case.
Form H4800, Fair Hearing Request Summary, provides a space for the names of HHSC's representative and supervisor. The supervisor is responsible for ensuring that either the HHSC representative participates in the hearing or that a back-up person is assigned. Additionally, the supervisor should ensure that the designated representative is sufficiently prepared and knowledgeable of the case to represent HHSC during the fair hearing process.
The hearing officer has the responsibility of setting the date and time of the hearing. In those program areas where Form H4800 may be completed by someone other than agency staff (contracted case management, HHSC representatives, etc.), it is important that the hearing officer be given the name(s) of those individuals who are to be notified of the date and time of the hearing. If there is not sufficient space on Form H4800 to provide this information, list the name(s) on Form H3800-A, Fair Hearing Request Summary (Addendum), Item 3, "Additional Information."
In those program areas where Form H4800 is completed by HHSC staff but someone other than, or in addition to, HHSC staff will appear (Attorney General's Office staff, Workforce Commission staff, home health nurses, nursing facility staff, etc.), the person completing Form H4800 is responsible for providing the hearing officer with the name(s) of those individuals who are to be notified of the date and time of the hearing. If there is not sufficient space on Form H4800 to provide this information, list the name(s) on Form H4800-A, Item 3, " Additional Information."
Applicants/recipients receiving MEPD programs are perceived by HHSC as essentially honest and entitled to the same protection under the law as all other individuals. When potential fraud is indicated, the allegations must be investigated.
HHSC also endorses the concept that people who provide services are essentially honest and are entitled to the same protection under the law as all other individuals. However, if there is an indication of potential fraud, the allegations must be investigated.
The Office of Inspector General (OIG) investigates waste, abuse and fraud in all health and human services programs in Texas. Any state employee or private citizen may report waste, abuse and fraud to the OIG.
HHSC staff, concerned citizens, providers (for example, doctors, dentists, counselors, etc.), Medicaid applicants/recipients and others can help prevent cases of waste, abuse and fraud by notifying OIG.
If applicant/recipient or provider waste, abuse or fraud is suspected in the Medicaid system, complete the OIG's online complaint form, which is available at: https://oig.hhsc.state.tx.us/wafrep/.
If access to the Internet is not available, contact the fraud hotline at 800-436-6184 or mail the complaint to:
Texas Health and Human Services Commission
Office of Inspector General
Mail Code 1361
P.O. Box 85200
Austin, TX 78708-5200
Revision 10-3; Effective September 1, 2010
The National Voter Registration Act of 1993 mandates that HHSC provide the applicant or recipient with an opportunity to register to vote at application, redetermination or when reporting a change of address. Staff must provide all applicants or recipients with an opportunity to register to vote, if the person desires to do so. Staff must:
The applicant or recipient may choose to:
At the person's request, HHSC staff will provide the same degree of assistance, including bilingual assistance, in completing Form H0025 as provided for the completion of other HHSC forms.
Document in the Agency Use Only section of the application or recertification form any actions taken regarding voter registration.
HHSC staff will not make a determination about the person's eligibility to vote. However, HHSC staff will not be required to offer the opportunity to register to vote to those applicants and recipients who:
HHSC is prohibited from influencing a person's political preference or party registration, displaying any political preference or party affiliation, or making any statement to a person, the purpose or effect of which is to discourage a person from registering to vote.
If the person has any questions regarding the voter registration process that cannot be answered, give the person the Secretary of State's toll-free number at 1-800-252-8683 or the telephone number of the local county voter registrar.
If a person files a completed mail-in voter registration application during a face-to-face interview, an appropriate HHSC employee will review it for completeness in the presence of the person. If the mail-in voter registration application does not contain all the required information and\or the required signature, the HHSC employee will return the application to the person for completion.
HHSC staff will transmit the completed Form H0025 to the local office liaison who will forward it to the appropriate county voter registrar within five days of receipt.
Do not pend, delay or deny benefits:
In the office
Share the mail-in Form H0025 with the person. If the person declines to register to vote, ask the person to sign Form H1350. File Form H1350 in the case record when returned, and retain the form for 22 months.
Form H0025 will be mailed to the applicant or recipient at the new address. If the person contacts the local office to decline the opportunity to register to vote after receipt of Form H0025, mail Form H1350 to obtain the person's signature. File Form H1350 in the case record when the person returns the form, and retain the form for 22 months.
Notes:
Revision 10-2; Effective June 1, 2010
When a person applies for Medicaid, HHSC will ask for documents and any other information needed to make sure all the requirements for Medicaid are met. HHSC will ask for information about income, resources and other eligibility requirements.
As a requirement of Medicaid, a person must provide HHSC MEPD staff with the necessary documentation and information to determine eligibility for Medicaid.
If HHSC sends an applicant or authorized representative a request for missing information or verification documents, or both, the applicant or authorized representative must provide the requested information to HHSC by the due date given in the request, or eligibility may be denied.
See Section B-6510, Failure to Furnish Missing Information.
Report to HHSC MEPD staff certain events that affect Medicaid eligibility and co-payment.
HHSC requires that the applicant/recipient or authorized representative must report certain events because they may affect eligibility or continued eligibility or the amount of the co-payment in the cost of care. See Chapter H, Co-Payment.
Who must make reports? The person(s) responsible for making required reports to HHSC include an:
Additional:
Although not all inclusive, events that must be reported are:
When reporting changes either in writing or verbally, include the following:
Revision 13-3; Effective September 1, 2013
Revision 13-3; Effective September 1, 2013
HHSC is required to provide interpreter services and written translated materials to applicants and recipients who are Limited English Proficient (LEP). HHSC also is required to provide an effective method to communicate with applicants and recipients who indicate they are deaf or hearing impaired. Applicants and recipients indicate on Form H1200, Application for Assistance – Your Texas Benefits, or during an interview that they need interpreter services. For more information on procedures, refer to the MEPD Standard Operating Procedures: MEPD Standard Operating Procedures, available to staff.
Revision 13-3; Effective September 1, 2013
Ensure that any requests for information given to LEP applicants/recipients are translated. In addition, if the specialist requests additional information to complete the case of an LEP, the specialist must ensure that the applicant/recipient understands the information requested.
Revision 09-4; Effective December 1, 2009
Revision 09-4; Effective December 1, 2009
(a) To be eligible for a Medicaid-funded program for the elderly and people with disabilities (MEPD), a person must be aged, blind, or disabled, according to the following criteria:
(1) Aged. A person must be 65 years of age or older to be considered aged, in accordance with 42 U.S.C. §1382c(a)(1)(A).
(2) Blind.
(A) To be considered blind for eligibility purposes, a person must meet the criteria in 42 U.S.C. §1382c(a)(2).
(B) There is no minimum age requirement for a person who is blind.
(C) A person must have a medical determination of blindness before the Texas Health and Human Services Commission (HHSC) can determine eligibility.
(3) Disabled.
(A) To be considered disabled for eligibility purposes, a person must meet the criteria in 42 U.S.C. §1382c(a)(3).
(B) There is no minimum age requirement for a person who is disabled, unless the person lives in an institution for mental diseases as described in §358.213 of this subchapter (relating to Resident of an Institution for Mental Diseases).
(C) A person must have a medical determination of a disability before HHSC can determine eligibility.
(b) A person under 65 years of age who has applied for Supplemental Security Income, and subsequently applies for retroactive coverage, must have a medical determination of blindness or a disability effective during any month of coverage that the person was under 65 years of age.
Revision 09-4; Effective December 1, 2009
In determining age for aged, blind, or disabled individuals, the age is reached the day before the anniversary of birth. This affects the month a disability determination is required for persons born on the first day of the month. Example: The person turns 65 on Jan. 1, and is eligible for Medicare Dec. 1, before the person’s 65th birthday in January. If the person meets all other eligibility criteria, the person can be certified for benefits for December without a disability decision.
Determine a person's age by the person’s statement on the application. Compare the reported information with Social Security Administration records using systems in place to exchange or request data. Other acceptable evidence includes such readily available sources as:
Revision 09-4; Effective December 1, 2009
A child is neither married nor a head of a household and is either:
Child status ceases effective with the month after the month of attainment of age 22 (age 18, if not a student) or the month after the month the person last meets the definition of child.
SSI policy defines full-time student as an individual attending at least:
A student is deemed to be in regular school attendance during normal vacation periods if he attends regularly during the month immediately following the vacation period. A person may be considered a full-time student without attending the required number of hours per week, if the person is disabled and physically unable to attend full-time, has difficulty obtaining transportation or is taking all that is needed to complete the person's education.
The age requirements involved in identifying a child apply only to a person who is otherwise eligible. A blind or disabled applicant who meets these age requirements, however, can become eligible for Medicaid, even though the person does not meet the definition of a child.
Revision 09-4; Effective December 1, 2009
In determining blindness for aged, blind or disabled individuals, blindness is met if a person is considered “legally blind” as defined by the Social Security Administration. Based on a medical determination of blindness, a person is considered blind if the visual acuity in the person's better eye is 20/200 or less with corrective lenses, or if the person has tunnel vision that limits the field of vision to 20 degrees or less.
Revision 09-4; Effective December 1, 2009
In determining disability for aged, blind or disabled individuals, disability is met if the person is considered disabled as defined by the Social Security Administration. Based on a medical determination of disability, a person is considered disabled if the person is unable to engage in any substantial, gainful activity because of a medically determinable physical or mental impairment that can be expected to result in death or has continued or can be expected to continue for at least 12 months. A child who is not engaged in substantial, gainful activity is considered disabled if the child suffers from any medically determinable physical or mental impairment of comparable severity to that which would preclude an adult from engaging in substantial, gainful activity.
Note: A person who lives in an institution for mental diseases (IMD) must be 65 years of age or older to be eligible for an MEPD program. Do not establish a medical determination for blindness or disability for a person who lives in an IMD who is less than 65 years old.
Revision 16-4; Effective December 1, 2016
Revision 12-4; Effective December 1, 2012
Receipt of Medicare is an indication that the person is either:
A medical determination is not required to establish blindness or disability if the person has Medicare. The receipt of the Medicare is satisfactory verification that the person has been determined to meet the SSA's criteria for aged, blind or disabled. This includes a person determined blind or disabled by SSA in the 24-month period before receiving Medicare. Upon verification of the receipt of a disability benefit, a medical determination is not required to establish blindness or disability if a person is currently receiving disability benefits from:
For an eligibility determination during the retroactive coverage months, a medical determination is not required to establish blindness or disability during that retroactive coverage period if a person:
Note: Do not use the Title XVI "Dsblty Onset Date" on the SSI Entitlement screen as the basis to establish blindness or disability for:
A medical determination is not required to establish blindness or disability if a person:
Revision 16-4; Effective December 1, 2016
When an individual does not have Medicare or is not receiving a disability benefit from SSI, RSDI, or Railroad Retirement (See E-4200, Railroad Retirement Benefits), a medical determination, including date of onset, of either disability or blindness is required. The date of onset can affect the start date of Medicaid.
The following must not be used to establish disability for MEPD programs:
An individuals under age 65 who lives in an institutional setting and who would, except for income, be eligible for SSI if they lived outside the facility, must meet the SSA's definition of disability or blindness. These individuals may or may not have applied for SSI cash benefits.
If a medical decision for determining blindness or disability is required, request a decision from the Disability Determination Unit (DDU). See Section D-2300, Requesting a Decision from the Disability Determination Unit (DDU).
Do not request a decision from the DDU in the following circumstances
| If an individual … | then … |
|---|---|
|
resides in a state supported living center or the Rio Grande State Center, |
the staff at these facilities, and not HHSC staff, is responsible for ensuring the completion of the forms for a disability determination. |
|
requests an eligibility determination during a retroactive period and the individual:
|
the DDU cannot establish an earlier date of onset for RSDI Title II blindness or disability because federal regulations prevent a state's disability determination to conflict with the RSDI Title II date of onset. |
A medical determination of disability or blindness is required when RSDI Title II blindness or disability is not established and an individual is:
To determine whether RSDI Title II blindness or disability is established, query the SSA records available.
Do not use the SSI Title XVI "Dsblty Onset Date" as the basis to establish blindness or disability.
Revision 14-4; Effective December 1, 2014
When a medical decision for determining blindness or disability is necessary, a decision must be requested from DDU. Complete and submit these forms for imaging, along with the medical records, to the Texas Health and Human Services Commission, P.O. Box 149027, Austin, TX 78714-9971:
In addition to these forms, submit the following when available:
DDU may request more complete medical documentation.
On receipt of Form H3034, Form H3035 or other medical records, DDU uses this information to determine whether the person meets SSA's definition of disability or blindness and makes the final decision about disability or blindness.
DDU will consider the date of onset for the retroactive period, if needed. Specify the retroactive months needed on Form H3034. DDU's date of onset, however, cannot precede the RSDI Title II disability onset date indicated on the SSA query.
Revision 11-4; Effective December 1, 2011
When the application is for a person who is younger than age 65 and has never had a disability determination, an override for the application due date default of 45 days is needed. The application due date will be 90 days from the file date. Follow the steps in the system procedure instructions for this override.
Sometimes an application cannot be certified within 90 days because a disability determination is pending past the initial 90 days. In these cases, send Form H1247, Notice of Delay in Certification, to the applicant and the facility administrator, if applicable.
Applications for which delay-in-certification procedures have been followed are excluded from the delinquent count in timeliness reports. These applications are excluded for 180 days (90 days + 90-day extension); however, if the application is still pending on the 181st day, it will be counted as delinquent. Applications that cannot be certified within the normal 90-day limit, plus the 90-day extension, must be denied. A new application will be necessary to reconsider eligibility.
Revision 14-4; Effective December 1, 2014
An applicant for Social Security disability benefits is evaluated for both SSI Title XVI and RSDI Title II disability eligibility. HHSC determines Medicaid eligibility for retroactive coverage for up to:
In these cases, the medical records; Form H3034, Disability Determination Socio-Economic Report; and Form H3035, Medical Information Release/Disability Determination, should be imaged in the Texas Integrated Eligibility Redesign System (TIERS). DDU uses this information to make the final decision (disability or blindness) for the retroactive coverage months. DDU enters the disability determination in case comments and in the Disability Determination — DDU page in TIERS, which indicates the decision, including the date of onset of the disability or blindness.
Federal regulations prevent a state's disability determination to conflict with the RSDI Title II date of onset, and DDU cannot establish an earlier date of onset for RSDI Title II blindness or disability. As a result, deny an application based on the person not meeting blind (Not Blind) or disabled (Not Disabled) criteria when a person applies for Medicaid and the person:
Note: Do not use the SSI Title XVI "Dsblty Onset Date" on the SSI Entitlement screen as the basis to establish blindness or disability for retroactive coverage.
Federal regulations prohibit a state from making a disability decision that conflicts with an SSA decision. DDU cannot make an independent decision until all appeals to SSA regarding the date of disability onset for both RSDI Title II and SSI Title XVI are settled.
Request medical records covering the period for which eligibility is being tested when:
Submit the following items for imaging to the Texas Health and Human Services Commission, P.O. Box 149027, Austin, TX 78714-9971:
Occasionally, Form 4116, State of Texas Purchase Voucher, is required to provide payment to medical providers for submitting medical records. If Form 4116 is required, submit this form for imaging with the medical records, Form H3034 and Form H3035.
Revision 13-2; Effective June 1, 2013
DDU will enter the disability determination in TIERS case comments and in the Disability Determination – DDU page. This determination will include notification about the decision, including the date of onset of the disability or blindness and if the individual is permanently excused from any further medical review.
Revision 13-2; Effective June 1, 2013
Some applicants for Medicaid in an institutional setting are former recipients of Medicaid.
If a person was certified for Medicaid in an institutional setting based on the medical decision for either disability or blindness reflected in TIERS case comments and documented on the Disability Determination – DDU page, continue to use the existing record to reinstate the Medicaid in an institutional setting, unless case comments indicates a review of the disability or blindness is needed.
In addition, if TIERS case comments and the Disability Determination – DDU page indicates the applicant is permanently excused from further medical review, staff can continue to use this decision for future ME-A and D-Emergency requests or applications.
Do not use the existing Disability Determination – DDU page to process an application in any other situations, except those mentioned above.
Revision 09-4; Effective December 1, 2009
At each periodic review, determine whether the decision about disability or blindness is current. Unless Form H3035, Medical Information Release/Disability Determination, indicates that the applicant is permanently excused from further medical review, complete a new Form H3034, Disability Determination Socio-Economic Report, and Form H3035 before the date of review indicated on Form H3035.
Revision 18-1; Effective March 1, 2018
Revision 09-4; Effective December 1, 2009
To be eligible for a Medicaid-funded program for the elderly and people with disabilities, a person must be a resident of the United States (U.S.) and the state of Texas.
(1) U.S. residence. The Texas Health and Human Services Commission (HHSC) follows 20 CFR §416.1603 in determining a person's U.S. residence.
(A) The U.S. residence requirement does not apply to:
(i) a child who is a citizen and is living with a parent who is a member of the U.S. Armed Forces assigned to permanent duty ashore outside the U.S.; or
(ii) to certain persons temporarily abroad for study.
(B) Once eligible for benefits, a person must maintain a presence in the U.S. in accordance with 42 U.S.C. §1382(f)(1). If a person has been outside the U.S. for 30 consecutive days, the person is not eligible for benefits until the person has been in the U.S. for 30 consecutive days.
(2) Texas residence. HHSC follows 42 CFR §435.403 in determining a person's state residence.
An inmate of a public institution, including a jail, prison, reformatory, or other correctional or holding facility, as defined in 42 CFR §435.1009 and §435.1010, is not eligible for Medicaid payment for Medicaid-covered services received while residing in the public institution.
A person who lives in an institution for mental diseases must be 65 years of age or older to be eligible for a Medicaid-funded program for the elderly and people with disabilities.
Revision 09-4; Effective December 1, 2009
To be eligible for Medicaid, a person must be a resident of the U.S.
To be eligible for an MEPD program under Texas Medicaid, a person must be a resident of the state of Texas. The person must have established residence in Texas and must intend to remain in Texas.
Consider a person a resident of the U.S. and Texas if the person has:
Accept the person's statement on the application or redetermination form regarding Texas residency.
Further evidence of Texas residency is required only if Texas residency is questionable. A person can prove residency by providing document(s) that indicate a Texas address. For example, sources of evidence could be from the following:
Revision 18-1; Effective March 1, 2018
A Medicaid recipient is not eligible for Medicaid for any month during all of which the person is outside of the U.S. If a person is outside of the U.S. for 30 or more days in a row, they are not considered to be back in the U.S. until they are back for 30 days in a row. A person may again be eligible for Medicaid in the month in which the 30 days end if they continue to meet all other eligibility requirements.
Note: The U.S. is considered the 50 States, the District of Columbia and the Northern Mariana Islands.
The period of absence begins with the day after the person's departure from the U.S. The period of absence ends for eligibility purposes:
Develop continuous presence in the U.S. if there is reason to believe the person has been outside the U.S. for 30 consecutive days or a full month.
If otherwise eligible, a person whose eligibility has been denied because of absence from the U.S. can be recertified effective with the day:
Revision 09-4; Effective December 1, 2009
The U.S. residence requirement does not apply to:
Revision 12-3; Effective September 1, 2012
When a recipient moves, the recipient is required to report this change within 10 days to HHSC. A permanent change of address or residence is important for the following reasons:
When a recipient wishes to visit another address within the state for more than a month, the recipient is required to report this change within 10 days to HHSC. If this COA is temporary, a temporary COA does not impact eligibility if the visit is for no longer than three months.
See Section F-3121, Intent to Return Policy.
Revision 09-4; Effective December 1, 2009
To be eligible for Texas Medicaid, a person must be a resident of the state of Texas; that is, the person must have established residence in Texas and must intend to remain in Texas.
Revision 11-4; Effective December 1, 2011
A visit to another state does not terminate Texas residence if the person intends to return when the purpose of the visit is completed.
If a Texas resident visits out of the state (but remains in the United States) with subsequent returns or expressions of intent to return, the person’s Texas residence is not interrupted. A recipient is responsible for requesting a temporary change of address because of an absence from the state. The recipient is also responsible for informing HHSC about the purpose, plans, date of departure and date of planned return.
If the recipient does not contact HHSC before departure, but HHSC learns about the recipient’s absence from some other source, treat this information as a reported change. Attempt to get the recipient’s out-of-state address. After receiving the out-of-state address, contact the recipient to determine whether the absence from the state is temporary, why the recipient left and when the recipient plans to return to Texas.
The length of out-of-state visits is not limited. Review the recipient’s situation every three months to determine where the recipient intends to live permanently.
If the recipient’s absence from the state is temporary and an annual review is scheduled, mail the redetermination packet directly to the recipient at the out-of-state address. If the nature of the recipient’s visit is questionable, additionally request the recipient to:
Review the recipient’s response on the redetermination packet as to residency and intent to remain a Texas resident. Redetermine eligibility based on the recipient’s usual living arrangement unless the recipient no longer indicates Texas residency with the intent to remain a Texas resident.
Reference: Chapter F, Resources, for treatment of a home and out-of-state property.
Revision 09-4; Effective December 1, 2009
A recipient leaving the state with no declared intent to return, and without any evidence that would indicate plans to return, is considered to have moved from the state and Medicaid is denied immediately. If the recipient subsequently returns to the state and declares the intent to remain, Medicaid may be resumed if the recipient meets all other eligibility requirements.
Revision 09-4; Effective December 1, 2009
Revision 09-4; Effective December 1, 2009
If a recipient is eligible for Medicaid in another state and receives Medicaid in that state, the person is not eligible for Medicaid from the state of Texas.
If a person is placed in an institution located in Texas by an agency of another state, the person remains a resident of the state that made the placement.
Revision 09-4; Effective December 1, 2009
Under certain conditions, HHSC makes vendor payment to out-of-state providers on behalf of Texas Medicaid recipients. An out-of-state provider must be contracted with Texas as a Medicaid provider in its own state to provide care or services to Medicaid recipients and the recipients must be eligible for Texas Medicaid for the time involved. No payment commitment can be made until all necessary forms have been completed.
An out-of-state provider can contact Texas' contracted Medicaid claims administrator, currently the Texas Medicaid and Healthcare Partnership (TMHP). TMHP's website for the Texas Medicaid Program is www.tmhp.com.
The provider should furnish as much information as possible about the recipient, including the recipient's full name, Texas Medicaid number, Social Security number, date of birth, date of admission and date of discharge.
Note: If the person receives SSI and intends to live in the other state, inform the person to notify the Social Security Administration immediately about the move.
Revision 09-4; Effective December 1, 2009
If a person from Texas wishes to apply for Medicaid while outside the state, the person should contact the other state's Medicaid agency. The other state's Medicaid agency determines whether:
If the other state's Medicaid agency determines that the person is not eligible for that state's Medicaid, the other state's Medicaid agency contacts HHSC.
HHSC sends the person an application to apply for Texas Medicaid.
When the completed application is returned, use the person's Texas address as the residence address and the out-of-state address as the mailing address. Consider the person as a resident of Texas for the month of application and for the retroactive coverage period if appropriate.
After eligibility is determined, a copy of the decision is sent to the other state's Medicaid agency.
Revision 09-4; Effective December 1, 2009
A person from another state may ask to apply for Medicaid in Texas. Although the opportunity to apply for Medicaid cannot be denied to another, ask the following questions to assist the person in determining whether an application in Texas is appropriate:
In some instances, a person might tentatively declare intent to live in Texas but is found to be ineligible for Medicaid in Texas. Be careful to avoid action that might jeopardize a person's continued eligibility for Medicaid from another state. Although a person might at first declare intent to live in Texas, the person might decide to continue receiving Medicaid from the other state (if the person learns of ineligibility for Medicaid in Texas). Consequently, the person might revoke the declaration of intent to live in Texas and keep the person's residence in the other state.
Revision 09-4; Effective December 1, 2009
If a recipient who receives a money grant (TANF, general assistance, state supplementary payments to SSI) or Medicaid, including Medicare Savings Program benefits, from another state and applies for Medicaid in Texas, determine whether:
Declaration to continue living in the other state — If the recipient declares the intent to continue living in the other state, the recipient is not eligible for Medicaid in Texas. Contact the out-of-state Medicaid agency to determine which services are covered and how providers file claims. Have the recipient inform any Texas Medicaid provider to send any claim to the out-of-state Medicaid agency in the recipient's state of residence.
Declaration to live in Texas — If a recipient who receives a money grant from another state (TANF, general assistance, state supplementary payments to SSI) makes a declaration of intent to live in Texas, this declaration does not automatically establish eligibility. Determine eligibility according to the requirements of the Texas Medicaid Program.
Impact on the medical effective date — If the intent to live in Texas is made by the recipient and the recipient meets Texas MEPD requirements, contact the out-of-state Medicaid agency of the recipient's former state of residence to determine the last day Medicaid claims will be paid by that state. The denial effective date is the last day for which the recipient 's former state of residence will pay Medicaid claims. This is not necessarily the denial effective date on the former state's computer system. The medical effective date for the recipient in Texas is no earlier than the day following the date the recipient 's former state of residence will pay Medicaid claims.
Revision 16-3; Effective September 1, 2016
If an out-of-state SSI recipient indicates an intent to live in Texas, refer the recipient to a Social Security Administration (SSA) office. SSA makes the SSI residence determination. SSA will modify the SSI file indicating the new address. The change in the SSI file will trigger a change in the new address for the Medicaid file.
If the SSI recipient indicates a need for medical care during the month of the move to Texas, give the recipient Form H1300, Declaration of Texas Residency, and refer the recipient to an SSA office for verification of SSI status. SSA accepts Form H1300 via fax.
When the completed Form H1300 is returned, process under ME – Nursing Facility, to begin Medicaid coverage in Texas effective the day after the last date claims will be paid in the former state. Once the application has been disposed, Form H1027-A, Medicaid Eligibility Verification, covering the recipient's residence in Texas can be issued, if needed.
Example: An SSI recipient moves to Texas on Aug. 10 and needs medical care. After receipt of confirmation of SSI status for the month of August and verification from the former state that it will pay no Medicaid claims after Aug. 9, the eligibility specialist processes the application using ME – Nursing Facility for 8/10/YYYY through 8/31/YYYY and issues Form H1027 for those dates, if needed.
Note: Remember that Medicaid coverage in Texas may begin no earlier than the day after the last date claims will be paid by the former state.
If the request for coverage of medical care received in the month of the recipient's move to Texas is made during a subsequent month (or received in the month of the move, but the application is not disposed until the following month), the procedure is the same as above except that the application is processed using ME-SSI Prior for the month of move to Texas. In this instance, the medical effective date would be the first day of the month of move and the denial date would be the last day of that month. Do not issue Form H1027 for a past month. Instead, inform the recipient that Your Texas Benefits Medicaid ID card will be sent so that receipt is within seven to 14 days. The recipient must notify all providers of the added coverage for purposes of timely claims filing.
Example: An SSI recipient moves to Texas on May 24 and receives medical care on May 26. On June 15, the recipient requests assistance for that expense. After receipt of confirmation of SSI status for the month of May and verification from the former state that it will pay no Medicaid claims after May 23, the eligibility specialist processes the application using ME-SSI Prior for 5/1/YYYY through 5/31/YYYY. Inform the recipient that Your Texas Benefits Medicaid ID card will be sent so that receipt is within seven to 14 days, which the recipient must then use to notify provider(s) of Medicaid eligibility.
Process as a manual SSI during the month of move. The medical effective date will be the first of the month.
Note: Even though the medical effective date precedes the actual date the recipient moves into the state, Texas medical claims would not have been incurred prior to the move date.
Revision 09-4; Effective December 1, 2009
In the following situations, the state in which the person resides is influenced by several factors.
Interstate institutional setting issue — If a person, regardless of his/her age, is placed in an institution located in Texas by an agency of another state, the person remains a resident of the state that made the placement.
Reminder: A person who lives in an institution for mental diseases must be age 65 or older to be eligible for an MEPD program.
Revision 09-4; Effective December 1, 2009
A public institution is an establishment that is operated or controlled by a federal or state government unit, or a political subdivision, such as the city or county. An inmate of a public institution, including a jail, prison, reformatory or other correctional or holding facility, is not eligible for Medicaid payment for Medicaid-covered services received while residing in the public institution.
Permanent release — After permanent release from a correctional facility like a jail, prison, reformatory or holding facility, a person is not considered to be under the control of that institution. If, after a permanent release from a correctional facility, a person enters a Medicaid contracted long-term care facility (Medicare, skilled nursing facility (SNF), nursing facility (NF) or intermediate care facility for persons with mental retardation (ICF/MR)), the person is not considered to be in a public institution.
Revision 15-4; Effective December 1, 2015
Revision 09-4; Effective December 1, 2009
Revision 09-4; Effective December 1, 2009
(a) An action by a fiduciary agent is the same as an action by the person for whom the fiduciary agent acts.
(1) An asset held by a fiduciary agent for another person is not a countable asset to the fiduciary agent.
(2) An asset held by a fiduciary agent for another person is a countable asset to the person for whom the fiduciary agent acts, unless otherwise excludable.
(b) A person's resources are available if the resources are being managed by a legal guardian, representative payee, power of attorney, or fiduciary agent. If, however, a court denies a guardian or fiduciary agent access to the person's resources, the resources are not considered available to the person.
(1) If a person's guardianship papers do not show that a legal guardian is prohibited access, and if the court has not subsequently ruled a prohibition, the resources are considered available.
(2) A guardian's routine need to petition the court for permission to dispose of a person's resources is not a prohibition.
(3) When the court rules on a petition to dispose of a person's resources, resources are considered available only to the extent to which the court has made the resources available for the person's benefit.
Revision 15-4; Effective December 1, 2015
Agents act on the person's behalf to sign applications and redetermination packets. When a guardianship exists, only that person can act on the person's behalf to sign applications and redetermination forms.
Guardian of the estate. Under Section 1151.101 and 1151.151 of the Texas Estates Code, it is the duty of the guardian of the estate to take care of and manage the estate as a prudent person would manage the person's own property. The guardian of the estate collects all debts, rentals or claims due to the ward, enforces all obligations in favor of the ward, and brings and defends suits by or against the ward. Only the guardian of the estate can deal with resources.
Guardian of the person. Under Section 1151.051 of the Texas Estates Code, the guardian of the person has the:
For HHSC purposes, the guardian of the person can sign documents, represent the person at hearings, and deal with small amounts of money. The guardian of the person is like other authorized representatives in that they have the authority to protect the interests of the ward.
Under Section 1151.004 of the Texas Estates Code, a court may appoint the same person to be both guardian of the estate and guardian of the person. If there are two guardians, one of the estate and one of the person, then the eligibility specialist must examine the court orders establishing the guardianships to decide which is the most appropriate to represent the person with HHSC.
A person's resources are available to him if they are being managed by a legal guardian, representative payee, power of attorney or fiduciary agent. If, however, a court denies a guardian or agent access to the resources, HHSC does not consider the resources available to the person.
If a person's guardianship papers do not show that the legal guardian is prohibited access, and if a court has not subsequently ruled a prohibition, the person's resources are considered available. A guardian's routine need to petition the court for permission to dispose of a person's resources is not a prohibition. When the court rules on a petition to dispose of a person's resources, resources are considered available only to the extent to which the court has made them available for the person's benefit.
If a legal guardian exists, obtain a copy of the guardianship or power of attorney document. Identify a fiduciary relationship by the way in which a resource is styled. A bank account established in two names connected by "for" or "by" indicates a fiduciary relationship. Another indication is an account established in two names with the designation of "representative payee" next to one of the names, or an account with the designation "special."
Revision 15-4; Effective December 1, 2015
Revision 09-4; Effective December 1, 2009
Whether or not a person is married or has children has some bearing on the treatment of income and resources in determining Medicaid eligibility, both in a community setting or an institutional setting.
If the living arrangement is in a community setting, deeming of income and resources affects the budget.
When the living arrangement is in an institutional setting, spousal impoverishment and dependant allowances may have a bearing on the budget. This chapter focuses on the community setting. Chapter J covers spousal impoverishment policy for institutional settings.
Revision 09-4; Effective December 1, 2009
When neither a person's spouse nor child is in an institutional setting, deeming from spouse-to-spouse or parent-to-child applies in household situations. Only those residing in the household are considered part of the household for deeming purposes.
Exceptions to deeming:
Deeming does apply in noninstitutional care situations (for example, adult foster care), if the eligible person is living with an ineligible spouse.
Revision 15-4; Effective December 1, 2015
For Medicaid purposes, whether two people are married governs whether:
Note: Someone who is married cannot be a child for Medicaid purposes.
Accept a person's allegation that he or she is married unless:
Normally, for Medicaid purposes, two people are married as of the first moment of the month. If a marital relationship ends by death, divorce or annulment in the same month it began, treat the marriage as if it had never existed. Otherwise, the termination of marriage is effective the month after the month of death, divorce or annulment.
In Texas, there are three ways to terminate a marriage:
Persons with void marriages or who have obtained a court annulment of their marriages are treated as though they were always individuals. In the instance of a divorce, persons are considered married through the end of the calendar month in which the divorce is issued.
For spouse-to-spouse deeming purposes, consider the following in the budget:
Revision 09-4; Effective December 1, 2009
A child is someone who is neither married nor the head of a household, and is:
Eligible child for deeming purposes. For deeming purposes, an eligible child is a natural or adopted child under age 18 who lives in a household with one or both parents, is not married and is eligible for Medicaid.
Deeming to such an eligible child no longer applies beginning the month following the month the child attains age 18.
A person attains a particular age on the day preceding the anniversary of his/her birth. Deeming applies in the month of attainment of age 18 regardless of whether an application filed that month is filed before or after the day of attainment.
Ineligible child for deeming purposes. For deeming purposes, an ineligible child must:
Verification and Documentation Guidelines
Revision 09-4; Effective December 1, 2009
A parent whose income and resources are subject to deeming is one who lives in the same household with an eligible child and is:
Deeming applies from a parent to a child when they live together in the same household, except in a Home and Community-Based Services waiver situation. Deem a parent's income and resources to an eligible child beginning the month:
Generally, the same deeming rules that apply to a parent also apply to the spouse of a parent (a stepparent).
Exceptions: Do not deem the income or resources of a stepparent living with an eligible child if the natural or adoptive parent:
Treat any absence by a natural or adoptive parent as permanent unless it is considered a temporary absence, such as military duty.
For parent-to-child deeming purposes, consider the following in the budget:
Note: A person whose parental rights have been terminated due to adoption no longer meets the definition of “parent” for Medicaid purposes. This remains true even if the adopted child later lives in the same household with the former parent.
Refer cases involving adopted Native American children who return to the household of a former parent to your regional attorney. The parent-child relationship in these cases is governed by tribal law and likely requires further legal interpretation.
Revision 14-4; Effective December 1, 2014
All U.S. citizens and nationals are entitled to apply for and receive Medicaid if they provide documentation of their citizenship and identity and meet all other eligibility requirements.
Revision 09-4; Effective December 1, 2009
(a) In accordance with 42 CFR §435.406, to be eligible for a Medicaid-funded program for the elderly and people with disabilities (MEPD), a person must be:
(1) a citizen or national of the United States (U.S.);
(2) an alien who entered the U.S. before August 22, 1996, who has lived in the U.S. continuously since entry, and who meets the definition of a qualified alien at 8 U.S.C. §1641; or
(3) an alien who entered the U.S. on or after August 22, 1996, who has lived in the U.S. continuously since entry, and who meets the definition of a qualified alien at 8 U.S.C. §1641 with the eligibility limitations in 8 U.S.C. §1612 and §1613.
(b) A person must provide proof of eligibility under subsection (a) of this section that establishes both identity and citizenship or alien status, unless the person:
(1) receives Supplemental Security Income (SSI) or has ever received SSI and was not denied due to citizenship;
(2) is entitled to or enrolled in any part of Medicare, as determined by the Social Security Administration (SSA); or
(3) is entitled to federal disability benefits based on SSA disability criteria.
Revision 09-4; Effective December 1, 2009
An individual may become a U.S. citizen by birth or naturalization.
For Medicaid eligibility purposes, a person meets the citizenship requirement if he/she:
The Immigration and Nationality Act of 1952 provides that a child of unknown parentage found in the U.S. while the child is under five years old is a citizen of the U.S. unless it is shown (before the child is 21) that the child was not born in the U.S.
Note: While all U.S. citizens are U.S. nationals, persons born in American Samoa or Swains Island are technically considered non-citizen U.S. nationals. For purposes of Medicaid eligibility, "citizenship" includes these non-citizen nationals when discussed in this section. A person born in the Independent State of Samoa (formerly known as Western Samoa) is not a U.S. national and therefore is not included in the discussion of citizenship in this section.
Revision 13-4; Effective December 1, 2013
The Child Citizenship Act (CCA) of 2000 amended the Immigration and Nationality Act to provide derivative citizenship to certain foreign-born children of U.S. citizens. This applies to individuals who were under age 18 on Feb. 27, 2001, and anyone born since that date. Children included in the provisions of the CCA are:
The CCA provides that foreign-born children who meet the conditions below automatically acquire U.S. citizenship on the date the conditions are met. They are not required to apply for a certificate of naturalization or citizenship to prove U.S. citizenship. These conditions are that the child:
Adopted children automatically become U.S. citizens if they meet all of the above conditions and were:
USCIS, under the Department of Homeland Security, is the federal agency formerly known as the Immigration and Naturalization Service (INS) that is responsible for citizenship and lawful immigration to the U.S.
Revision 11-4; Effective December 1, 2011
Persons from the Compact of Free Association States (CFAS) are not considered U.S. citizens or nationals. The CFAS includes the Republic of the Marshall Islands, the Federated States of Micronesia and the Republic of Palau. Citizens of the CFAS have a special status with the U.S. that allows them to enter the country, work here and acquire a Social Security number without obtaining an immigration status. They are not eligible for Medicaid, unless they have obtained a qualifying immigration status. Those CFAS citizens who do not have one of the immigration statuses listed in Section D-8000, Alien Status, may qualify only for ME-A and D-Emergency.
Revision 13-2; Effective June 1, 2013
A person applying for or receiving Medicaid and declaring to be a U.S. citizen or national must provide evidence of citizenship. Documentation must establish both citizenship and identity.
The following primary evidence documents are acceptable as proof of both citizenship and identity:
If a person does not provide one of these primary evidence documents that establish both U.S. citizenship and identity, the person must provide one document that establishes:
Levels of evidence of citizenship are documents that establish citizenship based on reliability of evidence. See Appendix V, Levels of Evidence of Citizenship and Acceptable Evidence of Identity Reference Guide. Begin with the second level and continue through the levels to explore the most reliable source of documentation of citizenship available. If a document from the second level is not used, include in the case record the reason why a more reliable source of documentation of citizenship is not available.
Example: If a hospital record of birth is used to document citizenship (third level), include in the case record a reason why a source from the second level is not used – "None of the second level of evidence of citizenship documents are available."
Note: When using the levels of evidence of citizenship, the same document cannot be the source to verify both citizenship and identity.
Example: If a person provides a birth certificate to verify citizenship, the person must provide a document other than a birth certificate to verify identity.
Note: Affidavits are to be used only as a last resort if the person is unable to provide any other documentary evidence of citizenship.
Criteria for acceptable affidavits:
Form H1097, Affidavit for Citizenship/Identity, incorporates the required criteria.
Documentation of citizenship and identity is a one-time activity. Once documentation of citizenship is established and documented in the case record, do not request again even after a break in eligibility. The documentation must be available and the case information must not be purged.
If the individual has a Social Security number (SSN), use Social Security Administration (SSA) records to verify citizenship by submitting a citizenship verification request via Wire Third-Party Query (WTPY). If the WPTY response indicates that citizenship is verified, no additional action is required. If the WTPY response indicates that citizenship is not verified and the individual is not exempt from providing verification of citizenship, allow the individual a WTPY Citizenship Resolution Period using policy in D-5320, Using Wire Third-Party Query (WTPY) to Verify Citizenship.
If the individual has applied for an SSN but has not been issued one and:
After allowing reasonable opportunity or a WTPY Citizenship Verification Resolution Period, if the applicant or recipient refuses or fails to provide proof, deny the individual until proof is provided.
If all applicants or recipients in the household refuse or fail to provide proof of citizenship, deny the Eligibility Determination Group (EDG).
Note: If a person declares U.S. citizenship but cannot provide documentation, do not certify the person for ME-A and D-Emergency.
Revision 13-1; Effective March 1, 2013
The following individuals are not required to provide evidence of identity and citizenship when they claim to be U.S. citizens or U.S. nationals and are:
Note: Neither the ineligible spouse of a person applying for Medicaid nor a parent applying for a child are required to provide evidence of citizenship and identity.
Revision 13-2; Effective June 1, 2013
If an applicant has an SSN, use WTPY to verify citizenship. WTPY will return a response indicating that citizenship is verified or not verified for the individual.
If the WTPY response comes back with Codes A or C indicating citizenship is verified, take no further action unless the response also comes back with an indication of death (Code C). If this occurs, treat the death information as a change.
If the WTPY response is returned with any other code indicating that citizenship is not verified and the individual is not exempt from providing verification (see D-5310, Exceptions to Documentation of Citizenship and Identity Requirement), take the following actions:
The day after the WTPY Citizenship Verification Resolution Period expires, TIERS will generate an alert that will create a task. Deny the individual if he/she has not provided citizenship verification.
Applicants requesting three months prior Medicaid coverage must provide citizenship verification before prior coverage can be provided.
If the applicant was denied and later reapplies:
Revision 09-4; Effective December 1, 2009
Notify a person applying for Medicaid about the requirement to provide proof of citizenship and identity. A person receiving Medicaid must also be notified at their next annual redetermination, if proof of citizenship and identity is not already in the case record.
Use Appendix XV, Notification to Provide Proof of Citizenship and Identity, to provide information about the requirement and some of the common acceptable sources of documentation of citizenship and identity.
Add a copy of Appendix XV to each application and redetermination packet. If documentation is already in the case record (for example, SOLQ/WTPY showing Medicare entitlement or enrollment), do not add a copy of Appendix XV to the application or redetermination packet.
Revision 09-4; Effective December 1, 2009
Inform an applicant or recipient of the reasonable opportunity to provide documentation of citizenship and identity. The reasonable opportunity to provide is different for applicants and recipients. Case action will be different if the person indicates that acceptable documentation does not exist, as opposed to refusing to furnish the documentation.
Revision 14-4; Effective December 1, 2014
Allow an applicant a reasonable opportunity to provide documentation. If the person makes a good faith effort to provide documentation of citizenship and is unable to locate or does not provide the documentation by the application due date, but meets all other eligibility criteria, do not deny the application based on the lack of documentation of citizenship. If the applicant meets all other eligibility factors except for verification of citizenship, do not delay certifying the application. Form TF0001, Notice of Case Action, instructs the applicant to submit documentation of citizenship within 95 days for each of the individuals listed on the form.
If the person refuses to provide documentation of citizenship within the 95 days, deny the application based on failure to furnish.
Revision 09-4; Effective December 1, 2009
Reminder: Because Medicare is one of the eligibility criterion for Medicare Savings Programs (MSP), documentation of citizenship is not required for MSP.
If proof of citizenship and identity is not in the case record at the time of redetermination, allow the Medicaid recipient a reasonable opportunity to provide documentation. If the person is making a good faith effort to provide documentation of citizenship and identity and is unable to locate or does not provide the documentation, do not deny eligibility based on the lack of documentation for citizenship or identity at this complete redetermination. Send a notice to the person upon completion of the redetermination informing the person that documentation must be provided by the next complete redetermination in order to continue receiving benefits.
If the person refuses to provide documentation of citizenship and identity, deny based on failure to furnish.
If a Medicaid recipient is denied for failing to provide proof of documentation of citizenship after a reasonable opportunity to provide is given, and the person later reapplies, consider the person as a new applicant when allowing a reasonable opportunity to provide documentation of citizenship and identity.
Revision 09-4; Effective December 1, 2009
If a person is unable to provide documentary evidence of citizenship and identity in a timely manner because of incapacity of mind or body or the lack of an authorized representative to assist, assist the person in obtaining documentary evidence of citizenship and identity by referring the person to appropriate entities.
The following is a nonexclusive list of entities that may be able to provide assistance:
Dialing 2-1-1 will connect persons with community-based organizations that may be able to help.
For persons born out of state, some sources to obtain a birth certificate are:
When assisting a person in providing documentary evidence of citizenship and identity, request available documents, regardless of the level of evidence. Ensure the case record comments address the situation.
Revision 18-1; Effective March 1, 2018
HHSC requires an applicant to provide his/her Social Security number (SSN). An exception to this requirement is for treatment of an emergency medical condition.
HHSC requires an applicant to apply for and obtain, if eligible, all other benefits to which he/she may be entitled, with some exceptions.
Revision 09-4; Effective December 1, 2009
In accordance with 42 CFR §435.910, a person must give his or her social security number to the Texas Health and Human Services Commission as a condition of eligibility, except as provided in §358.205(c) of this subchapter (relating to Alien Status for Treatment of an Emergency Medical Condition).
(c) An undocumented non-qualifying alien applying for Medicaid for the treatment of an emergency medical condition is exempt from providing proof of alien status or providing a Social Security number as described in 42 CFR §435.406(b).
To be eligible for a Medicaid-funded program for the elderly and people with disabilities, a person must apply for and obtain, if eligible, all other benefits to which the person may be entitled, in accordance with 42 U.S.C. §1382(e)(2).
Revision 14-2; Effective June 1, 2014
As a condition of eligibility, a person must furnish HHSC with his/her Social Security number (SSN). If the person is married, the person must also provide his/her spouse's SSN.
State office uses two tape exchanges with the Social Security Administration (SSA) to verify the person’s SSN.
Sources for verification of an SSN are:
The applicant should be given a reasonable opportunity to provide an SSN.
Revision 11-4; Effective December 1, 2011
Explain to the person the necessity and the procedure for obtaining a Social Security number (SSN) if the person does not have one. Document the explanation in the case record.
Give the person or authorized representative notice that an SSN must be obtained by the first redetermination. This notice can be on the eligibility letter or on Form H1020, Request for Information or Action. The person must apply for and secure an SSN by the redetermination date.
Complete Form H1106, Enumeration Referral, which is found in the Texas Works (TW) Handbook. Upon receipt of Form H1106, the Social Security Administration (SSA) processes an SSN application.
If necessary, give SSA-5, Application for a Social Security Number, to the person and assist the person in completing the SSA-5. Inform the person to forward the SSA-5 to SSA with proof of his/her age, identity and citizenship (or lawful admission to the U.S.).
Grant eligibility at application, if otherwise eligible, pending receipt of an SSN. Tell the person to inform HHSC as soon as the SSN is received. Upon receipt, enter the SSN in the system of record.
At the first redetermination, verify that the person applied for an SSN if the person cannot provide an SSN. Failure of the person or authorized representative to follow through and secure an SSN is grounds for denial at the first redetermination. Document the circumstances of the denial in the case comments.
Revision 09-4; Effective December 1, 2009
Medicaid is intended to be a program of last resort. Therefore, it is important to assess the other benefits for which a person may be eligible based on the person's own activities or on indirect qualifications through family circumstances.
If a person is not receiving potential benefits, notify the person in writing of the requirement to apply for and comply with the application requirements of the other benefit(s).
A person is not eligible for Medicaid if:
The notice informs the person or authorized representative that the person must take all appropriate steps to pursue eligibility for other benefits within 30 days of receipt of such notice. Appropriate steps include:
Revision 09-4; Effective December 1, 2009
"Other benefits" includes any payments for which a person can apply that are available to that person on an ongoing or one-time basis of a type that includes annuities, pensions, retirement benefits or disability benefits, including:
These benefits are common in that they:
See Section D-6340 through Section D-6380 for details regarding benefits subject to the application requirement.
Revision 09-4; Effective December 1, 2009
"Other benefits" exempt from the requirement to apply for other benefits are:
Revision 09-4; Effective December 1, 2009
"Other benefits" do not include:
Revision 09-4; Effective December 1, 2009
If a person who has no income applies for Medicaid with HHSC, refer that person to the Social Security Administration (SSA) for SSI benefits. SSI eligibility will provide a greater benefit to the person by allowing the person to receive a cash benefit as well as Medicaid.
Exception: Process the application and do not refer a person who has no income to SSA for SSI if the application is for Medicaid coverage for:
Revision 18-1; Effective March 1, 2018
A person who has applied for Supplemental Security Income (SSI) and who appears to be SSI-eligible, but for whom processing of the SSI claim has been delayed, may be certified under the appropriate MEPD program pending adjudication of the SSI claim. In order to certify MEPD eligibility, however, all eligibility criteria must be met. This expedited procedure does not negate the requirement that disability be established, or the utilization of benefits, or 30 consecutive days of institutionalization, if applicable.
Consider the age of the person when temporarily certifying the person.
DDU cannot render a disability decision for SSI applicants unless 90 days have elapsed since the SSI file date and SSA's disability decision is still pending. If SSA finds the person not to be disabled after the person has been certified for MEPD coverage, initiate denial of the MEPD case.
Once the person is eligible for SSI, the coverage in TIERS is adjusted via an interface.
The procedures outlined in this section are not routine procedures. Use them only in situations where there has been a delay in an SSI claim already filed. (The MEPD specialist must verify and document that an SSI application has been filed.) The procedure also applies only to applicants who are eligible under an existing MEPD coverage group. For example, there is no existing MEPD program that provides full Medicaid coverage on an ongoing basis to community-based clients with countable income below the SSI federal benefit rate.
Revision 09-4; Effective December 1, 2009
The most common types of benefits from the U.S. Department of Veterans Affairs (VA) are:
Explore the possibility of receipt of, or potential eligibility for, a VA benefit when it appears that a person is:
A person who is potentially eligible for some VA benefits must apply for those benefits. When referring a person to the VA, recommend that the person call the VA first to obtain information on application requirements and proof the person may need to bring.
Revision 10-1; Effective March 1, 2010
Refer a person for VA pension payments (based on a nonservice-connected disability) if all of the following conditions are met:
Refer the person for VA compensation payments if the veteran or deceased service person suffered a service-connected disability (even though minor) or died.
Refer a person for VA payment increases for medical expenses. However, do not monitor for the person’s compliance to apply for other benefits when it is to increase the VA payment for medical expenses. These VA payment increases for medical expenses are known as aid and attendance, housebound benefits or additional payments for unusual medical expenses and are considered exempt payments that do not affect eligibility or co-payment.
See the following references:
Exceptions:
See the following references:
Revision 14-1; Effective March 1, 2014
The wartime periods are:
| War | Time Periods |
| World War I | Apr 6, 1917 to Nov 11, 1918 |
| World War II | Dec 7, 1941 to Dec 31, 1946 |
| Korea | Jun 27, 1950 to Jan 31, 1955 |
| Vietnam (served in the Republic of Vietnam) | Feb 28, 1961 to Aug 4, 1975 |
| Vietnam (served other than in the Republic of Vietnam) | Aug 5, 1964 to May 7, 1975 |
| (Persian) Gulf War | Aug 2, 1990 through a date to be set by law or presidential proclamation (per VA) |
| Operation Enduring Freedom (Afghanistan) and Operation Iraqi Freedom | 2001 to present Note: This war period is not yet listed on the VA's website. Refer person to VA Benefit Counselor at 1-800-827-1000. |
Revision 09-4; Effective December 1, 2009
The VA may take a dependent's needs into account in determining a pension. Usually, however, the VA does not make a pension payment directly to a dependent during the lifetime of the veteran. Instead, the amount of the veteran's basic pension is increased if the veteran has dependents.
Augmented VA payment — A VA pension payment that has been increased for dependents is an augmented VA payment. For Medicaid purposes, the augmented benefit includes a designated beneficiary's portion and one or more dependents' portions.
Apportioned VA payment — A VA compensation payment made directly to the dependent of a living veteran is an apportioned payment. Apportionment is direct payment of the dependent's portion of VA benefits to a dependent spouse or child. The VA decides whether and how much to pay by apportionment on a case-by-case basis. Apportionment reduces the amount of the augmented benefit payable to the veteran or veteran's surviving spouse.
Revision 09-4; Effective December 1, 2009
To be eligible for Medicaid, a dependent of a veteran must apply for apportionment (direct payment) of an augmented VA benefit if the dependent specifically:
Dependents who are receiving a VA benefit by apportionment do not receive automatic cost-of-living adjustments. Do not refer these individuals to the VA to request an increase.
Revision 09-4; Effective December 1, 2009
If a person alleges either injury on the job or has what appears to be a work-related impairment, refer him/her to the appropriate agency for assistance.
Revision 09-4; Effective December 1, 2009
Refer a person for a private sector pension if the person or the person's former (divorced or deceased) spouse:
Revision 09-4; Effective December 1, 2009
Refer a person for a public sector pension if the person or the person's former (divorced or deceased) spouse, or a deceased parent if the person is a child, is not or has not received a pension based on public sector employment and meets the guidelines below:
Revision 09-4; Effective December 1, 2009
Revision 09-4; Effective December 1, 2009
Do not require a deemor to apply for other benefits. If a deemor applies for and receives other benefits on his/her own initiative, the amount of benefits he/she receives and/or retains is subject to the deeming policies for income and resources.
Revision 09-4; Effective December 1, 2009
Most of the types of benefits for which a person must apply offer choices about the method of payment. The person must apply for all other benefits payable at the earliest month and in the highest amount available based on the earliest month.
Note: Irrevocable choices and selections of benefits from pensions or retirement programs made before a person applies for Medicaid do not affect eligibility.
Revision 09-4; Effective December 1, 2009
Certain pensions and retirement programs permit a person to elect survivor's benefits for dependents by electing a reduced retirement benefit. Inform the person that he/she must elect the higher current benefit to retain Medicaid eligibility. Election of the reduced retirement benefit will result in the loss of Medicaid eligibility until such time as the pension or retirement program election is changed or the option for change is no longer available.
Some pensions and retirement programs require a spouse to apply a waiver of rights to a survivor's benefit. The person is not penalized for failing to comply with the requirement to apply for other benefits if the reduced retirement benefit results from the spouse’s refusal to sign a waiver of rights to a survivor's benefit.
Revision 09-4; Effective December 1, 2009
If a person can choose between a lump sum or an annuity as the payment method for a benefit, inform the person that he/she must choose the annuity option.
Consider lump sum payments as follows:
For a purchased annuity, see related policy in Chapter F, Resources, and Chapter I, Transfer of Assets.
Revision 09-4; Effective December 1, 2009
If a person can select the month in which benefits begin, whether retroactively or prospectively, direct the person to elect the earliest month benefits can begin, regardless of the impact on other benefits from that program. Election of a later month of entitlement to qualify for higher ongoing benefits or to protect benefits paid to other individuals is cause for denying Medicaid. Election of a later month will result in the loss of Medicaid eligibility until such time as the election is changed or the option for change is no longer available.
Revision 09-4; Effective December 1, 2009
If denial has occurred because of failure to pursue other benefits, establish or reestablish eligibility when:
Revision 09-4; Effective December 1, 2009
A person is eligible for Medicaid, despite failure to apply for other benefits within the 30-day period or to take other necessary steps to obtain other benefits, if there is good reason for not doing so. For example, there is good reason if:
According to Public Law 101-508, a person is not required to accept, as a condition of eligibility, payments that a state may make as compensation to victims of crime.
When applying for or receiving benefits under a Medicare Savings Program, a person is not required to apply for SSI benefits in order to be eligible for MSP coverage.
Revision 09-4; Effective December 1, 2009
No Apparent Eligibility — If a person does not meet the basic eligibility requirements for a benefit:
Prior Denial — If the person alleges having applied for other benefits previously and having been denied for reasons other than failure to pursue, accept the signed statement regarding the denial, unless there is evidence to the contrary.
Contributions Withdrawn — If a person alleges withdrawal of contributions from a public sector pension, accept the person's signed statement regarding the withdrawal unless:
Application Pending — If a person alleges an application for another benefit is pending:
Consider the followingwhen assessing the possibility of other benefits a person may be eligible for:
Revision 18-1; Effective March 1, 2018
Revision 09-4; Effective December 1, 2009
(a) Medicaid is considered the payor of last resort for a person's medical expenses. As a condition of eligibility, in accordance with 42 CFR §§433.138 - 433.148, an applicant or recipient must:
(1) assign to the Texas Health and Human Services Commission (HHSC) the applicant's or recipient's right to recover any third-party resources available for payment of medical expenses covered under the Texas State Plan for Medical Assistance; and
(2) report to HHSC any third-party resource within 60 days after learning about the third-party resource.
(b) If HHSC determines that a person's employer-based health insurance is cost-effective, the person must participate in HHSC's Health Insurance Premium Payment program as a condition of eligibility. HHSC denies eligibility to a person who voluntarily drops his or her employer-based health insurance or fails to provide HHSC with the information needed to determine cost effectiveness.
Revision 09-4; Effective December 1, 2009
Texas requires, as conditions of Medicaid eligibility, that a person must:
Medicaid is usually the payer of last resort. A TPR is a source of payment for medical expenses other than the person, HHSC or Medicaid. A TPR must be applied toward the person's medical and health expenses.
Under state law, an applicant or recipient of Medicaid automatically gives HHSC his/her right to financial recovery from personal health insurance, other recovery sources or personal injuries, to the extent HHSC has paid for medical services. This allows HHSC to recover the costs of medical services paid by the Medicaid program. Any applicant or recipient who knowingly withholds information regarding any sources of payment for medical services violates state law.
Fraud Referrals — Medicaid recipients must report any TPR within 60 days of learning about the coverage or liability. An applicant or recipient who knowingly withholds information regarding any sources of payment for medical services violates state law.
Refer the person for fraud, if the person:
Denial — Deny the person if the person refuses to:
See Appendix XVI, Documentation and Verification Guide.
Revision 18-1; Effective March 1, 2018
TPRs include:
A TPR is any individual, entity or program, including health insurance, that is or may be legally liable to pay all or part of the costs for medical assistance before money from the Medicaid program is spent.
Revision 18-1; Effective March 1, 2018
Examples of TPRs include, but are not limited to, the following:
Liability or casualty insurance and court settlements — Accidental injuries may result in third parties being liable for medical expenses. The usual sources of payment for medical expenses in these situations are automobile insurance; homeowners insurance; owners', landlords' and tenants' insurance; workers' compensation and lawsuit settlements.
Individual or group health insurance — Health insurance policies include individual or group contracts and commercial hospital, medical and surgical policies. A recipient may have medical insurance coverage from current employment, residual coverage from previous employment or private insurance paid for by the recipient or a relative. A recipient's relative may have personal or group insurance that covers the recipient's medical expenses.
TRICARE, formerly known as CHAMPUS, is a health insurance plan available to dependent children and spouses of active, retired and deceased military services personnel.
Parts A and B of Medicare provide a TPR for Medicaid recipients entitled to Medicare.
Revision 18-1; Effective March 1, 2018
Effective Feb. 22, 2013, HHSC (formerly DADS) implemented a Cost Avoidance method of Third Party Recovery for Nursing Facility, Hospice, and Non-State Intermediate Care Facility for Persons with Intellectual Disabilities (ICF/IID). Cost Avoidance requires that the provider bill the client’s long term care insurance (if applicable) before billing Medicaid. This ensures that Medicaid is the payer of last resort.
A person must reimburse HHSC as soon as they receive the third-party payment for medical services already paid by Medicaid.
A provider who receives a third party payment for services Medicaid has already paid must process an adjustment claim to report the third party payment amount on the claim. The Medicaid paid claim is reduced by the amount of the other insurance payment reported on the adjustment claim. Providers can contact Texas Medicaid and Healthcare Partnership (TMHP) for assistance with adjustment claims at 800-626-4117 option 3. To report other insurance coverage for a Medicaid individual, contact TMHP at the same number as above, option 6.
The two methods for using TPRs are:
Revision 18-1; Effective March 1, 2018
Inform the person to:
| If the person, the employer or other sources indicate that ... | then complete ... |
|---|---|
| Medicaid-eligible household members have private health insurance coverage, | information about the private health insurance on:
|
| health insurance coverage is available for Medicaid-eligible household members, but the members are not enrolled in the health insurance plan, | information about the available health insurance on:
|
To contact the TPR Unit with questions or problems concerning TPR:
HIPP Program Notes: Individuals approved for the HIPP Program receive reimbursement for the employee’s portion of an employer-sponsored health insurance premium payment. For eligibility and co-payment calculations, HIPP reimbursement checks are not considered income. For co-payment calculations, the reimbursed health insurance premium payment is not considered an incurred medical expense.
TMHP will take action to deny all benefits to a recipient who voluntarily drops his or her health insurance coverage or fails to provide TMHP with the information needed to determine cost effectiveness.
A recipient cannot appeal decisions made by TMHP. To obtain assistance in resolving problems or issues concerning HIPP, contact the TPR HIPP Unit at 800-440-0493.
For more information about the HIPP program, see HHS' HIPP website: https://hhs.texas.gov/services/financial/health-insurance-premium-payment-hipp-program.
Recipients may also call 800-440-0493 for more information.
Revision 18-1; Effective March 1, 2018
Major sources for post-payment recovery are liability or casualty insurance and court settlements resulting from accidental injuries. If a recipient reports an injury that requires medical treatment for which liability or casualty insurance may provide payment, ask the recipient to provide the date of the accident.
Report the recipient’s name, Medicaid number, and date of the accident to the HHSC TPR Unit and Provider Recoupment and Holds.
Third Party Recovery
HHSC OIG/TPR Unit
Mail Code 1354
4900 North Lamar Blvd.
Austin, TX 78751
Information can be sent via email to:
MCD_Third_Party@hhsc.state.tx.us; and
Provider Recoupments and Holds
Texas Health and Human Services Commission
Mail Code W-406
P.O. Box 149030
Austin, TX 78714-9030
701 W. 51st Street
Austin, TX 78751
When the TPR Unit at HHSC becomes aware of accidental injuries, it will seek cost recovery from recipients who receive a health insurance or settlement payment for medical services already paid by Medicaid.
Use Form H1210, Subrogation (Trusts/Annuities/Court Settlements), to report to Provider Claims any potential subrogation funds available from trusts, annuities and court settlements.
When a recipient reimburses HHSC for medical expenses, the reimbursement should be in the form of a personal check, cashier's check or money order. If reimbursement is received from a recipient, follow these steps:
| Step | Procedure |
|---|---|
| 1 | Give the recipient Form H4100, Money Receipt. |
| 2 | Enter the types and dates of the medical services in the "For" section of Form H4100. |
| 3 | If unsure about which medical services are involved, attach a memorandum giving as much information as possible about the reimbursement. |
| 4 | Attach a copy of any other information identifying the nature of the payment, such as a statement from the insurance company. |
| 5 | Send the reimbursement, a copy of Form H4100, and other information, if any, to HHSC Accounts Receivable, P.O. Box 149055, Mail Code 1470, Austin, TX 78714-9055. |
State office verifies the actual claims paid by Medicaid and refunds any overpayment.
Revision 18-1; Effective March 1, 2018
Because the Social Security Administration (SSA) determines eligibility for Supplemental Security Income (SSI) recipients, Medicaid eligibility specialists are not routinely involved in TPR information from these individuals. Instead, at the time an SSI recipient is certified for Medicaid and annually thereafter, the state office generates a letter to the recipient requesting information about any insurance coverage they may have. The recipient completes the insurance questionnaire enclosed with the letter and returns it in the envelope provided for that purpose directly to:
Texas Medicaid and Healthcare Partnership (TMHP)
Third Party Resources Unit
P.O. Box 202948
Austin, TX 78720-2948
TMHP enters data from the returned insurance questionnaire into the TPR system. TMHP also maintains a toll-free number (800-846-7307, option 2) that SSI recipients may use to ask questions about the form or about their health insurance.
SSA also reports TPR information for SSI recipients to HHSC. An SSI recipient who refuses to cooperate with HHSC in verifying TPR is ineligible for Medicaid.
Occasionally, an SSI recipient may ask for an explanation or help completing the insurance questionnaire. Explain the purpose of the form and the proper use of available TPRs and help the recipient complete and submit the form, if necessary. If an SSI recipient asks about a change in insurance coverage or about the availability of TPRs related to accidental injury, have the recipient report this information to the TPR Unit at 800-846-7307, option 2 or:
Texas Medicaid and Healthcare Partnership
Third Party Resources Unit
P.O. Box 202948
Austin, TX 78720-2948
Revision 09-4; Effective December 1, 2009
In Texas, SSA must inform SSI applicants and recipients and SSI recipients who move to Texas about the requirement under Section D-7200, Cooperation and Assignment of Rights for Medicaid Eligibility.
Revision 17-1; Effective March 1, 2017
Long-term care insurance policies pay for nursing facility care. The policies purchased by individuals specify the benefits covered. Long-term care insurance policies do not affect Medicaid eligibility. For individuals who have such policies, report the policies as a third-party resource (TPR), using Form H1039, Medical Insurance Input.
As of March 1, 2015, HHSC Provider Recoupment and Holds cannot accept other insurance payments for individuals when a managed care organization (MCO) pays the nursing facility claims. Nursing facility providers must contact the appropriate MCO for claims submitted on Medicaid eligible individuals enrolled in MCOs on or after March 1, 2015 with service dates on or after March 1, 2015.
For questions about other insurance on Fee-for-Service (FFS) claims or for claims submitted prior to March 1, 2015, contact HHSC Provider Claims Services at 512-438-2200, Option 4.
Send long-term care insurance checks to Provider Claims Services at the Texas Health and Human Services Commission. The payment of large sums from long-term care insurance companies may affect an individuals' resource eligibility if Provider Claims Services provides a refund.
Procedure for TPR checks received for long-term care insurance coverage on FFS claims:
Provider Recoupments and Holds, W-406
P.O. Box 149081
Austin, TX 78714-9081
The policy and procedures in this section do not apply to Long-Term Care Partnership (LTCP) qualified policies. Information for LTCP qualified policies is located in Chapter P, Long-Term Care Partnership (LTCP) Program.
Revision 18-1; Effective March 1, 2018
The HIPP program is a Medicaid benefit that helps families pay for employer-sponsored health insurance.
To qualify for HIPP, an employee must either be Medicaid eligible or have a family member who is Medicaid eligible. The HIPP program may pay for individuals and their family members who receive, or have access to, employer-sponsored health insurance benefits when it is determined that the cost of insurance premiums is less than the cost of projected Medicaid expenditures.
Note: An employee and the employee's Medicaid-eligible family member must be enrolled in the employer-sponsored health insurance in order to receive HIPP reimbursements.
Medicaid-eligible HIPP enrollees do not have to pay out-of-pocket deductibles, co-payments, or co-insurance for health care services that Medicaid covers when seeing a provider that accepts Medicaid. Instead, Medicaid reimburses providers for these expenses.
HIPP enrollees who are not Medicaid eligible must pay deductibles, co-payments, and co-insurance required under the employer's group health insurance policy.
Report individuals who are potentially eligible for HIPP on Form H1039, Medical Insurance Input. Send Form H1039 to HHSC's Third Party Resource (TPR) Unit, Mail Code 1354, or send via email to: MCD_Third_Party@hhsc.state.tx.us.
For the Medicaid Buy-In for Children (MBIC) program, when employer-sponsored insurance is entered into the Texas Integrated Eligibility Redesign System (TIERS), this information is automatically sent to HIPP. HIPP eligibility does impact the MBIC premium amount. See Section N-7400, Premium Amounts.
HHSC's TPR Unit refers Form H1039 to the current state Medicaid contractor, TMHP. If TMHP determines it is cost-effective for Medicaid to pay the individual's employer-sponsored health insurance premiums, then TMHP sends:
Note: Because an employer-sponsored health insurance premium deduction has already been counted as part of the recipient's income, a HIPP reimbursement check sent to recipients by TMHP is not income. Do not consider an incurred medical deduction for the reimbursed premium as income for recipients participating in HIPP.
TMHP will terminate HIPP enrollment if the individual is no longer enrolled in health insurance coverage or fails to provide TMHP with the information needed to determine cost effectiveness or proof of premium payments.
For more information about the HHSC's HIPP program, see HHSC's website: https://hhs.texas.gov/services/financial/health-insurance-premium-payment-hipp-program, or contact the Medicaid HIPP program at MCD_HIPP_Program@hhsc.state.tx.us.
Individuals may call 800-440-0493 for more information. Individuals may also visit the HIPP website at https://hhs.texas.gov/services/financial/health-insurance-premium-payment-hipp-program.
Revision 18-1; Effective March 1, 2018
Another post-payment resource is through the MERP. On March 1, 2005, Texas implemented MERP in compliance with federal Medicaid and state laws. The program is managed by HHSC. Under this program, HHSC may file a claim against the estate of a deceased Medicaid recipient who: 1) was age 55 or older at the time Medicaid services were received; and 2) initially applied for certain long-term care services and supports on or after March 1, 2005. The most complete, current and accurate source of information regarding MERP is the HHS website, Medicaid Estate Recovery Program.
Long-term care services and supports that are subject to MERP include:
Notes:
The acceptance of Medicaid assistance for the covered long-term care services provides a basis for a Class 7 probate claim. (This means there are six other classes of claims that receive priority in payment from the estate before Texas gets paid.) HHSC files a MERP claim in probate court against the estate of a deceased Medicaid recipient to recover the cost of certain Medicaid long-term care services and supports received by the Medicaid recipients. MERP will follow claims procedures specified in the Texas Estates Code and HHSC’s Medicaid Estate Recovery Program rules found at 1 TAC, Part 15, Chapter 373.
For notification requirements, see Section B-2620, HHSC MERP Notification Requirements.
Revision 17-4; Effective December 1, 2017
Revision 09-4; Effective December 1, 2009
(a) In accordance with 42 CFR §435.406, to be eligible for a Medicaid-funded program for the elderly and people with disabilities (MEPD), a person must be:
(1) a citizen or national of the United States (U.S.);
(2) an alien who entered the U.S. before August 22, 1996, who has lived in the U.S. continuously since entry, and who meets the definition of a qualified alien at 8 U.S.C. §1641; or
(3) an alien who entered the U.S. on or after August 22, 1996, who has lived in the U.S. continuously since entry, and who meets the definition of a qualified alien at 8 U.S.C. §1641 with the eligibility limitations in 8 U.S.C. §1612 and §1613.
(b) A person must provide proof of eligibility under subsection (a) of this section that establishes both identity and citizenship or alien status, unless the person:
(1) receives Supplemental Security Income (SSI) or has ever received SSI and was not denied due to citizenship;
(2) is entitled to or enrolled in any part of Medicare, as determined by the Social Security Administration (SSA); or
(3) is entitled to federal disability benefits based on SSA disability criteria.
(a) Title XIX of the Social Security Act (42 U.S.C. §1396 et seq.) and 42 CFR §440.255 require the state to provide Medicaid for the treatment of an emergency medical condition to an alien who is ineligible for regular Medicaid due to immigration status. The Texas Health and Human Services Commission administers the program in Texas.
(b) To qualify for Medicaid for the treatment of an emergency medical condition, an alien must:
(1) be:
(A) a qualified alien as defined in 8 U.S.C. §1641 and not meet the requirements to receive Medicaid as described in 8 U.S.C. §1612 and §1613; or
(B) an undocumented non-qualifying alien as described in 8 U.S.C. §1611;
(2) be otherwise eligible for regular Medicaid services; and
(3) require treatment of an emergency medical condition as described in 42 CFR §440.255.
(c) An undocumented non-qualifying alien applying for Medicaid for the treatment of an emergency medical condition is exempt from providing proof of alien status or providing a Social Security number as described in 42 CFR §435.406(b).
Revision 09-4; Effective December 1, 2009
To lawfully remain in the U.S., a person who is not a U.S. citizen or a U.S. national and is present in the U.S. must have authorization from the Department of Homeland Security (DHS).
Revision 17-4; Effective December 1, 2017
Alien — A person who is not a citizen or national of the U.S.
Foreign-born Alien — A person born outside the 50 states, District of Columbia, American Samoa, Swains Island, Guam, Northern Mariana Islands, Puerto Rico or the U.S. Virgin Islands.
U.S.-born Alien — A person born in the U.S. who, as a matter of international law, is not subject to the jurisdiction of the U.S. This occurs when a person is born to a parent who is a foreign diplomatic officer (ambassador, minister, chargé d' affaires, counselor, secretary or attaché of an embassy, legation or European Economic Community delegation).
Admission Stamp — The Department of Homeland Security (DHS) places the admission stamp in the alien’s passport, on the alien’s machine readable immigrant visa (MRIV) or on an I-94. The stamp shows:
The alien's class of admission and the validity date (that is, the date admitted until) are endorsed in ink by the admitting inspector.
Alien Category — A category based on the date of the alien status (date of entry) and the alien’s classification.
Alien Classification — A classification determined by the code on the alien's I-94 or I-551 that identifies the terms and conditions of the alien’s admission to the U.S.
Asylee — An alien already in the U.S. or at a port of entry who is granted asylum in the U.S. Asylum may be granted to those persons who are unable or unwilling to return to their countries of nationality, or to seek the protection of those countries, because of persecution or a well-founded fear of persecution.
Compact of Free Association Nonimmigrant — A permanent nonimmigrant who is residing in the U.S. under the provisions of the Compact of Free Association Act of 1985. Under this act, citizens of the Republic of the Marshall Islands, the Federated States of Micronesia and the Republic of Palau may enter, reside and work in the U.S. without restriction.
Conditional Resident Alien — An alien granted a two-year period of permanent resident status based on a “qualifying” marriage to a U.S. citizen or national, or to a permanent resident alien. A conditional resident alien has the same DHS documents as an immigrant lawfully admitted for permanent residence (LAPR), except that the I-551 expires after two years.
Note: The Immigration Act of 1990 also grants permanent resident status to alien entrepreneurs who enter the U.S. to engage in a new commercial enterprise and meet certain criteria for investment. These persons must apply for termination of conditional status or the LAPR status terminates.
DHS — Department of Homeland Security. On March 1, 2003, DHS absorbed the Immigration and Naturalization Service (INS).
Green Card — A vernacular term for the Alien Registration Receipt Card (I-551, I-151, AR-3 or AR-3a). The current version of the card is not green.
Illegal Alien (undocumented alien) — A foreign national who entered the U.S. without inspection or with fraudulent documentation or who, after entering legally as a nonimmigrant, violated status and remained in the U.S. without authorization.
Immigrant — An alien who has been lawfully afforded the privilege of residing permanently in the U.S.
Immigrant Visa — A document on security paper, issued by a U.S. consul abroad, that permits a foreign national to apply to DHS for admission into the U.S. as a permanent resident.
Immigration Status — The legal status conferred on an alien by immigration laws.
INA — Immigration and Nationality Act.
IRCA — Immigration Reform and Control Act of 1986. This is public law (P.L. 99-603) that amended and repealed certain sections of the INA. It provides for the legalization of certain illegal aliens and updates the registry date that allows DHS to process certain illegal aliens differently.
INS — Immigration and Naturalization Service. On March 1, 2003, the former Immigration and Naturalization Service officially became the Bureau of Citizenship and Immigration Services (BCIS), operating under the Department of Homeland Security.
Lawful Permanent Resident (LPR) — Aliens (non-citizens) who are lawfully authorized to live permanently within the United States.
Lawfully Admitted but Not for Permanent Residence — An alien lawfully admitted to the U.S. but not a permanent resident.
Nonimmigrant — An alien temporarily in the U.S. for a specific purpose. This group includes foreign government officials, visitors, students and temporary employees.
Nonimmigrant Visa — A stamp placed in a foreign national's passport which permits the foreign national to apply for temporary admission into the U.S.
Parolee — An alien who appears to be inadmissible to the inspecting DHS officer, but who is allowed to enter the U.S. under emergency conditions or when that alien's entry is determined to be in the public interest. Although parolees are required to leave when the conditions supporting their parole cease to exist, they may sometimes adjust their immigration status to asylee.
Passport — A travel document issued by a competent authority showing the bearer's origin, identity and nationality, if any, that is valid for the entry of the bearer into a foreign country.
Refugee — A person who is outside his country of nationality who is unable or unwilling to return to that country because of persecution or a well-founded fear of persecution. Unlike asylees, refugees apply for and receive this status prior to entry into the U.S.
SAW — Special Agricultural Worker, that is, seasonal agricultural workers residing in the U.S. who qualify for legalization under section 302 or 303 of IRCA. SAWs are treated as LAPR for Medicaid purposes.
Temporary Protected Status (TPS) — TPS is granted by DHS to persons living in the U.S. who are from certain designated countries where unsafe conditions make it a hardship to return to that country. Persons who qualify for TPS are authorized to remain in the U.S. for a specific period of time and are eligible for an I-766, Employment Authorization Document (EAD). Initial TPS aliens are issued an approval notice and EAD with “A-12” or “C-19” category; re-registered TPS aliens receive an approval notice and EAD only if requested.
U.S. Citizenship and Immigration Services (USCIS) — USCIS is the government agency that oversees lawful immigration to the U.S. The former Immigration and Naturalization Service was dismantled and separated into three components within the Department of Homeland Security:
Visa — A document issued by U.S. embassies and consulates in foreign countries that is a permit for a foreign national to proceed to a U.S. port of entry to apply to DHS for admission to the U.S. The DHS immigration office at the port of entry decides the conditions (that is, category of admission and length of stay in the U.S.) based on the visa category.
I-94 — The Arrival/Departure Record issued by DHS to all documented nonimmigrants (that is, students, visitors, parolees, refugees and Cuban/Haitian entrants).
I-151 — The version of the Alien Registration Receipt Card issued to aliens by INS from July 1946 through late 1978.
Grommeted I-151 — The Alien Registration Receipt Card with a grommet (that is, a hole surrounded by a metal ring) in the upper right corner. This card was previously issued by INS to an alien who had LAPR status but lived in Mexico or Canada and commuted to the U.S. to work.
I-551 — The current version of the Alien Registration Receipt Card (Type 1). Beginning in 1978, this card has been issued by INS (now DHS) to immigrants who have been granted LAPR status and are residing in the U.S. The second digit of the ISS/T field identifies the type of card.
Commuter I-551 — The Alien Registration Receipt Card (Type 2). This card is issued by DHS to an alien who has been granted LAPR status but lives in Mexico or Canada and commutes to the U.S. to work. The second digit of the ISS/T field identifies the type of card.
Temporary I-551 — The card issued to either an immigrant who has just entered the country and has not yet received an I-551 or to an immigrant who has lost his Alien Registration Receipt Card and has applied for a replacement I-551.
I-688 — A temporary resident card that was laminated and issued by INS to legalized aliens and SAWs whose status had been adjusted to lawful temporary resident (LTR). In certain cases, a label (I-688EXT) may have been placed on the back of the card to use until the I-551 was issued. This is not a current immigration form; DHS is no longer issuing this document. There are no currently valid I-688 cards (or I-688 cards with extension stickers).
I-688A — An employment authorization card issued by INS to legalize SAW applicants who filed an application to adjust their status to LTR. This is not a current immigration form; DHS is no longer issuing this document. There are no currently valid I-688A cards.
I-688B — The employment authorization document that was a laminated card given by DHS to nonimmigrants who were newly admitted or those with previous employment authorization who needed an extension. It replaced the “employment authorization” annotation previously placed on other DHS documents. This is not a current immigration form; DHS is no longer issuing this document. There are no currently valid I-688B cards.
I-688EXT — Form I-688 with an extended period of validity of the Temporary Resident Card. In certain situations, INS placed a sticker on the back of the card. This served as temporary evidence of permanent residence until the alien received an I-551. This is not a current immigration form; DHS is no longer issuing this document. There are no currently valid I-688 cards or I-688 cards with extension stickers.
I-766 — Employment Authorization Document. Only currently-valid document verifying employment authorization. It replaced all other employment authorization documents issued previously.
Revision 17-4; Effective December 1, 2017
For Medicaid eligibility purposes, an alien is any person who is not a natural-born or naturalized citizen or national of the U.S.
Effective Aug. 22, 1996, the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA) limited an alien’s eligibility for Medicaid.
Most aliens must meet two requirements to be eligible for full Medicaid and/or a Medicare Savings Program (MSP):
Generally, aliens are now referred to as:
Qualified aliens are potentially eligible for ongoing full Medicaid benefits and/or MSP. Non-qualified aliens are not eligible for ongoing Medicaid coverage however, may qualify for limited Medicaid eligibility for the treatment of an emergency medical condition only.
Except when it involves undocumented aliens, use the Systematic Alien Verification for Entitlements (SAVE) Verification Information System (VIS) to verify the alien status on all noncitizens.
Revision 13-1; Effective March 1, 2013
Except when it involves undocumented aliens, use SAVE VIS to verify the alien status on all non-citizens.
In relation to alien status, a qualified alien’s actual eligibility is based on the:
Use the date of entry into the U.S. and, if different, the date of entry with a qualifying alien classification to determine the correct category for the qualified alien.
The date on the alien's Department of Homeland Security (DHS) document or card often represents the alien's first date of entry into the U.S. However, in some cases, an alien may be present in the U.S. without a qualifying classification, depart, and then return to the U.S. with a qualifying alien classification. Other aliens may have entered the U.S., without a qualifying alien classification and remained continuously present in the U.S. until obtaining qualified immigrant status.
For these aliens, the date on their DHS document or card reflects the date of entry with a qualifying alien classification or the date the qualifying alien classification was granted, not the alien's original date of entry.
Allow aliens with a DHS document or card showing an entry date on or after Aug. 22, 1996, who claim to have entered before that date, an opportunity to submit evidence of their claimed date of entry. This evidence may include pay stubs, a letter from an employer, or a lease or utility bill in the alien's name.
Verifying continuous presence
DHS maintains a record of arrivals to and departures from the country for most legal entrants. This record may be used to establish that an alien has continually resided in the U. S., since before Aug. 22, 1996.
Verify via SAVE or file Form G-845S, Document Verification Request, (primary verification) and Form G-845S, Supplement, (if manual secondary verification is required), with DHS to verify continuous presence in the U.S. Any single absence from the U.S. of more than 30 days, or a combined absence of more than 90 days, is considered to interrupt "continuous presence."
Other entrants, including aliens who entered the U.S. without USCIS documents, must provide documentary evidence showing proof of continuous presence, such as a letter from an employer or a series of pay stubs, or utility bills in the alien's name and spanning the period of time in question.
Note: Once an alien obtains a qualifying alien status, he does not have to remain continuously present in the U.S.
Revision 17-4; Effective December 1, 2017
Revision 17-4; Effective December 1, 2017
MEPD provides full Medicaid and/or MSP to qualified aliens whose eligibility is mandatory under federal requirements. Mandatory qualified aliens fall into three categories. Refer to the following sections for information about the three categories of qualified aliens potentially eligible for full Medicaid and/or MSP:
Revision 14-4; Effective December 1, 2014
The following qualified aliens are immediately eligible for full Medicaid and/or MSP benefits, provided they meet other program requirements, but are limited to seven years of eligibility:
Note: Amerasians who enter as legal nonimmigrants as defined in Section D-8610, Ineligible Aliens, (for example, foreign students pursuing studies in the U.S.) cannot be qualified aliens unless their classification changes.
Under federal law, a qualified alien in this category is limited to seven years of potential eligibility for full Medicaid and/or MSP unless the qualified alien fits into another category or becomes a naturalized citizen.
Start the Clock — The clock on the seven years begins to run from the date the person obtains a qualified alien classification, not from the date the person becomes eligible for full Medicaid and/or MSP.
Stop the Clock — The clock on the seven years stops with the beginning of the first month after the seventh anniversary of the date the person obtained qualified alien classification. Once the seven-year period ends, in order to remain eligible for full Medicaid and/or MSP, the alien described in this section must either:
Consider Medicaid for the treatment of an emergency medical condition when the seven-year period expires and the person does not meet either of the above.
Revision 17-4; Effective December 1, 2017
Certain aliens are exempt from the five-year waiting period and the seven-year limited period when they meet exception criteria known as LPR conditions (itemized below).
If the following aliens meet all other eligibility criteria, these aliens are immediately eligible for full Medicaid and/or MSP without time limits:
If the qualified alien does not meet one of the LPR conditions and neither becomes a naturalized citizen nor meets citizenship status, consider Medicaid for the treatment of an emergency medical condition, if the person meets all other eligibility criteria.
For this category, also see specific policy and procedures for the following LPR conditions:
Revision 14-4; Effective December 1, 2014
Aliens lawfully admitted for permanent residence on or after Aug. 22, 1996, are not eligible for full Medicaid and/or MSP benefits for a period of five years from the date they enter the U.S. or obtain a qualified alien classification, whichever is later, unless they meet:
Start the Clock — The clock on the five-year waiting period begins to run from the date the person:
Stop the Clock — The clock stops:
Once the five-year period ends, a qualified alien with a five-year waiting period who meets all other eligibility criteria must do one of the following to be eligible for full Medicaid and/or MSP:
Consider Medicaid for the treatment of an emergency medical condition if the person does not meet one of the above or is still within the five-year waiting period.
Revision 14-4; Effective December 1, 2014
The Social Security Administration (SSA) defines a quarter as a period of three calendar months.
A quarter of coverage is credit for a requisite (necessary) amount of covered earnings assigned to a calendar quarter on a worker's earnings record.
A qualifying quarter is credit for a requisite (necessary) amount of covered earnings and/or non-covered earnings assigned to a calendar quarter for determining eligibility of an LAPR alien.
Individuals can get up to four qualifying quarters of credit each calendar year based on their own earnings. Individuals also can be credited with additional quarters in a calendar year based on the earnings of a parent or spouse.
To be potentially eligible for full Medicaid and/or MSP, an LAPR alien must be credited with 40 qualifying quarters, either from the alien’s own record, or combined with the quarters earned by a spouse or parent.
Note: The 40-qualifying-quarter requirement does not exempt the individual from the five-year waiting period (bar).
See the policy that follows to determine if the LAPR alien meets the 40-qualifying-quarter requirement.
Revision 12-4; Effective December 1, 2012
Quarters from a spouse — Aliens can count their spouse's quarters earned during the marriage in addition to their own quarters to meet the 40 qualifying quarter requirement. For example, if each spouse has 20 quarters, the quarters are added and both spouses are credited with 40 quarters.
Count the spouse's quarters earned during the marriage when the spouse is either a citizen or an alien and any of the following conditions apply:
When determining whether to credit a person's quarters to his spouse, count quarters earned beginning with the quarter from the date of marriage.
Do not count quarters earned by divorced spouses for either ex-spouses.
Note: Aliens who divorce after certification retain their eligible alien status through the end of the current certification period. This also applies to stepchildren.
Quarters from a parent – Aliens also can count the quarters earned by a living or deceased parent in addition to their own quarters to meet the 40 qualifying quarter requirement. In this instance, a parent means the natural or adoptive parent or the stepparent.
Count the parent's quarters when the parent is either a citizen or an alien and the quarters were earned before the child turned 18, including quarters earned before the child was born.
Death of a stepparent does not end the relationship. However, if the parent and stepparent are divorced, the stepparent's quarters are not counted.
Note: Quarters earned by a child are not counted toward the eligibility of a parent.
Revision 12-4; Effective December 1, 2012
Federal law requires that quarters earned on or after Jan. 1, 1997, cannot be credited if the person who earned the quarters received means-tested public benefits.
When determining the total amount of qualifying quarters earned, do not allow any quarters earned on or after Jan. 1, 1997, if the person received TANF, SNAP, Medicaid or SSI benefits in that quarter.
The Wire Third Party Query (WTPY) system response does not reflect receipt of these benefits. Staff should verify if federal means-tested benefits were received by any person contributing quarters so that applicable quarters are deducted before determining the number of qualifying quarters.
Example: An LAPR alien files an application for benefits on Oct. 10, 2012. He has never worked and has no qualifying quarters of his own. He has been married for 30 years and his spouse, who is a U.S. citizen and who has been working since they were married, earned her 40th qualifying quarter in March 2012.
Spouse received SNAP in January 2012 and February 2012; however, she has not been certified to receive SNAP or to be eligible for any other federal means-tested public benefit since February 2012.
Result: As the 40th qualifying quarter was earned while receiving SNAP, it cannot be allowed. Since the spouse continues working, the 40th qualifying quarter is earned in the quarter ending June 2012. Since all 40 qualifying quarters were earned during their marriage, the LAPR alien meets the 40 qualifying quarter determination.
Revision 14-4; Effective December 1, 2014
Non-covered wages are those earned by a person whose employer was not required to pay into the Social Security system (such as certain city, federal, school or religious organization employees).
If the alien cannot meet the 40-qualifying-quarter requirement using covered or non-covered earnings verified by the SSA, then obtain sufficient income verification from the employer to determine if the alien earned quarters for the period in question using non-covered earned wages.
If the alien reports self-employment with non-covered earned wages, obtain sufficient information about this employment to verify that the alien:
Acceptable documents include, but are not limited to, pay stubs, employer statements, W-2s, and income tax forms including all applicable schedules. If HHSC already has verification of the income, do not request additional information.
Use the chart below to determine if the person earned sufficient non-covered wages to earn a quarter.
| Year | Amount Required for a Quarter | Amount Required for 4 Quarters |
|---|---|---|
| 2014 | $1,200 | $4,800 |
| 2013 | $1,160 | $4,640 |
| 2012 | $1,130 | $4,520 |
| 2010–2011 | $1,120 | $4,480 |
| 2009 | $1,090 | $4,360 |
| 2008 | $1,050 | $4,200 |
| 2007 | $1,000 | $4,000 |
| 2006 | $970 | $3,880 |
| 2005 | $920 | $3,680 |
| 2004 | $900 | $3,600 |
| 2003 | $890 | $3,560 |
| 2002 | $870 | $3,480 |
| 2001 | $830 | $3,320 |
| 2000 | $780 | $3,120 |
| 1999 | $740 | $2,960 |
| 1998 | $700 | $2,800 |
| 1997 | $670 | $2,680 |
| 1996 | $640 | $2,560 |
| 1995 | $630 | $2.520 |
| 1994 | $620 | $2,480 |
| 1993 | $590 | $2,360 |
| 1992 | $570 | $2,280 |
| 1991 | $540 | $2,160 |
| 1990 | $520 | $2,080 |
| 1989 | $500 | $2,000 |
| 1988 | $470 | $1,880 |
| 1987 | $460 | $1,840 |
| 1986 | $440 | $1,760 |
| 1985 | $410 | $1,640 |
| 1984 | $390 | $1,560 |
| 1983 | $370 | $1,480 |
| 1982 | $340 | $1,360 |
| 1981 | $310 | $1,240 |
| 1980 | $290 | $1,160 |
| 1979 | $260 | $1,040 |
| 1978 | $250 | $1,000 |
Example: A person worked for the school district as a custodian from 2001 through 2011. The school district did not pay into the Social Security system. The specialist requested that the person provide verification of earnings for this particular period. (Note: If the State Online Query (SOLQ) shows an F on the 40-quarter record, SSA has verified those non-covered wages, and the specialist does not need to reverify them.)
The person brought a statement from the school district verifying the person’s wages. The person earned $9,000 for 2011. Using the chart above, the income required to earn a quarter for 2011 is $1,120. The person can be credited with four quarters for 2011 because the person earned more than the amount required ($1,120 x 4 = $4,480).
Revision 17-4; Effective December 1, 2017
Determine all persons whose quarters can be included in the quarter coverage count. See D-8341, Combining Qualifying Quarters of Spouse/Parent.
If the alien applicant/recipient and/or person whose quarters will be included did not sign the application form, obtain the person’s signature on Form SSA-3288, Social Security Administration Consent for Release of Information. When a completed and signed Form SSA-3288 cannot be obtained because the person refuses to complete it, SSA cannot release information about that individual.
If a person, other than the LPR applicant, refuses to sign the Form SSA-3288, do not request earnings history for that person. Determine eligibility based on the qualifying quarters of the LPR applicant/recipient. If the LPR applicant/recipient does not meet the qualifying quarter requirement, deny the case.
A signed Form SSA-3288 is not required when requesting information on:
Use the 40 Quarters Verification System in TIERS to request 40 quarters from SSA to determine how many countable quarters are in the LPR's SSA earnings records.
Note: WTPY may still be used to obtain information on 40 Qualifying Quarters.
Run Inquiry to determine if any person whose quarters are being considered received SSI, SNAP, TANF or Medicaid in any month on or after January 1997. Record the eligibility dates for these benefits so that applicable quarters are deducted from the total before determining if the alien applicant/recipient meets the 40-qualifying-quarter requirement.
Note: Determine if it is possible for the alien to meet the 40-quarter requirement first by obtaining the number of years the alien and each person included in the quarter coverage calculation has lived in the U.S. If the combined number of years totals less than 10 years, the alien will not meet the requirement. (Must earn 4 quarters/year x 10 years = 40 quarters.)
Revision 12-4; Effective December 1, 2012
SSA does not complete the posting of covered earnings quarters for any one year until the following year (around August). For instance, quarters earned in 2011 may not be posted on the WTPY system until August 2012. These quarters are referred to as Lag quarters.
The quarters of covered earnings are based on the calendar year's total earnings. Each year the amount of income needed to earn a quarter changes. State office advises staff of the change each year.
Example: In 2011, an individual must earn $1,120 to earn one quarter. If the individual earned at least $4,480 for 2011 ($1,120 x 4), the individual has four qualifying quarters for the year.
Do not allow credit for an incomplete or future quarter.
Example: The quarter of July-September 2011 cannot be counted until October 2011, even though the individual earned enough income by March 2011 to receive credit for three quarters in 2011.
Note: The WTPY response will not reflect receipt of federal means-tested benefits. Staff should conduct inquiry to verify if SSI, SNAP, TANF or Medicaid benefits were received by any person contributing quarters so that an accurate count of the qualifying quarters is made. See D-8342, Qualifying Quarters Earned on or After Jan. 1, 1997.
Revision 14-4; Effective December 1, 2014
Certain aliens lawfully admitted for permanent residence (LAPR) are immediately eligible for full Medicaid and/or MSP benefits, provided they meet other program requirements and certain LAPR conditions.
A description of the LAPR conditions follows.
Revision 14-4; Effective December 1, 2014
This LAPR condition applies to:
Verification of honorable discharge or active duty status requires presentation of a copy of the veteran's discharge certificate or current orders showing "Honorable" discharge from, or active duty in, the Army, Navy, Air Force, Marine Corps or Coast Guard.
Neither a general discharge "Under Honorable Conditions" nor service in the National Guard satisfies this LAPR condition.
Contact the local Veterans Affairs (VA) regional office if an applicant presents:
Aliens meeting the criteria in this section are immediately eligible for full Medicaid and/or MSP, provided they meet all other eligibility criteria.
Revision 14-4; Effective December 1, 2014
Loss of eligibility related to "Veteran/Active Duty" status can occur under the following circumstances:
Change in Active Duty/Veteran Status
A qualified alien who is eligible based on the veteran/active duty policy (including a spouse or dependent child of an active duty member/veteran) loses full Medicaid and/or MSP eligibility the month after the month the active duty member separates from the armed forces with a discharge that is not characterized as honorable or that is based on alien status.
Spouse of Veteran/Active Duty Member
Eligibility as a spouse of a veteran or active duty member of the armed forces ends with the month after the month any of the following occur:
Unmarried Dependent Child of Veteran/Active Duty Member
Eligibility as an unmarried dependent child of a veteran or active duty member ends with the month after the month any of the following occur:
Revision 17-4; Effective December 1, 2017
Although born outside the U.S., the following American Indians are considered qualified aliens and are immediately eligible for full Medicaid and/or MSP, provided they meet all other eligibility criteria.
Certain Canadian-born Indians — Canadian-born Indians who establish "one-half American Indian blood" are considered qualified aliens and may freely cross borders and live and work in the U.S. without Department of Homeland Security (DHS) documentation. Accept as evidence of "one-half American Indian blood" a document that indicates the percentage of American Indian blood in the form of a:
If the person cannot present any listed document to verify the American Indian status, refer the person to DHS to determine the alien status. Do not accept a Certificate of Indian Status card ("Band" card) issued by the Canadian Department of Indian Affairs or any other document not directly issued by the individual's tribe.
Federally recognized U.S. Indian tribes — U.S. Indian tribes federally recognized under Section 4(e) of the Indian Self-Determination and Education Assistance Act are each authorized by the Bureau of Indian Affairs to define the requirements for tribal membership. Some tribes afford membership to non-U.S. born individuals. If a foreign-born person claims membership in a federally recognized Indian tribe, request a membership card or other tribal document showing membership in the tribe. If the person has a membership card or other tribal document showing membership in the tribe, contact state office. State office will determine if the tribe is included on the list of recognized Indian tribes published annually by the Bureau of Indian Affairs in the Federal Register.
See Appendix V, Levels of Evidence of Citizenship and Acceptable Evidence of Identity Reference Guide, for information on Form I-872, American Indian Card, as evidence of U.S. citizenship. Form I-872 showing the class code "KIC" indicates citizenship status.
Revision 17-4; Effective December 1, 2017
To be immediately eligible for full Medicaid and/or MSP, an alien living in the U.S. on Aug. 22, 1996 must:
Note: This includes non-qualified aliens who received Medicaid on Aug. 22, 1996, due to permanent residence under color of law (PRUCOL) and continue to meet PRUCOL criteria.
Consider Medicaid for the treatment of an emergency medical condition if the alien described in this section does not meet another LPR condition or alien classification. See D-8600 Non-Qualified Aliens through D-8620 Illegal Aliens.
Revision 17-4; Effective December 1, 2017
To determine the alien status for retroactive coverage, use the policy in the following:
Note: Before denying SSI, the Social Security Administration (SSA) will test the person for an extension beyond the seven-year limited period. Qualified aliens who were lawfully residing in the U.S. on Aug. 22, 1996 and who are blind or disabled may continue to be eligible for SSI beyond the seventh year, assuming all other factors of eligibility are met, regardless of:
If a denied SSI recipient applies for an MEPD program, determine the reason for the SSI denial. If the SSI denial was based on alien status (for example, expiration of the seven-year limited period) to be eligible for an MEPD program, the qualified alien must:
Note: Individuals denied SSI whose alien classification is lawfully residing in the U.S. on Aug. 22, 1996 and are blind or have a disability, are not eligible for continued Medicaid or a Medicare Savings Program.
Revision 14-4; Effective December 1, 2014
Generally, non-qualified aliens are divided into two groups:
These groups of non-qualified aliens are not eligible for regular Medicaid and/or MSP. They may be eligible for Medicaid coverage for treatment of an emergency medical condition.
Revision 14-4; Effective December 1, 2014
Except for cases involving undocumented aliens, use the Systematic Alien Verification for Entitlements (SAVE) Verification Information System (VIS) to verify the alien status on all noncitizens.
Some aliens may be lawfully admitted to the U.S. as "legal nonimmigrants," but only for a temporary or specified period of time.
The following categories of individuals are "legal nonimmigrants":
These aliens are called “ineligible aliens” because they are not eligible for full Medicaid, MSP or ME-A&D Emergency due to the temporary (non-resident) nature of their admission status.
Exception: In some cases, an alien in a currently valid legal nonimmigrant classification may meet the residence rules of Texas. When the residency requirement is met, the person is eligible for Medicaid for the treatment of an emergency medical condition if all other eligibility criteria also are met.
Example 1: A domestic employee for a foreign government representative currently conducting business in Texas receives emergency medical care. She files an application for assistance with the medical expenses. The individual states she does not intend to remain in Texas; she is here only while her employer concludes his business. Result: The individual is not eligible for full Medicaid, MSP or ME-A&D Emergency due to the temporary nature of her admission status.
Example 2: An agricultural contract worker suffers an injury while on the job and is hospitalized. He files an application for assistance with the medical expenses, as he does not have any medical insurance. The individual states he intends to remain in Texas. He provides verification of his permanent address and rental agreement. Result: The individual is potentially eligible for ME-A&D Emergency because he meets residence requirements. See Section D-3200, Eligibility.
Reminder: If a legal nonimmigrant’s time period has expired with no changes to the classification status, follow the procedures in Section D-8620, Illegal Aliens.
Note: People from the Compact of Free Association States are "legal nonimmigrants." They are not eligible for Medicaid unless they have obtained a qualified alien status (see Section D-5220, Compact of Free Association States).
Revision 13-4; Effective December 1, 2013
Types of Department of Homeland Security (DHS) documentation for ineligible aliens who are legal nonimmigrants include, but are not limited to:
Explore eligibility for Medicaid coverage for treatment of an emergency medical condition for an alien if there is no proof of alien status.
Revision 13-1; Effective March 1, 2013
Illegal aliens were either never legally admitted to the United States for any period of time or were admitted for a limited period of time and did not leave the United States when the period of time expired.
Illegal aliens are only eligible for Medicaid for treatment of an emergency medical condition if they meet all other eligibility criteria, including residency requirements. See Section D-3200, Eligibility. Illegal aliens do not have to provide a Social Security number.
When an alien receives a final deportation order but continues to stay, consider the alien to be illegal.
Except for cases involving undocumented aliens, use SAVE VIS to verify the alien status on all non-citizens.
Contact with the Department of Homeland Security (DHS) is not allowed except when the person has given written approval and a request to do so.
If an alien does not wish to contact DHS or give permission, explore eligibility for Medicaid coverage for treatment of an emergency medical condition.
Revision 17-4; Effective December 1, 2017
Only qualified aliens are potentially eligible for full Medicaid and/or MSP if otherwise eligible. As part of the Medicaid eligibility determination, verify:
Complete verification by:
Document the:
If a certified alien's document expires before the next redetermination, re-verify the alien's immigration status. The alien’s immigration status does not require reverification if the USCIS documents have not expired.
Note: If the alien’s USCIS document is expired and the SAVE response shows the individual is a Lawful Permanent Resident - Employment Authorized and the Date Admitted is “Response is Indefinite,” the individual meets the alien status criteria.
Revision 13-1; Effective March 1, 2013
Except for cases involving undocumented aliens, use SAVE VIS to verify the alien status on all non-citizens.
Documentary evidence in conjunction with DHS verification provided via the online SAVE response or via manual process with Form G-845, Document Verification Request, (primary verification) and Form G-845S, Supplement, Document Verification Request Supplement, (secondary verification) is used to establish qualified alien status.
Once the documentary evidence (usually an alien status card) and the SAVE verification have been completed, use the charts in Section D-8900, Alien Status Eligibility Charts, for treatment of the alien status in the eligibility determination process.
Explore eligibility for Medicaid coverage for treatment of an emergency medical condition for an alien if there is no proof of alien status.
Revision 13-1; Effective March 1, 2013
If the alien presents an I-551 (Alien Registration Receipt Card) or other acceptable evidence of LAPR status, query SAVE online to verify the document and status. Some LAPR aliens have conditional permanent resident status. This is indicated by an I-551 valid for only a two-year period. These aliens must apply for removal of the conditional basis 90 days before the second anniversary of the admittance date to the U.S. Failure to do so results in termination of the alien's lawful status. A conditional I-551 is identified by an expiration date two years later than the admittance/adjudication date, and status must be re-verified upon expiration. If the alien is a national of Cuba or Haiti who adjusts to LAPR status under the Nicaraguan and Central American Relief Act (NACARA) or the Haitian Refugee Immigration Fairness Act (HRIFA), contact state office for more information on treatment.
For a LAPR, follow policy in:
Revision 17-4; Effective December 1, 2017
Permanent Resident Card and Employment Authorization Document (EAD)
As of May 1, 2017, the Permanent Resident Card and EADs:
Note: Permanent Resident Cards and EADs will remain valid until the expiration date shown on the card. Some older Permanent Resident Cards do not have an expiration date. The older Permanent Resident Cards without an expiration date also remain valid.
A revised I-551, Alien Registration Receipt Card (Type 1), was first issued in late 1989.
Card Front — Form I-551 is a laminated card. The background is off pink. The agency name is shown in white on a blue background just under the words “RESIDENT ALIEN.” The seal is light blue. The front includes a photograph of the alien's face, fingerprint and signature. An expiration date is always shown. Cards expire 10 years after issue, but may be renewed.
Note: A modified I-551 was first issued in January 1992. All cards issued Feb. 1, 1993, or later are modified. The only difference is a noticeable removal of the background printing behind the fingerprint block.
Card Back — A map of the U.S. appears on the upper portion of the card back, surrounded by an overlapping rainbow print. The lower portion of the back contains four lines of text, the bottom three of which are machine readable and on a white background.
The original Alien Registration Receipt Card (Type 1) was issued from 1977 to late 1989.
Card Front — Form I-551 is a laminated card. The agency name is shown in white on a pastel blue background just under the words "RESIDENT ALIEN." The seal is light pastel blue. The front includes a photograph of the alien's face, fingerprint and signature.
Card Back — A map of the U.S. appears on the card back, overlaid by machine readable typed data. The first digit of the issue/type code indicates the number of alien registration cards issued to the person. The second digit identifies the type card.
Form I-151 is the version of the Alien Registration Receipt Card issued to aliens by the former Immigration and Naturalization Service (INS) from July 1946 through late 1977. Form I-151 is not a valid immigration document. The card lacks security features and presents more opportunities for alteration and fraud than the immigration documents currently being issued. From 1992 through 1996, the INS conducted a “Green Card Replacement” project to replace the I-151 cards in circulation. Although the card is not a valid immigration document, the person may still retain lawful permanent status.
For pictures of these cards, see Appendix LIV, Description of Resident Alien Cards.
Revision 17-4; Effective December 1, 2017
If an alien presents Form I-766 annotated with "274a.12(a)(3)" or "A3" as evidence of refugee status, query SAVE online to verify the document and status. If the SAVE online response results in a determination of ineligibility, verify alien status using Form G-845 and supplement to Form G-845. The Form I-94 annotated with stamp showing admission under section 207 of the Immigration and Nationality Act (INA) is also a DHS document for refugees.
For a refugee, follow policy in:
Revision 17-4; Effective December 1, 2017
A parolee may present a DHS Form I-94 that indicates the bearer has been paroled pursuant to Section 212(d)(5) of the Immigration and Nationality Act (INA), with an expiration date of at least one year from the date issued or indefinite.
DHS Form I-766 annotated "A4" or "C11" indicates status as a parolee, but does not reflect the length of the parole period.
If the individual cannot provide Form I-94, contact DHS to verify status and length of the parole period before certification.
For a parolee, follow policy in:
Revision 17-4; Effective December 1, 2017
An asylee may present a Department of Homeland Security (DHS) Form I-94 annotated with a stamp showing grant of asylum under Section 208 of the Immigration and Nationality Act (INA), a grant letter from the Asylum Office or an order of an immigration judge.
Derive the date status granted from the date on Form I-94, the grant letter or the date of the court order. If the date is missing from Form I-94, request the grant letter from the alien. If it is not available, verify the date status was granted with DHS.
DHS Form I-766 annotated "A5" indicate status as an asylee. However, the date of the form does not reflect when the status was granted. Request Form I-94, the grant letter from the Asylum Office of DHS or the alien's copy of a court order of the immigration judge granting asylum to obtain the date status was granted. Verify with DHS if none of these are available.
If the alien alleges having been granted asylum within the previous seven years, contact DHS using Form G-845 and Form G-845 supplement with a copy of Form I-551 attached.
For an asylee, follow policy in:
Revision 17-4; Effective December 1, 2017
For an alien whose deportation was withheld under Section 243(h) of the Immigration and Nationality Act (INA) or whose removal was withheld under Section 241(b)(3) of the INA, obtain one of the following:
Department of Homeland Security (DHS) Form I-766 annotated "A10" indicate deportation was withheld under Section 243(h) of the INA or removal was withheld under Section 241(b)(3) of the INA, but normally do not reflect the date of withholding. Request the alien's copy of the court order to obtain the date of withholding. If not available, verify with DHS.
If the alien alleges having had deportation/removal withheld within the previous seven years, contact DHS using Form G-845 and supplement with a copy of Form I-551 attached.
Note: Aliens who have been granted a suspension of deportation are not eligible for Medicaid benefits on the basis of that status alone. The description and annotations on the DHS documents must be as shown above in order to establish eligibility based on withholding of deportation or removal.
For an alien whose deportation was withheld, follow policy in:
Revision 13-1; Effective March 1, 2013
An alien could meet more than one classification. The seven-year period of limited eligibility, if applicable, begins with the earliest date an alien meets "Cuban/Haitian entrant" classification or one of the other seven-year classifications, such as asylee, refugee, etc. Absent evidence to the contrary, accept any of the following as convincing evidence of Cuban or Haitian nationality for purposes of determining whether an alien is a "Cuban/Haitian entrant:"
For a Cuban/Haitian entrant, follow policy in:
Revision 17-4; Effective December 1, 2017
An alien who has been, or whose child or parent has been, battered or subjected to extreme cruelty in the United States by a U.S. citizen or lawful permanent resident spouse or parent can be considered a qualified alien.
For the alien and children to emigrate or remain in the United States, the alien’s spouse must file a petition for lawful permanent residence status for the alien relative. Unless the spouse files this petition, the alien and children have no lawful immigrant status and face being deported.
Since the 1994 enactment of the Violence Against Women Act, a battered alien may self-petition for lawful permanent residency via INS Form I-360, Petition for Amerasian, Widow(er) or Special Immigrant, without the cooperation or knowledge of the abuser.
The alien must provide DHS documentation that identifies the alien as the self-petitioning spouse and/or child of an abusive U.S. citizen or lawful permanent resident and does not live with the abuser.
Examples of acceptable DHS documents include:
Qualified aliens with a battered alien status do not need to be credited with 40 qualifying quarters of Social Security coverage nor do they have a seven-year limited eligibility period. The following battered aliens meet the alien status criteria if they:
Consider Medicaid for the treatment of an emergency condition when the battered alien does not meet alien status criteria.
Revision 17-4; Effective December 1, 2017
The U.S. Department of Health and Human Services certifies individuals who meet the victims of severe human trafficking requirements so they may remain in the U.S. up to four years. Law enforcement authorities can extend the status beyond four years for individuals whose presence is required for a continuing investigation.
These individuals meet the alien status criteria to be potentially eligible for benefits without a five-year waiting period and continue to meet the eligibility criteria without a limited eligibility period as long as the law enforcement extension continues, or they adjust to another acceptable alien status.
Staff must request a copy of the USCIS Notice of Extension to verify the individual has an approved extended Victims of Severe Human Trafficking status based on the law enforcement need. SAVE does not provide verification for victims of trafficking. Staff must call the trafficking verification toll-free number at 866-401-5510 to confirm the validity of the USCIS extension letter.
After four years or expiration of a law enforcement extension, individuals who have not adjusted to another alien status must leave the U.S. If they remain, they are considered undocumented and ineligible for ongoing benefits.
Revision 17-4; Effective December 1, 2017
The Systematic Alien Verification for Entitlements (SAVE) program's Verification Information System (VIS) is a web-based application that provides alien status information using the applicants' alien registration number.
The SAVE System provides the following types of responses:
If the alien’s U.S. Citizenship and Immigration Services (USCIS) document is expired and the SAVE response shows the individual is a Lawful Permanent Resident - Employment Authorized and the Date Admitted is “Response is indefinite,” the individual meets alien status criteria.
Use the SAVE Verification Information System:
Exceptions:
When SAVE does not contain information about victims of severe trafficking or non-alien family members, call the trafficking verification toll-free number at 866-401-5510 to confirm the validity of the certification letter or Derivative T Visa and to notify the Office of Refugee Resettlement of the benefits for which the individual is applying.
SAVE does not normally contain information about American Indians born outside of the U.S. See Section D-8420, American Indians Born Outside the U.S.
Revision 09-4; Effective December 1, 2009
Supervisors complete and route Form 4743, Request for Applications and System Access, to the regional security officer for employees who need access to the SAVE system.
Revision 13-4; Effective December 1, 2013
To obtain primary verification of alien status, follow these steps to access the Systematic Alien Verification for Entitlements (SAVE) System:
Use the policy found in Section D-8610, Ineligible Aliens, if the message is TEMPORARY RESIDENT/TEMPORARY EMPLOYMENT AUTHORIZED.
Note: If using Data Broker through TIERS, a copy of the SAVE screen is not needed, as the inquiry will be stored in the Data Broker history.
Note: Staff should enter the correct alien number as listed on the document, not a default or fictitious number (for example, AAA000000, etc.).
Revision 09-4; Effective December 1, 2009
To request additional verification:
Select Display Case Summary List to open the Case Summary List page. The list displays the Case Status for cases that require action, cases in process and closed cases. Click the Verification Number to view the Case Details. The user is able to print the case details, request additional verification and close the case.
If the system is unable to verify the immigration status with the information provided by the user in the automated additional verification request, or the document appears counterfeit, altered or expired, use the manual process in Section D-8840, Secondary Verification of Alien Immigration Status.
Revision 09-4; Effective December 1, 2009
If you are unable to verify an alien's immigration status through primary verification procedures, implement the following secondary verification procedures:
If the applicant's name has changed since the alien registration card was issued, attach a document that verifies the name change.
If the alien is otherwise eligible, do not delay, deny or reduce the household's benefits while waiting for a response from BCIS.
When the G-845 is returned, follow these procedures:
| If the response indicates that the alien's document is ... | then ... |
|---|---|
| valid, | file the G-845 in the legal section of the case folder. |
| not valid and the case is certified, |
|
It is estimated that the G-845 will be returned in a maximum of 10 workdays. Document secondary verification activities in the case record regarding:
Note: The Immigration Reform and Control Act of 1986 (IRCA) mandates "presumptive eligibility" for aliens; that is, they are eligible for entitlement benefits unless proven otherwise. Grant eligibility for benefits before receiving the secondary verification from DHS if:
Aliens are allowed the same length of time as all other applicants/recipients to appeal a decision affecting their eligibility.
Reference: U.S. Citizenship and Immigration Services, Districts and Sub Offices by State.
Revision 14-2; Effective June 1, 2014
If you are unable to verify an alien's immigration status through primary or secondary verification procedures, allow the applicant a reasonable opportunity of 95 days following the date on which a notice is sent to an individual to provide another source of citizenship or alien status verification.
Revision 13-1; Effective March 1, 2013
An alien's eligibility is based on the Department of Homeland Security’s qualifying classification and other criteria as shown in the MEPDH and in the following charts.
Revision 17-4; Effective December 1, 2017
Chart A — Entry Before 1996
| If the alien entered the U.S. before Aug. 22, 1996, and the USCIS document is an ... | then the alien is ... |
|---|---|
|
eligible if the alien meets the criteria in Section D-8320, Qualified Aliens Not Subject to a Waiting Period or Limited Period. Unless the alien meets the criteria in Section D-8320, consider Medicaid for the treatment of an emergency medical condition. |
Note: Follow your policy clearance request procedures for questions about documents or immigration statuses not listed in this chart.
Revision 17-4; Effective December 1, 2017
Chart B — Entry On or After Aug. 22, 1996 – Qualified Aliens With No Waiting Period
| If the alien entered the U.S. on or after Aug. 22, 1996, and the USCIS document is an ... | and ... |
|---|---|
|
If less than seven years have passed since the date of qualified alien classification, usually the entry date, then the alien is eligible if the alien meets the criteria in Section D-8310, Qualified Aliens Subject to a Seven-Year Limited Period. Unless the alien meets the criteria in Section D-8310, consider Medicaid for the treatment of an emergency medical condition. Note: Victims of Severe Human Trafficking are limited to four years unless status is extended by law enforcement. If seven years or more have passed from the date of qualified alien classification, usually the entry date, then the alien is eligible if the alien meets the criteria in Section D-8320, Qualified Aliens Not Subject to a Waiting Period or Limited Period. Unless the alien meets the criteria in Section D-8320, consider Medicaid for the treatment of an emergency medical condition. Note: The refugee retains this eligibility period even if the refugee has adjusted to lawful permanent resident (LPR) status during the seven-year limited period. |
|
Not eligible, unless the alien has applied for and been approved by DHS for LAPR. If LAPR, the alien must meet the LAPR conditions in Section D-8320, Qualified Aliens Not Subject to a Waiting Period or Limited Period.Unless the alien meets the criteria in Section D-8320, consider Medicaid for the treatment of an emergency medical condition. |
|
Afghani or Iraqi Special Immigrant – Special immigrant status under 101(a)(27) of the INA may be granted to Iraqi and Afghan nationals who have worked on behalf of the U.S. government in Iraq or Afghanistan. Acceptable documentation includes:
For those special immigrants who are adjusting their status to LPR status in the U.S., acceptable documentation includes:
These special immigrants also may demonstrate nationality with an Afghani or Iraqi passport. Note: The entry date for an Afghani special immigrant must be Dec. 26, 2007, or later. An Iraqi special immigrant's entry date must be Jan. 26, 2008, or later. |
If less than seven years have passed since the date of qualified alien classification, usually the entry date, then the alien is eligible if the alien meets the criteria in Section D-8310, Qualified Aliens Subject to a Seven-Year Limited Period. Unless the alien meets the criteria in Section D-8310, consider Medicaid for the treatment of an emergency medical condition. If seven years or more have passed from the date of qualified alien classification, usually the entry date, then the alien is eligible if the alien meets the criteria in Section D-8320, Qualified Aliens Not Subject to a Waiting Period or Limited Period. Unless the alien meets the criteria in Section D-8320, consider Medicaid for the treatment of an emergency medical condition. Note: The special immigrant retains this eligibility period even if the special immigrant has adjusted to lawful permanent resident (LPR) status during the seven-year limited period. |
Note: Follow your policy clearance request procedures for questions about documents or immigration statues not listed in this chart.
Revision 17-4; Effective December 1, 2017
Chart C — LPR Aliens With or Without the Five-Year Waiting Period
| If the LPR alien entered the U.S. before Aug. 22, 1996, and the DHS document is an ... | then ... |
|---|---|
|
I-551, Resident Alien Card, and does not meet one of the classification codes in Charts A or B, Notes:
"Processed for I-551, Temporary Evidence of Lawful Admission for Permanent Residence, valid until ______, Employment Authorized."
|
The LPR alien is eligible if the LPR alien meets the criteria in Section D-8320, Qualified Aliens Not Subject to a Waiting Period or Limited Period, or Section D-8430, LPR Residing in the U.S. on Aug. 22, 1996. Unless the LPR alien meets the criteria in Section D-8320 or Section D-8430, consider Medicaid for the treatment of an emergency medical condition. |
| If the LPR alien entered the U.S. on or after Aug. 22, 1996, and the DHS document is an ... | |
|
I-551, Resident Alien Card, and does not meet one of the classification codes in Charts A or B, Notes:
"Processed for I-551, Temporary Evidence of Lawful Admission for Permanent Residence, valid until ______, Employment Authorized." Allow aliens with a DHS document or card showing an entry date on or after Aug. 22, 1996, who claim to have entered before that date, an opportunity to submit evidence of their claimed date of entry. |
If five years or less have passed since the date of qualified alien classification, usually the entry date, then the LPR alien is not eligible. Unless the alien meets criteria other than 40 qualifying quarters in Section D-8320, Qualified Aliens Not Subject to a Waiting Period or Limited Period, the LPR alien is only potentially eligible for Medicaid for the treatment of an emergency medical condition during the five-year waiting period. (Having 40 qualifying quarters does not exempt a person from the five-year waiting period.) If more than five years have passed since the date of qualified alien classification, usually the entry date, then the LPR alien is eligible if the LPR alien meets the criteria in Section D-8320. Unless the LPR alien meets the criteria in Section D-8320, consider Medicaid for the treatment of an emergency medical condition. |
Follow your policy clearance request procedures for questions about documents or immigration statuses not listed in this chart.
Revision 18-2; Effective June 1, 2018
Generally, aliens who seek admission to the U.S. as lawful permanent residents must establish that they will not become "public charges." Many aliens establish that they will not become public charges by having sponsors pledge to support them by signing affidavits of support.
Revision 12-4; Effective December 1, 2012
A sponsored alien is an individual who has been sponsored by a person who signed an affidavit of support (USCIS Form I-864, Affidavit of Support Under Section 213A of the Act, or USCIS Form I-864-A, Contract Between Sponsor and Household Member) on or after Dec. 19, 1997, agreeing to support the alien as a condition of the alien's entry into the U.S.
A sponsor is someone who brings family-based or certain employment-based immigrants to the U.S. and demonstrates that he can provide enough financial support to the immigrant so the individual does not rely on public benefits.
Revision 16-3; Effective September 1, 2016
Note: Sponsor-to-alien deeming policy does not apply to individuals applying for Emergency Medicaid Coverage for Aliens. Please see Section A-2200 for more.
The applicant/recipient must first be eligible based on all eligibility criteria before proceeding with sponsor-to-alien deeming.
Keep in mind that most alien applicants who have sponsors will not be eligible aliens. One example of a sponsored alien who could be eligible (and subject to sponsor-to-alien deeming) is a sponsored legally admitted for permanent residence (LAPR) alien who is the spouse of a veteran of the U.S. Armed Forces.
Deeming of income and resources for the eligibility and copayment budgets apply regardless of whether:
This is because the sponsor agreed to support the alien as a condition of the alien's admission to the U.S. when signing the affidavit of support.
If the alien's sponsor is the alien's ineligible spouse or parent, sponsor deeming, not spouse-to-spouse or parent-to-child deeming, applies in the case. If sponsor deeming does not apply, for instance the alien has 40 qualifying quarters or meets another exception in D-9220, then apply spouse-to-spouse or parent-to-child deeming.
The income and resources of the sponsor's spouse are included if the sponsor and his or her spouse live in the same household.
For deeming purposes, a sponsor does not include an organization such as a church congregation or a service club, or an employer who only guarantees employment for an alien upon entry to the U.S. but does not sign an affidavit of support.
Revision 12-4; Effective December 1, 2012
The income and resources of an alien are deemed to include the income and resources of the alien's sponsor beginning from the alien's date of admission into the U.S.
The date of admission is the date established by the U.S. Citizenship and Immigration Services as the date the alien is admitted for permanent residence.
Deeming ceases to apply the month after the month:
Deeming ceases to apply in the month the LAPR alien can be credited with 40 quarters.
If none of the above events occurs, deeming continues indefinitely.
Revision 12-4; Effective December 1, 2012
Sponsor-to-alien deeming does not apply to all aliens.
Deeming does not apply to aliens:
Exceptions also apply when:
Revision 12-4; Effective December 1, 2012
When sponsor-to-alien deeming applies, the alien is responsible for providing
Reminder: Sponsor's spouse's information is required when he is the co-sponsor or lives in the same household as the sponsor.
If the alien fails to provide the requested sponsor verification by the required date, deny the application based on failure to furnish information.
Note: Normal verification procedures apply. For instance, if the type of assistance allows for acceptance of verbal statements as verification, accept the applicant/recipient's declaration for the required information.
Revision 12-4; Effective December 1, 2012
Evaluate the resources of an alien's sponsor and the sponsor's spouse (if living in the same household). Before deeming a sponsor's resources to an alien, allow the same exclusions to the sponsor's resources as for the applicant/recipient.
Next, allocate for the sponsor or for the sponsor and his spouse a portion of the resources. The amount of the allocation is based on the following.
Add the remainder to the alien's countable resources. If both members of an eligible couple have the same sponsor, the entire amount of the sponsor's resources is deemed to each member. The couple's countable resources include the sum of their deemed resource amounts.
If an alien is sponsored by more than one individual (other than two sponsors who are married to each other and living together), the sponsor-to-alien deeming rules are applied separately to the resources of each sponsor to determine the total resources deemable to the alien.
If only one member of a couple is sponsored, and that member is an ineligible spouse, sponsor-to-alien deeming does not apply to the eligible member of the couple (nor would it be applicable to the ineligible member of the couple).
Revision 12-4; Effective December 1, 2012
Example 1: Sponsor does not live with spouse
After applying all applicable resource exclusions, the specialist determines the sponsor has $3,200 in countable resources. The current resource limit for an individual is $2,000.
$1,200 ($3,200-$2,000) of the sponsor's resources is deemed to the alien.
Example 2: Sponsor lives with non-sponsor spouse
After applying all applicable resource exclusions, the specialist determines the sponsor and sponsor's spouse have combined countable resources of $3,500. The current resource limit for a couple is $3,000.
$500 ($3,500-$3,000) of the sponsor's and sponsor's spouse's resources is deemed to the alien.
Example 3: Sponsor lives with spouse, who is also alien's sponsor
After applying all applicable resource exclusions, the specialist determines the sponsor and sponsor's spouse have combined countable resources of $3,500. The current resource limit for an individual is $2,000.
None of the sponsor's and sponsor's spouse's resources are deemed to the alien, since their value is under $4,000 (twice the individual resource limit of $2,000).
Revision 15-4; Effective December 1, 2015
Evaluate the earned and unearned income of an alien's sponsor and the sponsor's spouse (if living in the same household). Unlike the treatment of resources, the sponsor's income does not receive the same income exclusions given to an applicant.
Include all the income of a sponsor of an alien and, when applicable, the income of the spouse of the sponsor, except for support and maintenance assistance and income excluded under federal laws other than the Social Security Act. See D-9500, Income Excluded from Sponsor-to-Alien Deeming, for a list of this excluded income.
Allocations are given to the sponsor and the sponsor's dependents, if applicable. A dependent is defined as someone for whom the sponsor is entitled to take a deduction on his personal income tax return.
Exception: An alien and an alien's spouse are not considered to be dependents of the alien's sponsor for the purposes of these rules.
The dependent's income is not subtracted from the dependent's allocation.
Next, deduct allocations for the sponsor and the sponsor's dependents as follows:
Deem the balance of the income to the alien as unearned income. If both members of an eligible couple have the same sponsor, the sponsor's income is deemed to each member. The couple's countable income includes the sum of their deemed income amounts.
If an alien is sponsored by more than one individual (other than two sponsors who are married to each other and living together), the sponsor-to-alien deeming rules are applied separately to the income of each sponsor to determine the total income deemable to the alien.
If only one member of a couple is sponsored and that member is an ineligible spouse, sponsor-to-alien deeming does not apply to the eligible member of the couple (nor would it be applicable to the ineligible member of the couple).
Note: When the sponsor's income is deemed to the alien applicant/recipient, cash, support and maintenance provided by the sponsor are not counted as income unless the indigence exception is granted. See D-9220, Deeming Exceptions.
Revision 18-2; Effective June 1, 2018
Example 1: Sponsor lives with non-sponsor spouse and children; only sponsor has income.
An alien applicant has no income, and the sponsor has monthly earned income of $3,300 and unearned income of $70. The sponsor's dependents (spouse and three children) have no income.
Add the sponsor's earned and unearned income for a total of $3,370 and apply the allocations for the sponsor and his dependents.
Total allocations equal $2,250: $750 (FBR for an individual) for the sponsor + $375 (one-half the FBR for an individual) for the non-sponsor spouse + $1,125 (one-half the FBR for an individual, $375 each) for the sponsor's three children.
Deduct the allocation amount of $2,250 from the sponsor's total income of $3,370, which leaves $1,120 to be deemed to the alien as his unearned income. This amount is subject to the $20 general income exclusion when determining his eligibility.
Example 2: Sponsor lives with non-sponsor spouse and children; both sponsor and spouse have income.
An alien couple with no income applies for benefits. The sponsor has earned income of $2,350, and the non-sponsor spouse has earned income of $450. Their two children have no income.
Combine the sponsor's and spouse's income for a total of $2,800 ($2,350+$450) and apply the allocations for the sponsor and his dependents.
Total allocations equal $1,875: $750 (FBR for an individual) for the sponsor + $375 (one-half the FBR for an individual) for the non-sponsor spouse + $750 (one-half the FBR for an individual, $375 each) for the sponsor's two children.
Deduct the allocation amount of $1,875 from the sponsor's and spouse's total income of $2,800, which leaves $925. This amount must be deemed independently to each applicant. The $1,850 deemed income ($925 each) is unearned income to the alien couple and is subject to the $20 general income exclusion when determining the couple's eligibility.
Example 3: Sponsor lives with spouse, who is also alien's sponsor, and children; both sponsors have income.
An alien couple with no income is applying for benefits. The sponsor has earned income of $2,350, and the co-sponsor, who lives with him, has earned income of $650. Their two children have no income.
Combine the sponsor's and co-sponsor's income for a total of $3,000 ($2,350 + $650) and apply the allocations for the sponsors and dependents.
Total allocations equal $2,250: $1,500 (two times the FBR for an individual, $750 each) for the sponsor and co-sponsor + $750 (one-half the FBR for an individual, $375 each) for the two children.
Deduct the allocation amount of $2,250 from the sponsors' total income of $3,000, which leaves $750. This amount must be deemed independently to each applicant. The $1,500 deemed income ($750 each) is unearned income to the alien couple and is subject to the $20 general income exclusion when determining the couple's eligibility.
Note: Examples may not reflect the most current FBR amounts.
Revision 12-4; Effective December 1, 2012
Revision 12-4; Effective December 1, 2012
Revision 12-4; Effective December 1, 2012
Revision 12-4; Effective December 1, 2012
Revision 12-4; Effective December 1, 2012
Revision 12-4; Effective December 1, 2012
Revision 12-4; Effective December 1, 2012
If deeming income or resources from a sponsor results in the alien being found:
Ineligible — indicate on the notice that the denial was a result of deeming income or deeming resources from the alien's sponsor.
Eligible — indicate on the notice that the sponsor(s) may be liable for repayment of benefits received by the alien applicant/recipient.
Revision 18-1; Effective March 1, 2018
Revision 10-1; Effective March 1, 2010
(a) The Texas Health and Human Services Commission (HHSC) follows §1612 of the Social Security Act (42 U.S.C. §1382a) and 20 CFR §§416.1101 - 416.1104 regarding the definition and general treatment of income for the purpose of determining financial eligibility and calculating a co-payment.
(b) A lump sum payment is countable income in the month of receipt and is a resource thereafter.
(c) A person in an institutional setting may retain a personal needs allowance (PNA) in an amount set by the HHSC executive commissioner in accordance with Chapter 32 of the Texas Human Resources Code.
(1) The PNA is not applied toward the cost of medical assistance furnished in an institutional setting.
(2) For a person receiving the reduced SSI federal benefit rate, HHSC issues a supplement to give the person a PNA at the minimum level set by the HHSC executive commissioner.
(d) An action by a fiduciary agent is the same as an action by the person for whom the fiduciary agent acts.
(1) Monies received by a fiduciary agent for another person are not income to the fiduciary agent. If the fiduciary agent is authorized to keep part of the money as compensation for services rendered, the compensation for services rendered is unearned income to the fiduciary agent.
(2) Monies received by a fiduciary agent for another person are charged as income to the person when the monies are received by the fiduciary agent.
The Texas Health and Human Services Commission averages monthly countable income that is predictable but varies in amount from month to month.
The Texas Health and Human Services Commission follows 20 CFR §§416.1160-416.1166 regarding the definition and treatment of deemed income for a person in a noninstitutional setting.
The Texas Health and Human Services Commission follows 20 CFR §416.1149 and §416.1167 regarding the definition and treatment of a temporary absence from a person's living arrangement for deeming purposes for a person in a noninstitutional setting.
The Texas Health and Human Services Commission exempts cafeteria plan benefits as defined in and based on §125 of the Internal Revenue Code (IRC), except that:
(1) cash received under a cafeteria plan in lieu of benefits is not exempt, but is counted as earned income; and
(2) payroll deductions used to purchase cafeteria plan benefits in addition to or instead of those purchased under a salary reduction agreement are not exempt, but are part of the employee's wages and are counted as earned income.
If a person's pension or benefit checks are reduced because of recovery of overpayments, the following apply:
(1) All overpayments except Retirement, Survivors, and Disability Insurance (RSDI).
(A) If a person was receiving Supplemental Security Income (SSI) or assistance under a Medicaid-funded program for the elderly and people with disabilities (MEPD) at the time of overpayment, the Texas Health and Human Services Commission (HHSC) disregards as income the amount being recovered. HHSC counts the net amount of the benefit (that is, the gross benefit minus the amount being recouped) for the purpose of determining eligibility and calculating a co-payment.
(B) If a person was not receiving SSI or assistance under MEPD at the time of overpayment, HHSC counts the recovered amount as income. HHSC counts the gross amount of the benefit for the purpose of determining eligibility and calculating a co-payment.
(2) RSDI overpayments.
(A) If a person receives an overpayment of Social Security (RSDI or Title II) benefits, recoupment is not voluntary. HHSC counts the net amount of the RSDI benefit (that is, the gross RSDI minus the amount being recouped) for the purpose of determining eligibility and calculating a co-payment.
(B) If a person receives an overpayment of SSI benefits and the person is still eligible for SSI, the recoupment is voluntary. HHSC determines if the person signed a voluntary agreement for recoupment. If there is a signed agreement, HHSC counts the gross RSDI for the purpose of determining eligibility and calculating a co-payment. If there is no signed agreement, there should be no recoupment from RSDI benefits.
(C) If a person receives an overpayment of SSI benefits and the person is no longer eligible for SSI, recoupment of any RSDI or Title II benefits is not voluntary. HHSC counts the net amount of the RSDI benefit (that is, the gross RSDI minus the amount being recouped) for the purpose of determining eligibility and calculating a co-payment.
(a) The Texas Health and Human Services Commission (HHSC) follows 20 CFR §416.1112 and §416.1124 regarding income exclusions, except when testing income eligibility under the special income limit HHSC does not allow the exclusions:
(1) in 20 CFR §416.1112(c)(4), (5), and (7); or
(2) in 20 CFR §416.1124(c)(12), unless:
(A) the person meets the criteria under §1929(b)(2)(B) of the Social Security Act (42 U.S.C. §1396t(b)(2)(B)); and
(B) the Centers for Medicare and Medicaid Services has authorized HHSC to allow the exclusion.
(b) HHSC also excludes income described in the appendix to Subpart K in 20 CFR Part 416.
The Texas Health and Human Services Commission follows the federal regulations indicated in the table in this section regarding the treatment of income not otherwise described in this division
| Type of Income | Section(s) in 20 CFR: |
|---|---|
| Assistance received due to a major disaster; repair or replacement of lost, damaged, or stolen resources due to a disaster | 416.1150 416.1151 |
| Earned income | 416.1110-416.1112 |
| Support and maintenance assistance, including home energy assistance | 416.1157 |
| Income used to fulfill a plan to achieve self-support (PASS) for a person who is blind or disabled | 416.1180-416.1182 |
| In-kind support and maintenance | 416.1130-416.1148 |
| Unearned income | 416.1120-416.1124 |
Revision 09-4; Effective December 1, 2009
A person is eligible for Medicaid if the person:
This chapter covers treatment of income to budget to determine eligibility and, if applicable, co-payment. Treatment of budgets is covered in other chapters.
For purposes of Medicaid, income is anything a person receives in cash or in kind that can be used to meet the person’s needs for food and shelter. It is the receipt of any property or service a person can apply, either directly or by sale or conversion, to meet basic needs for food and shelter. Income is normally counted on a monthly basis; not all income goes into the budget to determine eligibility and the co-payment.
The receipt of a payment – in the form of cash, property, or service – is income in the month of receipt and a resource as of 12:01 a.m. on the first day of the month after receipt.
Revision 09-4; Effective December 1, 2009
Calendar quarter — A period of three full calendar months beginning with January, April, July or October.
Child — A person who is not married, is not the head of a household, and is either under age 18 or is under age 22 and a student.
Couple — An eligible individual and his or her eligible spouse.
Supplemental Security Income (SSI) benefit rate — The payment amount in the SSI program.
Federal benefit rate — The monthly payment rate for an eligible individual or couple. It is the figure from which countable income is subtracted to find out how much a person’s federal SSI benefit should be. The federal benefit rate does not include the rate for any state supplement paid by us on behalf of the state.
Shelter — Includes room, rent, mortgage payments, real property taxes, heating fuel, gas, electricity, water, sewerage and garbage collection services. A person is not receiving in-kind support and maintenance in the form of room or rent if the person is paying the amount charged under a business arrangement. A business arrangement exists when the amount of monthly rent required to be paid equals the current market rental value.
Income — The receipt of any property or service a person can apply, either directly or by sale or conversion, to meet basic needs for food and shelter.
Countable income — The amount of a client's income after all exemptions and exclusions.
Income of spouse — Income considered when one member of a couple is institutionalized. Income paid to one spouse is considered to be the income of that spouse, unless a fair hearings process establishes otherwise, or the payor provides evidence that the income is augmented for a spouse, such as VA benefits. Income from community property paid to only one spouse is considered the income of that spouse regardless of state law governing community property or division of marital property. (Consult the regional attorney about ownership of income from a trust.)
Revision 09-4; Effective December 1, 2009
There are two major types of income:
Income, whether earned or unearned, is received in either of two forms:
Cash — Currency, checks, money orders or electronic funds transfers (EFT), such as:
In-kind — Noncash items such as:
Income, whether cash or in-kind, is received in either of two ways:
Fixed — Income received on a regular, predictable schedule (usually monthly) and for the same amount each month, such as:
Variable — Income that is either received on a varying schedule or for different amounts, such as:
Revision 09-4; Effective December 1, 2009
In general, anything received in a month, from any source, is income to a person, if it meets the person’s needs for food and shelter. Anything the person owned prior to the month under consideration is subject to the resource counting rules.
An item received in the current month is income for the current month only. If held by the person until the following month, that item is subject to resource counting rules.
Exceptions: Occasionally, a regular periodic payment (for example, wages, pension or VA benefits) is received in a month other than the month of normal receipt. As long as there is no intent to interrupt the regular payment schedule, consider the funds to be income in the normal month of receipt.
A lump sum payment is income in the month of receipt and is a resource thereafter.
Revision 09-4; Effective December 1, 2009
An action by a fiduciary agent is the same as an action by the person for whom the fiduciary agent acts.
Revision 09-4; Effective December 1, 2009
A garnishment or seizure is a withholding of an amount from earned or unearned income in order to satisfy a debt or legal obligation.
Amounts withheld from income as garnishment to satisfy a debt or legal obligation are countable income.
Revision 16-4; Effective December 1, 2016
A division of income and property in a divorce settlement is not considered a garnishment or lien placed against income. When an individual is paying income to a former spouse, consider court documentation before determining the ownership and accessibility of the income. A legal review of the documentation may be necessary to determine ownership and accessibility of income and a pension plan for each of the former spouses. For verification, use one of the following sources:
If none of the above sources are available, obtain an individual's sworn affidavit that explains why one of the sources above is not available (for example, the documentation does not exist, the court or agency will not release the information or the source refused to cooperate).
A court may issue an order called a domestic relations order that provides income such as spousal support which may also be called alimony (see E-3320 , Alimony and Support Payments), to the former spouse.
A Qualified Domestic Relations Order (QDRO) is a property settlement that assigns all or a portion of a retirement plan to the former spouse. An employer or retirement plan administrator may refuse to recognize a QDRO and separate the retirement plan payments to each individual. Consider the portion of the retirement plan payments as income to each individual as stipulated in the QDRO, regardless if the retirement plan administrator pays each individual their portion or only pays the retiree who then pays the former spouse.
Note: For individuals who are active or retired from the military, a marital division of property may be similar to a domestic relations order or a QDRO. A legal review of the documentation may be necessary to determine ownership and accessibility of income and a pension plan for each of the former spouses.
If income of an ineligible spouse, parent or ineligible child is garnished to pay court-ordered or Title IV-D enforced support payments, do not consider the income used by these individuals to make support payments. Support payments are payments made under a court order or enforced in compliance with a state agreement under Title IV-D. Title IV-D child support payments are usually made directly to the state.
An irrevocable waiver of income must be evaluated for a transfer of assets penalty. See Chapter I, Transfer of Assets.
If a person's pension or benefit checks are reduced because of recovery of overpayments, the amount considered as income is based on the source of the payment.
If a person receives an overpayment of Social Security (RSDI or Title II) benefits, recoupment is not voluntary. HHSC counts the net amount of the RSDI benefit (for example, the gross RSDI minus the amount being recouped) for the purpose of determining eligibility and calculating a co-payment.
If a person receives an overpayment of SSI benefits and the person:
If a person was receiving SSI or assistance under MEPD at the time of overpayment, HHSC disregards as income the amount being recovered. HHSC counts the net amount of the benefit (for example, the gross benefit minus the amount being recouped) for the purpose of determining eligibility and calculating a co-payment.
If a person was not receiving SSI or assistance under MEPD at the time of overpayment, HHSC counts the recovered amount as income. HHSC counts the gross amount of the benefit for the purpose of determining eligibility and calculating a co-payment.
Some things a person receives are not income because the person cannot use those things as food or shelter, or cannot use those things to obtain food or shelter. In addition, what a person receives from the sale or exchange of that person’s own property is not income; the proceeds of the sale or exchange of the person’s property remains a resource. The following are some items that are not income.
Medical care and services. Medical care and services are not income if they are any of the following:
A premium payment for supplementary medical insurance benefits (SMIB) under Title XVIII (Medicare), paid by a third party directly to the Social Security Administration, is not income.
Refunds to a recipient from the state’s Third-Party Recovery Unit are made if TPR payments (for example, from medical insurers) for a given medical service exceed the amount Medicaid paid for that same service. These refunds are income to the person upon receipt.
Examples of medical services include:
A social service is any service, other than medical, that is intended to assist a person with a physical disability or social disadvantage to function in society on a level comparable to that of a person who does not have such a disability or disadvantage. No in-kind items are expressly identified as social services.
Social services. Social services are not income if they are any of the following:
Examples of social service programs:
Note: Wages and salaries from Title V of the Older Americans Act, such as Green Thumb and Senior Texan Employment Program (STEP), are countable earned income.
Examples of governmental programs that may provide medical and social services in combination are:
Examples of nongovernmental organizations that provide medical and social services in combination are the:
Examples of what is not a social service:
Cash received in conjunction with medical or social services:
In-kind items received in conjunction with medical or social services:
Receipts from the sale, exchange or replacement of a resource are not income, but are resources that have changed their form. This includes any cash or in-kind item that is provided to replace or repair a resource that has been lost, damaged or stolen.
Example: If a person sells an automobile, the money a person receives is not income; it is another form of a resource. If fair market value was received for the sale of the automobile, no transfer of assets occurred.
Income tax refunds. Any amount refunded on income taxes the person has already paid is not income. Income tax refunds are subject to restitution policy (in the month of receipt) for co-payment purposes, to the extent that withholding tax was excluded in the co-payment budget.
Payments by credit life or credit disability insurance. Payments made under a credit life or credit disability insurance policy on the person's behalf are not income.
Example: If a credit disability policy pays off the mortgage on the person's home after the person becomes disabled in an accident, neither the payment nor the increased equity in the home is income.
Bills paid for the person. Payment of the person's bills by someone else directly to the supplier is not income. However, the value of anything a person receives because of the payment if it is in-kind income is counted.
Receipt of certain noncash items. Any item a person receives (except shelter as defined in Section E-1210, Other Terms, or food) that would be an excluded nonliquid resource (as described in Chapter F, Resources) if a person kept it is not income.
Example: A community takes up a collection to buy a specially equipped van, which is the person's only vehicle. The value of this gift is not income because the van does not provide the person with food or shelter and will become an excluded nonliquid resource under in the month following the month of receipt.
Replacement of income a person has already received. If income is lost, destroyed or stolen and a person receives a replacement, the replacement is not income.
Weatherization assistance. Weatherization assistance (for example, insulation, storm doors or storm windows) is not income.
Money a person borrows or money a person receives as repayment of a loan is not income. However, interest a person receives on money a person has lent is income. Buying on credit is treated as though a person were borrowing money and what a person purchases this way is not income.
A loan requires a bona fide agreement that is legally valid and made in good faith. For the borrower, the loan agreement itself is not a resource. The cash provided by the lender is not income, but is the borrower's resource if retained in the month following the month of receipt.
Proceeds (amount borrowed) of either a commercial loan or an informal loan for which repayment is required with or without interest are not counted as income in the month in which they are received. The proceeds are considered to be a resource in the following month(s). To claim exemption of the proceeds of a loan, a person must prove that he acknowledges an obligation to repay and that some plan for repayment exists. If these conditions can be verified, no written contract is required.
Note: Federal Educational Loans (Federal PLUS Loans, Perkins Loans, Stafford Loans, William D. Ford Loans, etc.) under Title IV of the Higher Education Act (HEA) are exempt from income and resources.
See Chapter F, Resources, and Chapter I, Transfer of Assets.
See Section E-3110, Wages, for a definition of earned income from wages. Employers make various payments on behalf of their employees that are not earnings and are not available to meet food or shelter needs. If an employer pays an employee's share of Social Security (FICA) or unemployment compensation taxes without making a reduction in the employee's wages, the amount the employer pays is considered income.
The following payments by an employer are not income unless the funds for them are deducted from the employee's salary:
See Section E-3110, Wages, for a definition of earned income from wages. If an employer pays an employee's share of Social Security (FICA) or unemployment compensation taxes without making a reduction in the employee's wages, the amount the employer pays is considered income. The amount the employer pays is not considered income in the following two work situations:
When considering a person’s earned income, do not consider mandatory payroll deductions as income for the purpose of determining a co-payment. The mandatory payroll deductions are:
A cafeteria plan is a written benefit plan offered by an employer in which:
A qualified benefit is a benefit the Internal Revenue Service (IRS) does not consider part of an employee's gross income. Qualified benefits include, but are not limited to:
Cash is not a qualified benefit.
A salary-reduction agreement is an agreement between employer and employee whereby the employee, in exchange for the right to participate in a cafeteria plan, accepts a lower salary or foregoes a salary increase.
Most cafeteria plans are funded by salary-reduction agreements. However, employers may make contributions to fund basic benefit levels under a cafeteria plan without a salary-reduction agreement.
Salary reductions to purchase qualified benefits under a cafeteria plan are not part of the employee's wages and are not income for eligibility or co-payment purposes.
Payroll deductions may be used to purchase cafeteria-plan benefits in addition to or instead of cafeteria-plan benefits provided under a salary-reduction agreement or employer contribution. The amount of the individual's payroll deductions for cafeteria plan benefits is the employee's wages and is earned income.
Important: Pay slips that appear to show payroll deductions may actually show how funds from a salary-reduction agreement have been allotted among qualified benefits.
The following indicators on a pay slip may indicate an approved cafeteria plan: Flex, Choices, Sec. 125, or Cafe Plan.
Revision 13-2; Effective June 1, 2013
This section covers income that is exempt in both the eligibility and co-payment budgets.
Although it is necessary to look into the source and amount of all income, not all income is budgeted when determining eligibility and co-payment. Under federal requirements, some income is exempt from the eligibility budget and the budget to determine co-payment.
For the eligibility budget and co-payment budgets, if income meets certain criteria, document and verify if necessary, but do not budget:
Revision 09-4; Effective December 1, 2009
Many federal statutes, in addition to the Social Security Act, provide exemptions for payments from certain sources. If the income in this section meets certain criteria, exempt the income from the eligibility budget and the budget to determine co-payment.
Revision 09-4; Effective December 1, 2009
Do not count in the eligibility budget or the budget to determine co-payment any receipts for the following:
Revision 12-2; Effective June 1, 2012
Do not count in the eligibility budget or the budget to determine co-payment any receipt for the following:
Revision 09-4; Effective December 1, 2009
Do not count in the eligibility budget or the budget to determine co-payment any receipt for the following:
Revision 09-4; Effective December 1, 2009
Revision 09-4; Effective December 1, 2009
Do not count in the eligibility budget or the budget to determine co-payment any receipt for the following:
Revision 09-4; Effective December 1, 2009
Do not count in the eligibility budget or the budget to determine co-payment any receipt for the following:
Revision 09-4; Effective December 1, 2009
Do not count in the eligibility budget or the budget to determine co-payment any receipt for the following:
Revision 16-3; Effective September 1, 2016
Do not count in the eligibility budget or the budget to determine co-payment any receipt for the following:
Revision 10-1; Effective March 1, 2010
Revision 10-1; Effective March 1, 2010
An earned income tax credit (EITC) is a special tax credit that reduces the federal tax liability of certain low-income working taxpayers. This tax credit may or may not result in a payment to the taxpayer. EITC payments are allowed as an advance from an employer or as a refund from the Internal Revenue Service.
The child tax credit (CTC) is a special refundable federal tax credit that is available to certain low-income taxpayers with earned income. They must be parents, step-parents, grandparents or foster parents with a dependent child. This child tax credit may provide a refund to individuals even if they do not owe any tax.
Any refund of federal income taxes a person receives under Section 32 of the Internal Revenue Code (relating to EITC or CTC ) and any payment a person receives from an employer under Section 3507 of the Internal Revenue Code (relating to advance payment of an EITC) is exempt. Exempt this income from the eligibility budget and the budget to determine co-payment.
Relationship of income to resources. An unspent EITC or CTC payment is not counted as a resource for the month it is received and for the nine months following the month of receipt. After that, count any remaining funds from the EITC or CTC payment as a resource. See Section F-2260, Exclusions from Resources Provided by Other Statutes.
Example: The EITC payment is received in May. The EITC payment is not income in May. Any remaining funds from the EITC payment are a resource as of the first of March of the following year.
Revision 09-4; Effective December 1, 2009
A person who is under age 22 and regularly attending school is considered a student. A student's income is exempt from the eligibility budget and the budget to determine co-payment, up to the monthly limit but not more than the calendar year annual limit.
This exemption may apply to an eligible or ineligible:
Apply the exemption:
The limits are set by the Social Security Administration for the SSI program and published annually in the Federal Register. The monthly and yearly limits are calculated annually based on increases in the cost of living index. Under this calculation, these amounts will never be lower than the previous year's amounts. However, there may be years when no increases result from the calculation.
See "Special Income Exemption for Student" in Appendix XXXI, Budget Reference Chart, for the monthly and yearly amount limits for the exemption.
Revision 09-4; Effective December 1, 2009
Revision 09-4; Effective December 1, 2009
Exempt from the eligibility budget and the budget to determine co-payment any amount received from any public agency as a return or refund of taxes paid on real property or on food purchased.
Revision 09-4; Effective December 1, 2009
Exempt from the eligibility budget assistance based on need that is wholly funded by a state or one of its political subdivisions, including a recognized Indian tribe. Assistance is based on need if it is provided under a program that uses the amount of income as one factor to determine eligibility. The Temporary Assistance for Needy Families (TANF) program is an example.
Revision 09-4; Effective December 1, 2009
If not totally exempt under policy in Section E-2130, Education and Employment, exempt from the eligibility budget and the budget to determine co-payment any portion of a grant, scholarship, fellowship or gift used for paying tuition, fees or other necessary educational expenses at any educational institution, including vocational or technical education. Any portion of such educational assistance that is not used to pay current tuition, fees or other necessary educational expenses, but will be used for paying this type of educational expense at a future date is excluded from income in the month of receipt. This exclusion does not apply to any portion set aside or actually used for food or shelter.
Revision 09-4; Effective December 1, 2009
Exempt from the eligibility budget and the budget to determine co-payment the value of food that a person and household raise, if it is consumed by the household.
Revision 13-2; Effective June 1, 2013
Exempt from the eligibility budget one-third of the total amount of child support payments for an eligible child.
See Section E-3321, Child Support Payments
Revision 10-1; Effective March 1, 2010
Treat the following payments based on policy in Section E-2320, Assistance Based on Need, or do not consider payments as income based on policy in Section E-1700, Things That Are Not Income:
Consider a utility allowance given under any of these to be income, unless the allowance is paid directly to the utility company and the client has no access to the allowance. Utility benefits under Section E-2120, Housing and Utilities, are exempt.
When considering disaster assistance, payments precipitated by an emergency or major disaster are not counted as income or resources when determining Medicaid eligibility.
If precipitated by an emergency or a major disaster, do not consider the following as income:
For treatment of resources from disaster assistance, see Section F-2270, Exclusions from Resources Related to Disaster Payments.
Revision 09-4; Effective December 1, 2009
Treat the following gifts based on policy in Section E-2320, Assistance Based on Need, or do not consider the payments as income based on policy in Section E-1700, Things That Are Not Income.
Revision 09-4; Effective December 1, 2009
Gifts from tax-exempt organizations, such as the Make-A-Wish Foundation, to children with life-threatening conditions, as required by Public Law 105-306, effective retroactively to Oct. 28, 1996, are exempt. The exclusions apply to children under age 18. The gift must be from an organization described in Section 501(c)(3) of the Internal Revenue Code of 1986 and that is exempt from taxation under Section 501(c). Document the case record with an oral or written statement from the organization that the gift was made based on the child having a life-threatening condition. No additional medical development is necessary.
The following gifts to or for the benefit of a child described above are excluded from income:
If an in-kind gift is converted to cash, the cash counts as income in the month converted. For purposes of this exclusion, an in-kind gift is any gift other than cash, including gifts of food or shelter.
The exclusion also applies to a deeming situation if the gift is made to a parent for the benefit of a child with a life-threatening condition.
Revision 09-4; Effective December 1, 2009
Do not count the value of any commercial transportation ticket that is received as a gift and is not converted to cash. See Section E-3371, Gifts of Domestic Commercial Transportation Tickets.
Revision 09-4; Effective December 1, 2009
Relocation assistance provided under Title II of the Uniform Relocation Assistance and Real Property Acquisitions Policies Act of 1970 (Subchapter II, Chapter 61, Title 42 of the U.S. Code) is excluded from income.
Relocation assistance provided by a state or local government that is comparable to assistance provided under Title II of the Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970 that is subject to the treatment required by Section 216 of that Act. State or local relocation assistance payments are excluded from countable resources for nine months after the month of receipt.
Revision 09-4; Effective December 1, 2009
Do not count in the eligibility budget or the budget to determine co-payment any payment received from a fund established by a state to aid victims of crime. Unspent payments received from a fund established by a state to aid victims of crime are excluded from resources for nine months. A person is not required to apply for benefits from a crime victims’ compensation fund.
Revision 09-4; Effective December 1, 2009
Revision 09-4; Effective December 1, 2009
Do not count hazardous duty pay of a spouse or parent absent from the home because of active military service.
Do not count in the eligibility budget or the budget to determine co-payment any receipt of unearned income for the hostile fire pay or imminent danger pay portion of military income, commonly known as combat pay.
Any unspent hostile fire pay or imminent danger pay becomes a resource if retained into the following month and not otherwise excluded.
In a deeming situation, exclude from deemed resources for the nine-month period following the month of receipt the unspent portion of any retroactive payment of:
Revision 09-4; Effective December 1, 2009
Do not count in the eligibility budget or the budget to determine co-payment interest earned on excluded burial funds and any appreciation in the value of an excluded burial arrangement that is left to accumulate and become a part of a separately identifiable burial fund. If the burial funds increase by more than $1,500 because of contributions by client actions, the amount in excess of $1,500 is a countable resource.
Revision 09-4; Effective December 1, 2009
Public Law 104-193, the Personal Responsibility and Work Opportunity Reconciliation Act of 1996, requires the representative payees of SSI recipients under age 18 to establish designated accounts when there are retroactive payments for more than six months payable to the recipients. These designated accounts, including accrued interest or other earnings produced by the accounts, are excluded from countable resources. This exclusion was effective Aug. 22, 1996.
Do not count in the eligibility budget or the budget to determine co-payment interest or other earnings on any designated account established for SSI recipients under age 18 for retroactive benefits, as required by Public Law 104-193, effective Aug. 22, 1996.
Revision 10-1; Effective March 1, 2010
The following payments, regardless of when received, are not counted as income and are excluded from resources:
Revision 18-2; Effective June 1, 2018
Revision 13-2; Effective June 1, 2013
Earned income may be in cash or in-kind. Payment of earned income may be:
To budget variable earned income:
Converting Monthly Income
The eligibility system will convert income that is received other than monthly to a monthly amount by using the following conversion process below:
Weekly earnings are converted to monthly amounts by multiplying weekly earnings by 4.33. For example, if weekly earnings are $150, the calculation is: $150 weekly earnings X 4.33 = $649.50 monthly earnings.
Bi-weekly earnings are converted to a monthly amount by averaging the bi-weekly earnings, then multiplying the average bi-weekly earnings by 2.17. For example, if average bi-weekly earnings are $300, the calculation is: $300 average bi-weekly earnings X 2.17 = $651 monthly earnings.
When projecting earned income, if there is verification of the actual amount of earnings received during an entire calendar month, use the actual amount received instead of the above procedures for converting weekly and bi-weekly earnings to a monthly amount. For example, the client earns $150 each week. During July, he received the following payments: $150 on July 1, $150 on July 8, $150 on July 15, $150 on July 22, and $150 on July 29. The amount budgeted is the actual income received in July ($750), not $649.50 ($150 weekly earnings X 4.33 = $649.50). $649.50 would be used as the projected income for following months beginning in August.
Note: When income is new or terminated and only a partial month's income is received in the start or terminated month, do not convert the income. Use actual, unconverted income.
Revision 10-2; Effective June 1, 2010
Wages are what a person receives (before any deductions) for working as someone else's employee.
Wages include salaries, commissions, bonuses, severance pay and any other special payments received because of employment. They may also include the value of food, clothing or shelter, or other items provided instead of cash, referred to as in-kind earned income.
If a person is a domestic or agricultural worker, the law requires the value of food, clothing or shelter, or other items provided instead of cash, be treated as in-kind unearned income.
Note: If a person receives wages from an S Corporation and is also a shareholder of the S Corporation, consult the regional attorney.
Wages or Self-Employment
Under certain conditions, services performed as an employee may be considered self-employment rather than wages. Typically, services provided by ministers, real estate agents or newspaper vendors are considered self-employment rather than wages. Statutory employees are independent contractors and are treated as self-employed individuals. There are four categories of statutory employees:
Kinds of Wages
Some, but not all, forms of wages are:
Salaries — Payments (fixed or hourly rate) received for work performed for an employer.
Commissions — Fees paid to an employee for performing a service (for example, a percentage of sales). Commissions are wages when paid if the payment stems from an employer-employee relationship. The wages of a salesperson paid on a straight commission basis are the gross commissions paid minus any amounts paid specifically as advances or reimbursements for travel or business expenses incurred in the employer's business. Advances against commissions to be earned in the future are wages when paid.
Bonuses — Amounts paid by employers as extra pay for past employment (for example, for outstanding work, length of service, holidays, etc.) as part of the employment relationship.
Severance Pay — Payment made by an employer to an employee whose employment is terminated independently of his wishes or payment is made due to voluntary early retirement and normally considered earned wages. When an employee’s severance pay is budgeted, contact state office for special treatment of some severance pay.
Military Basic Pay — The service member's wage, which is based solely on the member's pay grade and length of service. When military personnel wages are budgeted, contact state office for special treatment of the service member’s compensation.
Special Payments Received Because of Employment —Items such as vacation pay, advanced/deferred wages, etc. Payments are not wages after the first six months. Any payments, or portion thereof, received by an employee during the first six months period, which according to the employer, are attributable to the employee's own contributions to the plan are not wages. Such payments are a return on the employee's premium rather than pay for service.
Note: Workers' compensation payments are not wages.
References:
Revision 10-1; Effective March 1, 2010
Net earnings from self-employment are the gross income from any trade or business that a person operates, less allowable deductions for that trade or business. Net earnings also include a person’s share of profit or loss in any partnership to which a person belongs. These are the same net earnings that a person would report on a federal income tax return.
If a person is both employed and self-employed, his earned income consists of his wages plus net earnings from self-employment. Typically, services provided by ministers, real estate agents or newspaper vendors are considered self-employment rather than wages. Statutory employees are independent contractors and are treated as self-employed individuals. There are four categories of statutory employees:
See Section E-6000, Self-Employment Income, for more details on treatment of this type of earned income.
Revision 09-4; Effective December 1, 2009
Farm income is earned income when either the person or spouse is doing the farming or operating the farm as a business. See Section E-6000, Self-Employment Income, for more details on treatment of this type of earned income.
Revision 09-4; Effective December 1, 2009
Payments for services performed in a sheltered workshop or work activities center are what a person receives for participating in a program designed to help a person become self-supporting, even though payment does not meet the definition of wages.
Revision 09-4; Effective December 1, 2009
Royalties that are earned income are payments to a person in connection with any publication of the person’s work. Honoraria that are earned income are those portions of payments, such as an honorary payment, reward or donation, received in consideration of services rendered for which no payment can be enforced by law.
If a person receives a royalty as part of a trade or business, see Section E-3120, Self-Employment. See Section E-6000, Self-Employment Income, for more details on treatment of this type of earned income.
If a person receives another type of royalty or honorarium, investigate unearned income policy.
Revision 09-4; Effective December 1, 2009
Refunds on account of earned income credits are payments made to a person under the provisions of Section 43 of the Internal Revenue Code of 1954, as amended. These refunds may be greater than taxes a person has paid. A person may receive earned income tax credit payments along with any other federal income tax refund a person receives because of overpayment of the person’s income tax. Advance payments of earned income tax credits are made by the employer under the provisions of Section 3507 of the same code. A person can receive earned income tax credit payments only if a person meets certain requirements of family composition and income limits.
Federal income tax refunds made on the basis of taxes a person has already paid are not income to a person, as stated in Section E-1740, Miscellaneous Things That May Not Be Income.
Revision 10-1; Effective March 1, 2010
The census is a count of everyone living in the United States and is mandated by the U.S. Constitution. The U.S. Census Bureau conducts the census every 10 years.
Wages paid by the Census Bureau for temporary employment related to census activities are excluded income for the Medicare Savings Programs (MSP). Do not include these wages in the eligibility budget for MSP.
These wages for temporary employment are not countable income in the month of receipt, but are considered a resource thereafter.
Wages paid by the Census Bureau for temporary employment related to census activities are included in eligibility or co-payment budgets for any other Medicaid for the Elderly and People with Disabilities (MEPD) program that is not an MSP.
For cases with a combination of regular Medicaid benefits and an MSP, the wages are countable in the eligibility budget (and co-payment, if applicable) for the regular Medicaid program, but are excluded in the eligibility budget for MSP.
Example: Individual is being considered for Pickle with Qualified Medicare Beneficiary (QMB) benefits. The wages paid by the Census Bureau for temporary employment related to census activities are included in the eligibility budget for Pickle, but are excluded in the eligibility budget for QMB.
Revision 16-2; Effective June 1, 2016
Unearned income is any income that is not earned. Unearned income may be in cash or in-kind. Unearned income includes these types of income:
Income tax refunds are subject to restitution policy (in the month of receipt) for co-payment purposes, to the extent that withholding tax was not included in the co-payment budget.
To determine the amount of unearned income, consider the amount actually available to the person. Reduce the gross amount by any ordinary or necessary expenses incurred in receiving the unearned income. For example, compensation for damages incurred in an accident would be the settlement amount less any legal, medical or other expenses. Medicare premiums, other health insurance premiums and income tax withheld from unearned income are not deductible expenses for eligibility determination. Income tax withheld from unearned income is also not a deductible expense for the co-payment calculation.
Revision 09-4; Effective December 1, 2009
This section includes sources of unearned income.
Revision 09-4; Effective December 1, 2009
This unearned income is usually related to prior work or service. It includes, for example, private pensions, Social Security benefits, disability benefits, veterans’ benefits, workers’ compensation, railroad retirement annuities and unemployment insurance benefits. Payments from these sources are usually stable and fixed. See Section E-4000, Fixed Income.
Revision 09-4; Effective December 1, 2009
A Medicaid-qualifying trust is one that the person, his spouse, guardian or anyone holding his power of attorney establishes using the person's money, and the person is the beneficiary.
Amounts distributed from the trust to the person or used for the person's health, personal or other maintenance needs are countable income.
For example, if terms of the trust direct the trustee to pay a health care provider for medical services, the person is receiving the benefit of payment although no money is paid directly to him, and the amount is countable income.
Revision 09-4; Effective December 1, 2009
Resources in a testamentary or inter vivos trust are countable if the person is the trustee and has the legal right to revoke the trust and use the money for his own benefit. If he does not have access to the trust, the trust is not counted as a resource. If a trust is not counted as a resource, payments or disbursements from the trust made to or on behalf of the person are considered income. Payments or disbursements used to purchase medical or social services for the person are not considered income to the person.
Revision 09-4; Effective December 1, 2009
Payments from the corpus or income generated by the corpus, to or for the benefit of the person, excluding payments for medical/social services, are income.
Payments from the corpus or income generated by the corpus for any other purpose are a transfer of assets.
Revision 09-4; Effective December 1, 2009
Any distribution to or for the benefit of the person from corpus or income generated by the trust, except payments for medical and social services, is countable income. A payment to or for the benefit of the person is counted under trust provisions only if such payment is ordinarily counted as income.
Revision 10-1; Effective March 1, 2010
Income directed to the trust is disregarded from countable income when testing eligibility for institutional settings.
Any source of non-exempt/non-excludable income which is not directed to the QIT account during the calendar month of receipt is countable income for that month.
If countable income exceeds the special income limit, the person is income-ineligible for the month. Applicants may not be certified for any calendar month(s) in which they are income-ineligible. For active persons, restitution is requested in the amount of the vendor payment for any calendar month(s) in which they are income-ineligible.
Notes:
Examples:
Revision 16-4; Effective December 1, 2016
Alimony and spousal support payments are cash or in-kind contributions to meet some or all of an individual's needs for food or shelter. Alimony (sometimes called maintenance) is an allowance made by a court from the funds of one spouse to the other spouse in connection with a suit for separation or divorce. Support payments may be made voluntarily or because of a court order.
Alimony and spousal support payments are unearned income to the individual receiving the payments. Verify the amount and frequency of alimony or spousal support payments.
For verification, use one of the following sources:
If none of the above sources are available, obtain an individual’s sworn affidavit that explains why one of the sources above is not available (for example, the documentation does not exist, the court or agency will not release the information, or the source refused to cooperate). See E-1410 , Division of Marital Income and Property.
If the alimony is not received in cash, determine its current fair market value.
To determine countable income, deduct any expenses that may have been incurred in obtaining the income, such as legal fees and court costs.
Determine whether the alimony is to be treated as a lump-sum payment, infrequent or irregular income, or regular and predictable income.
Revision 13-2; Effective June 1, 2013
Consider payments as child support if:
Consider cash gifts or donations as cash contributions, not child support. A cash gift or donation is money that only benefits the child for a specific purpose, such as a birthday present, or to purchase clothes, toys or personal items.
Child support collected through the Office of Attorney General (OAG) may be distributed through warrants, direct deposits or the Texas Debit Card. A person also may receive payments through another state’s Office of Attorney General. Several other states use debit accounts for the distribution of child support payments.
When child meets definition in D-1210, Definition of a Child:
When child does not meet definition in D-1210:
If a recipient receives child support for a child (including an adult child) but uses the money for the recipient’s personal or household needs instead of the child’s, count it as unearned income to the recipient. Do not count the amount actually used for or provided to the child as income to the recipient.
The eligibility specialist must document how the child support monies are used.
If a single payment covers two or more children (including at least one who is not an applicant/recipient) and the support order does not specify a portion for each child, prorate the payment among all of the children. When two or more children receive child support from the same father and one is an eligible child, the payment is always prorated.
Revision 09-4; Effective December 1, 2009
Dividends and interest are returns on capital investments, such as stocks, bonds or savings accounts.
Royalties include compensation paid to the owner for the use of property, usually copyrighted material such as books, music or art, or natural resources such as minerals, oil, gravel or timber. Royalty compensation may be expressed as a percentage of receipts from using the property or as an amount per unit produced.
To be considered royalties, payments for the use of natural resources also must be received:
An outright sale of natural resources by the owner of the land or by the owner of rights to use of the land constitutes the conversion of a resource. Proceeds from the conversion of a resource are not income.
Royalties are unearned income unless they are:
If royalties are earned income, see Section E-3150, Certain Royalties and Honoraria.
Revision 10-1; Effective March 1, 2010
Interest and dividends are returns on loans or investments such as stocks, bonds or savings accounts.
Dividends from insurance policies are not included because those dividends are refunds of overcharges on premiums. Appendix XXXV, Treatment of Insurance Dividends, indicates that when dividends are:
Note: The dividend accumulation is a countable resource, like the balance of a savings account. The interest earned on the dividends would be excluded from income when paid. Interest left to accumulate becomes part of the countable resources.
Revision 09-4; Effective December 1, 2009
Determine if any interest or dividends are accrued on fully countable resources.
Revision 16-4; Effective December 1, 2016
Determine if any interest or dividends are accrued on certain excluded or partially excluded resources.
The following are excluded or partially excluded resources based on federal statutes other than the Social Security Act:
See Section E-2000, Exempt Income, for other sources and for treatment of interest or dividends accrued on other unspent types of payments.
Example: An individual in a nursing facility received a payment for being a former prisoner of North Vietnam. The payment made by the Department of Defense is not a countable resource. The payment was deposited into an account that accrues interest. Do not count interest accrued on the unspent portion from the payment in the eligibility or co-payment budgets.
Revision 09-4; Effective December 1, 2009
Determine if any interest or dividends are accrued on all other resources.
Interest accrued on retained amounts of SSA/SSI lump sums during the nine-month resource exclusion period is not excluded as income. However, some or all of the amount earned may be excluded as infrequent or irregular income.
Burial funds — Continue to follow policy for burial funds in Chapter F, Resources, in all aspects of calculating countable resources and consideration of the interest accrued.
Steps to follow:
| When the source of the dividend or interest is received on ... | then ... |
|---|---|
| a fully countable resource, | the dividends or interest are not counted as income regardless of the frequency and amount in the eligibility budget. Count in the co-payment budgets. |
| certain excluded or partially excluded resource, | the dividends or interest are not counted as income in either the eligibility or co-payment budgets. |
| all other resources (different than those above), | the dividends or interest are counted as income in the eligibility or co-payment budgets according to the treatment of that particular resource as outlined in the handbook. |
Exclude interest and dividends if they meet the definition of infrequent or irregular income as specified in Section E-9000, Infrequent or Irregular Income.
See Appendix XVI, Documentation and Verification Guide.
Note: In a spousal situation, if the institutionalized person is diverting income to the community spouse, a joint bank account balance is equally divided between the two. Even though only one-half of this balance is countable for the institutionalized person, treat the interest/dividends as if accrued on a fully countable resource.
Revision 16-4; Effective December 1, 2016
An Achieving a Better Life Experience (ABLE) program allows an individual with a disability or family members of the individual to establish a tax-free savings account to maintain health, independence and quality of life for the benefit of the individual with a disability. The individual must meet the criteria of the state's ABLE program in which the individual enrolls. The ABLE account funds can be used for the individual's disability-related expenses, which supplement, but do not replace, private insurance and/or public assistance.
Interest and dividends earned on an ABLE account are not countable income to the designated beneficiary.
Income of the designated beneficiary of an ABLE account, or an individual whose income is counted when determining eligibility, that is deposited into an ABLE account, remains countable when determining eligibility.
Contributions to an ABLE account from individuals other than the designated beneficiary, and any distributions from an ABLE account, are not considered income to the designated beneficiary.
Request information to verify an ABLE account. Verification must include the following information:
Verification documents may vary among states. Examples of acceptable documentation include participation agreements, ABLE account contracts, financial statements, and annual income tax filing documents.
Revision 16-4; Effective December 1, 2016
School-Based Savings Accounts are accounts set up by students or their parents at financial institutions that partner with school districts. Individuals may set up school-based savings programs through savings accounts, Certificates of Deposit (CDs), Series I savings bonds, and Tuition Savings Plans under IRS Code, Section 529 or U.S.C. Section 530.
Interest earned on School-Based Savings Accounts is excluded from income.
Related Policy
F-2320, School-Based Savings Accounts
Revision 10-1; Effective March 1, 2010
In this context, the term "spouse" includes a spouse whose income is considered in the co-payment determination process. Interest payments on joint bank accounts are considered as follows:
All interest payments and deposits are divided equally among the applicant/recipient, spouse or parent.
If an applicant/recipient has disproved ownership of all or a part of the funds in a joint account, deposits by co-holders are not considered as income before the change in the account designation. Interest payments are income to the eligible individual in proportion to the amount of the funds owned.
References:
Section F-4121, Joint Bank Accounts
Section E-3331, Interest and Dividends
Determine ownership by verifying bank records and obtaining statements from the co-holders of the account.
Revision 09-4; Effective December 1, 2009
Ownership of Land and Mineral/Timber Rights
If the person owns the land to which the mineral rights or timber rights pertain, the current market value of the land can be assumed to include the value of the mineral rights. Additional development is unnecessary.
Ownership of Mineral Rights/Timber Rights Only
If the person does not own the land to which the mineral rights pertain, obtain a current market value estimate from a knowledgeable source.
Some documents concerning royalty payments will provide both a gross and a net payment amount. When the difference between the gross and the net figures is due to income taxes withheld or windfall profit tax deductions, use the gross figure when determining income.
When the difference between the gross and net figures represents a production or severance tax (most oil royalties will be reduced by this tax), use the net figure when determining income. The production or severance tax is a cost of producing the income and, therefore, is deducted from the gross income.
Document location/address of property in the case comments section. Document percentage of interest owned in case comments; the accessibility to interest in land resources; and whether land resources are excluded as a resource.
Document calculation of countable equity value in case comments if not excluded.
Notes:
Sources for verifying the value of land resources:
Sources to verify ownership include:
Conversion of a resource from the sale of timber is not considered income except when:
Some documents concerning royalty payments will provide both a gross and a net payment amount. When the difference between the gross and the net figures is due to income taxes withheld or windfall profit tax deductions, use the gross figure when determining income.
Note: Consider whether royalty payments are excludable as irregular and/or infrequent income. See Section E-5000, Variable Income.
Revision 09-4; Effective December 1, 2009
In accordance with Public Law 100-647, effective Nov. 10, 1988, income received by a member of an Indian tribe from the exercise of recognized fishing rights is treated as unearned income for SSI and Medicaid purposes. Fishing rights must have been secured as of March 17, 1988, by a treaty, Executive Order or Act of Congress.
Revision 09-4; Effective December 1, 2009
Rents are payments a person receives for the use of real or personal property such as land, housing or machinery. Ordinary and necessary expenses in the same taxable year are deducted from rental payments. These include only those expenses necessary for the production or collection of the rental income and they must be deducted when paid, not when they are incurred. Some examples of deductible expenses are interest on debts, state and local taxes on real and personal property and on motor fuels, general sales taxes, and expenses of managing or maintaining the property.
Records for the IRS can be used. However, depreciation or depletion of property is not considered a deductible expense.
Rent is payment, either as cash or in-kind, which a person receives for the use of real or personal property, such as land, housing or machinery. Rental income is considered unearned income unless it is derived from self-employment, that is, someone is in the business of renting properties.
Net rental income (gross rent less expenses incurred in the production/collection of the income) is used in budgeting. Expenses are deducted from the month in which they were paid, regardless of when they were incurred. Rental deposits are not considered to be income while subject to return to the tenant; they become income to the landlord at the time of use.
Revision 09-4; Effective December 1, 2009
If the rental agreement is between the authorized representative and the tenant, and the authorized representative provides a statement to the effect that he does not and will not make the payments available to the person, the rental payments are not considered to be the person's income.
A referral to Adult Protective Services (APS) may be appropriate.
However, if the authorized representative is the person's guardian or power of attorney (POA), the payments are countable income to the person, unless extenuating circumstances indicate otherwise.
If the rental agreement is between the person and the tenant, the payments are income to the person, regardless of whether the authorized representative is make them available.
If the authorized representative is not making the rental payments available to the person, a referral to APS may be appropriate.
Revision 09-4; Effective December 1, 2009
If the person's homestead is vacant and a third party is making the person's mortgage payments using his (the third party's) own funds, these payments are not income to the person.
If the person's home is rented and the lease agreement specifies that the tenant pays the person's mortgage company in lieu of rent, these payments are countable income to the person and are treated as rental income.
If the person's home is rented and there is no lease agreement, voluntary payments of the person's mortgage by the tenant directly to the mortgage company are considered to be a "gift" to the person and are countable income.
Revision 09-4; Effective December 1, 2009
In multiple family residences, if the units in the building are of approximately equal size, prorate allowable expenses based on the number of units designated for rent compared to the total number of units. If the units are not of approximately equal size, prorate allowable expenses based on the number of rooms in the rental units compared to the total number of rooms in the building. (The rooms do not have to be occupied.)
For rooms in a single residence, prorate allowable expenses based on the number of rooms designated for rent compared to the number of rooms in the house. Do not count bathrooms as rooms; basements/attics are counted only if they have been converted to living spaces.
For land rental, prorate expenses based on the percentage of total acres for rent. There are various types of land rental, including hunting/fishing leases, pasture leases, sharecropping and other farm income not derived from self-employment.
Revision 09-4; Effective December 1, 2009
The following table lists some common deductions that arise in budgeting rental income. The list is not intended to be all-inclusive; supervisory approval should be obtained when questionable deductions arise.
| Expense | Deductibility |
|---|---|
| Money paid to or for employees not living in the home | Allowable |
| Money paid to or for employees living in the home | Allowable |
| Federal, state or local income taxes | Allowable |
| Sales tax | Allowable |
| Property tax | Allowable |
| Utilities for rental property | Allowable |
| Advertising for tenants | Allowable |
| Realtor or management company fees | Allowable |
| Supplies | Allowable |
| Actual expenses for roomers | Allowable |
| Interest for loans on property | Allowable |
| Depreciation related to self-employment | Allowable |
| Net loss from same period | Allowable |
| Real estate insurance | Allowable, except for liability insurance |
| Farming-related expenses (feed, seed, plants, seedlings, farm supplies, breeding fees, fertilizer and lime, crop insurance, crop storage, fees for livestock testing, etc.) | Allowable for self-employment farming Allowable for unearned income farming only if part of the lease agreement |
| Repairs or maintenance of property | Allowable if property is rented or between tenants Not allowable, if prior to initial rental of property |
| Capital asset purchases | Not allowable |
| Capital asset improvements | Not allowable |
| Payment on principal of loan for income-producing property | Not allowable |
| Travel to/from property | Not allowable |
| Net loss from previous period | Not allowable |
| Depreciation related to unearned income (for example, rental income) | Not allowable |
Revision 09-4; Effective December 1, 2009
For both the eligibility and co-payment budgets, regular variable income policy applies. If the monthly rental income is fixed and there are no allowable expenses to deduct, the eligibility budget may be projected for 12 months. Eligibility can also be certified on an annual basis, whether the income is fixed or not, if it is in the person's interest to do so.
For co-payment purposes, project income and expenses for only six months at a time. Anticipated expenses must be projected for the review period when they are expected to occur. For example, at the January annual review, the eligibility specialist would budget tax deductions based on the amount of taxes paid last year.
Note: The most recent federal tax return, including Schedule E, is helpful in identifying past expenses and in estimating future rental income.
See Appendix XVI, Documentation and Verification Guide.
Revision 09-4; Effective December 1, 2009
Count payments a person gets that were occasioned by the death of another person, except for the amount of such payments that a person spends on the deceased person's last illness and burial expenses. Last illness and burial expenses include related hospital and medical expenses, funeral, burial plot and interment expenses, and other related costs.
Example: If a person receives $2,000 from their uncle's life insurance policy and spends $900 on his last illness and burial expenses, the $1,100 balance is unearned income. If a person spends the entire $2,000 for the last illness and burial, there is no unearned income.
Note: This section does not refer to a person's receipt of proceeds as a result of cashing in his insurance policy. In that situation, consider the proceeds according to the policy for conversion of resource.
Verify countable proceeds of a life insurance policy by one or more of the following methods:
Revision 18-2; Effective June 1, 2018
A prize is generally something a person wins in a contest, lottery or game of chance.
An award is usually something a person receives as the result of a decision by a court, board of arbitration or the like. An award is also something of value conferred or bestowed on someone because of merit or need. Awards do not involve competition.
If a prize or award is not in cash, count the current fair market value of the prize or award, less any expenses involved in obtaining it. For example, deduct legal fees from an award received because of a lawsuit.
Consider income from prizes and awards according to frequency and the nature of the prize or award. Count a prize or award as unearned income in the month of receipt. Review Section E-9000, Infrequent or Irregular Income, to determine if the prize or award is to be treated as a lump-sum payment, infrequent or irregular income, or regular and predictable income. Consider regular and predictable awards as monthly unearned income.
See Appendix XVI, Documentation and Verification Guide.
Reference: Section E-3390, Texas Lottery Commission
Revision 17-4; Effective December 1, 2017
An inheritance is cash, other liquid resources, noncash items or any right in real or personal property received at the death of another. An inheritance is income in the month of receipt unless the inherited item would be an excluded resource.
Example: An individual inherits a vehicle valued at $4,000 and the individual does not own any other vehicles. Per policy in F-4221 Automobile, one vehicle is excluded regardless of value. Because the vehicle is an excluded resource, the value of the vehicle is not considered as income in the month ownership is received.
Inheritances as a result of the death of another person, to the extent that they are used to pay the expenses of the deceased's last illness and burial, are not considered income.
Notes:
If the inheritance is not received in cash, determine its current fair market value. To determine countable income, deduct any expenses that may have been incurred in obtaining the inheritance, such as legal fees and court costs.
Determine whether the inheritance is to be treated as a lump-sum payment, infrequent or irregular income, or regular and predictable income.
See Section E-5000, Variable Income, and Section E-9000, Infrequent or Irregular Income.
See Appendix XVI, Documentation and Verification Guide.
Revision 17-4; Effective December 1, 2017
A gift is something a person receives which is not repayment to a person for goods or services a person provided and which is not given to a person because of a legal obligation on the giver's part.
A gift is something that is given irrevocably (i.e., the giver relinquishes all control).
Donations and contributions may meet the definition of a gift.
A cash gift or contribution is considered unearned income in the month of receipt.
The value of any non-cash item (other than food or shelter) is considered unearned income in the month of receipt. A non-cash item is not considered income if the item would become a partially or totally excluded non-liquid resource if retained in the month after the month of receipt.
Expenses involved in obtaining the income are excluded.
If the gift is not received in cash, determine its current fair market value. To determine the countable amount, deduct any expenses that may have been incurred in obtaining the gift, such as legal fees and court costs.
Determine whether the gift is to be treated as a lump-sum payment, infrequent or irregular income or regular and predictable income.
Gift of cash
A cash gift is counted as unearned income in the month of receipt. Review the infrequent or irregular income policy.
Gift of a car
A gift of a car that qualifies as an excluded resource if retained into the month after the month of receipt is not income. If the car does not qualify as an excluded resource (e.g., it is a second car), the car is counted as income in the month it is received and a resource beginning the next month.
See Section E-5000, Variable Income, and Section E-9000, Infrequent or Irregular Income.
See Appendix XVI, Documentation and Verification Guide.
Revision 09-4; Effective December 1, 2009
The value of domestic commercial transportation tickets (given as a gift to the person or spouse) is not income unless converted to cash. Domestic transportation is limited to the 50 states, District of Columbia, Commonwealth of Puerto Rico, Virgin Islands, Guam, American Samoa and Northern Mariana Islands.
Revision 09-4; Effective December 1, 2009
Real Property — The effective date of receipt is the date of death unless there is a contested will. If there is a contested will, the effective date of receipt is the date the will is probated.
Personal Property — The effective date of receipt is the date the person actually takes possession.
Note: Prior to Aug. 11, 1993, a disclaimer to an inheritance is not considered as a transfer of resources if transacted before receipt of an inheritance. The disclaimer must be a written statement acknowledged before a notary or other person authorized to take acknowledgement of conveyances of real property.
Examples:
After Aug. 11, 1993, a disclaimer of inheritance may result in a transfer of assets penalty regardless of the date the disclaimer is signed or effective.
See Chapter I, Transfer of Assets.
Revision 09-4; Effective December 1, 2009
The facility may allow a resident's family to use personal funds to pay an agreed-upon amount (in addition to the Medicaid rate) in order to have a private room.
For Medicaid eligibility purposes, if the family pays the difference, consider how it is being paid.
Revision 09-4; Effective December 1, 2009
This is food or shelter furnished to a person based on the living arrangement. See Section E-8000, Support and Maintenance.
Revision 18-2; Effective June 1, 2018
Count the gross amount of winnings as unearned income in the month received, regardless of the frequency of pay.
The following Texas Lottery Commission information displays on the Data Broker combined report, if applicable:
Note:
The information provided by the Texas Lottery Commission through Data Broker is considered verification of winnings.
Notes:
Reference:
Revision 18-2; Effective June 1, 2018
Information in this section concerns common periodic payments that are unearned income; however, the information is not inclusive.
Revision 18-2; Effective June 1, 2018
The Social Security Administration (SSA) pays Social Security benefits (RSDI) under provisions of the Social Security Act. Black Lung benefits under the Coal Mine Health and Safety Act of 1969. are also Social Security benefits.
A person who receives Social Security benefits may be enrolled in Medicare Part B, in which case the Medicare (SMIB) premiums are taken out of the Social Security checks before the checks are received. Determine whether the person is enrolled. If so, add the SMIB premium (see Appendix XXXI, Budget Reference Chart) to the benefit received to determine the total Social Security benefit used to determine eligibility.
Note: An SMIB premium may be different if a beneficiary enrolled late in Medicare or is eligible for a variable SMIB premium. The person may also have Medicare Part D taken out of the Social Security check.
See Appendix XVI, Documentation and Verification Guide.
For applications, verify gross benefits.
For reviews, if the recipient’s statement agrees with the conversion amount and there is no indication that the RSDI benefit has changed, do not reverify.
Verify the amount of Social Security benefit by one or more of the following methods:
Note: The Social Security Administration refigures SSA benefits if the individual has earnings from the previous year and other changes. This refiguring usually occurs during October, but may occur at other times. Staff may need to obtain an SOLQ/WTPY at redeterminations to ensure they have current/updated amounts. See Section F-2150, SSI and RSDI Retroactive Lump Sum Payments; Section F-2151, Examples of SSI and RSDI Retroactive Lump Sum Payments; and Section E-1610, SSA Overpayments.
Revision 09-4; Effective December 1, 2009
Railroad retirement benefits may be paid to a person or to the person's dependents or survivors. Some examples of railroad retirement benefits are sick pay, annuities, pensions and unemployment insurance benefits.
If a person is enrolled in Medicare Part B under his/her railroad retirement annuity number, determine the total railroad retirement benefit by adding the current SMIB premium amount to the benefit received.
See Appendix XVI, Documentation and Verification Guide.
Revision 12-1; Effective March 1, 2012
The U.S. Department of Veterans Affairs (VA) has numerous programs that make payments. Treatment of VA payments depends on the nature of the payment. The most common types of VA payments are:
Note: VA aid and attendance allowance, housebound allowances and payment adjustment for unusual medical expenses are exempt from both eligibility and co-payment. However, if these payments are deposited into a qualifying income trust (QIT) account, they are countable for co-payment.
Revision 09-4; Effective December 1, 2009
The VA determines the designated beneficiary of a check based on the laws and regulations for payment of each benefit.
Augmented VA payment. A VA pension payment that has been increased for dependents is an augmented VA payment. For Medicaid purposes, the augmented benefit includes a designated beneficiary's portion and one or more dependents' portions. An augmented VA benefit usually is issued as a single payment to the veteran or the veteran's surviving spouse. When veteran’s benefits are augmented for a dependent, the dependent's portion is not countable income to the applicant/recipient (the veteran or veteran's surviving spouse) of the check. If the applicant/recipient is the dependent, the applicant/recipient’s portion is countable income to the applicant/recipient.
Apportioned VA payment. A VA compensation payment made directly to the dependent of a living veteran is an apportioned payment. Apportionment is direct payment of the dependent's portion of VA benefits to a dependent spouse or child. The VA decides whether and how much to pay by apportionment on a case-by-case basis. Apportionment reduces the amount of the augmented benefit payable to the veteran or veteran's surviving spouse.
A portion of a VA benefit paid by apportionment to a dependent spouse or child is VA income to the dependent spouse or child. It is not a support payment from the designated beneficiary.
See Section D-6350, Veterans Benefits, for requirements to apply for benefits.
Revision 10-1; Effective March 1, 2010
Pension payments are based on a combination of service and a nonservice-connected disability or death.
Most VA pension payments are based on need. As such, these payments are unearned income to which the $20 general income exclusion does not apply.
Pension payments are usually paid monthly; however, when the monthly payment due is less than $19, VA will pay quarterly, biannually or annually. VA may also make an extra payment if an underpayment is due.
Pensions are paid to:
There are several periodic payments from VA benefits:
Because VA pensions and parents' DIC payments are generally based on need, the $20 general income exclusion in the eligibility determination is not applied.
The following pensions are not based on need:
These pensions are unearned income and the $20 general exclusion does apply to these exceptions. Assume that a VA pension is needs-based unless there is evidence to the contrary. See Section G-4110, Twenty-Dollar General Exclusion.
Revision 10-1; Effective March 1, 2010
The Jan. 1, 1979, increase in VA pension benefits caused many SSI recipients to become ineligible. Public Law 96-272 gave protection to a person drawing VA pension benefits "grandfathered" from Dec. 31, 1978. A person who has been eligible for a VA pension since before 1979 is not required to apply for an increase in VA payment for medical expenses known as aid and attendance or housebound benefits. These additional payments are for unusual medical expenses and are considered exempt income that does not affect eligibility or co-payment.
Refer persons who have changed to the 1979 pension plan or who initially obtain entitlement to a VA pension after Jan. 1, 1979, to apply for aid and attendance or other potentially available benefits. However, do not monitor for the person’s compliance to apply for other benefits when it is to increase the VA payment for medical expenses since aid and attendance or housebound benefits are considered exempt income that does not affect eligibility or co-payment.
Determine whether the person is receiving an aid and attendance or housebound allowance as part of his/her VA benefit.
See Section D-6351, VA Pension or Compensation.
Revision 11-4; Effective December 1, 2011
If a veteran without a spouse or child or a surviving spouse without a child is covered by Medicaid for services furnished by a nursing facility, the maximum pension that can be paid to or for the veteran or surviving spouse for any month after the month of admission to such nursing facility is $90. This reduced pension is an aid and attendance allowance in all cases, and not income.
VA law (38 U.S.C. 5503) provides that the amount of the VA pension for an institutionalized Medicaid recipient having neither a spouse nor child (or in the case of a surviving spouse, having no child) cannot exceed $90 per month.
The $90 VA pension may not be used in determining what the person in an institutional living arrangement must pay toward the cost of care. The limited VA pension, up to the amount of $90, is not counted as income in the eligibility or co-payment budget.
There is no association between the reduced pension and the personal needs allowance (PNA). If a veteran has income from other sources, the income from other sources may be considered countable. HHSC is to perform the co-payment calculations to determine the amount of the veteran’s liability toward the cost of care.
Do not refer a person who is receiving the $90 VA pension in an institutional setting to apply for other benefits when it is to increase the VA payment for medical expenses since aid and attendance or housebound benefits are considered exempt income that does not affect eligibility or co-payment. If the person’s only income is the $90 VA pension, refer the person to the Social Security Administration for SSI.
See Section D-6351, VA Pension or Compensation.
A person who has a capped $90 VA aid and attendance is eligible for the PNA up to $60 per month. See the examples below:
In a situation in which a veteran has a $90 capped VA aid and attendance and does not have another source of income from which to deduct the $60 PNA, the person will have $90 for their personal expenses and the co-payment is zero. In a situation in which a veteran has a $90 capped VA aid and attendance and the veteran's other source of income is less than $60, the PNA will be up to, but not exceed, $60. This person will have up to $150 for their personal expenses ($90 plus up to $60). There is no state supplement to bring the PNA up to $60 if the veteran does not have other income from which to subtract the PNA. The PNA deduction comes first in the order of all co-payment deductions, including those for incurred medical expenses (IME).
If a person's only income in a facility is the VA pension capped at $90 per month, certify the person for Medicaid, provided the person meets other program requirements, and refer the person for SSI.
Revision 11-4; Effective December 1, 2011
VA compensation is unearned income and is based primarily on service in the armed forces. Payments are made to veterans, dependents or survivors.
The VA makes compensation payments to a veteran because of a service-related disability. The VA also makes compensation payments to a spouse, child or parent of a veteran because of the service-related death of the veteran.
Note: If a person or a recipient moves from a community setting to an institutional setting, entitlements to additional VA benefits may be appropriate due to a change in the situation or increased medical needs. If a person is a veteran or an unmarried widow or widower of a deceased veteran, explore possible entitlement to VA benefits. If the person is potentially eligible but no payment is reported, the person may be required to file for a VA benefit. See Section D-6350, Veterans Benefits, for requirements to apply for benefits.
Because VA compensation is not based on need, deduct the $20 general income exclusion in the eligibility determination. See Section G-4110, Twenty-Dollar General Exclusion.
Note: The $20 exclusion does not apply to VA pensions or parents' DIC payments.
Neither the beneficiary's award letter nor the VA check indicates whether aid and attendance is included in a person's total VA payment. To verify the type and amount of benefits received, contact the VA using Form H1240, Request for Information from Bureau of Veterans Affairs and Client's Authorization.
Do not include aid and attendance allowance, housebound allowance and VA reimbursement for unusual medical expenses as a part of the total VA benefit. See Section E-4315, VA Aid and Attendance and Housebound Payments.
Revision 11-4; Effective December 1, 2011
Dependency and Indemnity Compensation (DIC) is a monthly benefit paid to eligible survivors of certain deceased veterans:
The surviving spouse is eligible if he/she:
Note: A surviving spouse who remarries on or after Dec. 16, 2003, and on or after attaining age 57 is entitled to continue to receive DIC.
The $20 exclusion does not apply to VA pensions or parents' DIC payments.
A surviving child is eligible if the child is:
Whenever there is no surviving spouse of a deceased veteran entitled to DIC, the children of the deceased veteran are eligible for DIC.
Additional allowances could be included in the DIC benefit for aid and attendance or housebound.
Neither the beneficiary's award letter nor the VA check indicates whether aid and attendance is included in a person's total VA payment. To verify the type and amount of benefits received, contact the VA using Form H1240, Request for Information from Bureau of Veterans Affairs and Client's Authorization.
Do not include aid and attendance allowance, housebound allowance and VA reimbursement for unusual medical expenses as a part of the total VA benefit. See Section E-4315, VA Aid and Attendance and Housebound Payments.
Revision 09-4; Effective December 1, 2009
The VA provides educational assistance through different programs, including vocational rehabilitation. Medicaid policies on income and resources depend on the nature of the VA program. The veteran’s period of eligibility to receive benefits for educational assistance are as follows:
Dependents and survivors of veterans may also be eligible for educational benefits. The VA makes payments under Chapter 35, Survivors and Dependents Educational Assistance Program (a non-contributory program), to:
Note: Survivors and dependents have 10 years from the date of the veteran's service-connected death or date of 100% disability to participate in this program.
Do not consider as income the following:
References: The policy in the following items details VA payments that are either not considered as income or exempt as income.
Do consider the following as income:
Note: The $20 general income exclusion applies to countable VA educational assistance and these payments are subject to deeming. See Section G-4110, Twenty-Dollar General Exclusion.
Revision 16-4; Effective December 1, 2016
VA pays an allowance to veterans and dependents who are in regular need of the aid and attendance of another individual or who are housebound. This allowance is combined with the individual’s pension or compensation payment.
This special VA allowance can be paid to:
If an individual is in an institutional setting (for example, a nursing facility) because of mental or physical incapacity, the VA presumes eligibility for aid and attendance.
Based on policy regarding medical expenses paid by a third party, do not consider in the eligibility and co-payment budgets the following VA payments:
Reference: Section E-1720, Social Services That Are Not Income.
Exception: If aid-and-attendance allowances, housebound allowances and reimbursements for unusual medical expenses are deposited into a QIT, the amount deposited is countable for co-payment budgeting. Aid-and-attendance allowances, housebound allowances, and reimbursements for unusual medical expenses are not countable for co-payment budgeting if separated from the pension or compensation benefit before depositing the VA pension into a QIT. Separating and depositing the VA pension amount does not invalidate the QIT.
If it appears that the individual may be entitled to an aid-and-attendance allowance and is not receiving one, refer the individual to the VA. While living in the community, an individual receives a housebound allowance, but that allowance is adjusted to the aid-and-attendance allowance if the individual moves to an institutional setting. Do not monitor for the individual’s compliance to apply for other benefits when it is to increase the VA payment for medical expenses since aid-and-attendance or housebound benefits are not considered income and will not affect eligibility or co-payment.
Neither the beneficiary's award letter nor the VA check indicates whether aid-and-attendance is included in an individual's total VA payment. To verify the type and amount of benefits received, contact the VA using Form H1240, Request for Information from Bureau of Veterans Affairs and Client's Authorization.
When the income is not considered for the eligibility and co-payment budgets, enter aid-and-attendance allowance, housebound allowance, and VA reimbursement for unusual medical expenses as a separate income source. See Appendix XVI, Documentation and Verification Guide.
Revision 09-4; Effective December 1, 2009
A lump sum clothing allowance is payable in August of each year to a veteran with a service-connected disability for which a prosthetic or orthopedic appliance (including a wheelchair) is used. The allowance is intended to help defray the increased cost of clothing due to wear and tear caused by the use of such appliances.
A VA clothing allowance is not income.
Reference: Section E-1720, Social Services That Are Not Income
Revision 09-4; Effective December 1, 2009
Do not consider the following types of VA benefits as income or resources for Medicaid purposes:
Note: Interest and dividends earned on unspent payments are exempt from income.
Reference: Section E-2150, Other – Exempt Income
Revision 09-4; Effective December 1, 2009
A VA contract for payment of nursing facility services does not affect Medicaid eligibility. If an application is filed, proceed with the eligibility determination. If the person is certified while the contract is still in effect, the VA contract is reported as a third-party resource on Form H1039, Medical Insurance Input.
Revision 15-3; Effective September 1, 2015
There are two types of annuities:
Pension or retirement payments may be made directly by a former employer or from a fund, insurance or any similar source. An example of a retirement payment is teacher retirement.
Determine the gross and net amounts of the monthly payments. Also determine whether the organization making the payments is providing any other benefits to the person.
Note: When income tax is withheld from retirement, pension or disability benefits, use the gross income amount for the eligibility and co-payment calculations.
See Chapter G, Eligibility Budgets, and Chapter H, Co-Payment.
See Appendix XVI, Documentation and Verification Guide.
Certain pension and retirement payments allow for the person to request a reduced amount. If the reduction is irrevocable, accept the reduced amount in determining the person's eligibility. However, for a person in an institutional setting (for example, a nursing facility or a Home and Community-Based Services waiver program), investigate the reduction for transfer of assets in Chapter I, Transfer of Assets.
If the person is receiving a reduced benefit, ask the person to provide a written statement from an official of the organization addressing the amount of the original benefit, the amount of the reduced benefit, the date of the reduction, and information about the revocability or irrevocability of the reduction.
If the pension or retirement payments are revocable, the person must apply for maximum entitlements.
Reference: Section I-1400, Transfer of Income
If a person’s income from annuities, pensions and retirement plans is greater than the special income limit, but not enough to pay private-pay costs in an institutional setting, the person can consider a QIT. QITs allow people to legally divert their income into a trust, after which the income is not counted for eligibility purposes. For more information, see Appendix XXXVI, Qualified Income Trusts (QITs) and Medicaid for the Elderly and People with Disabilities (MEPD) Information. The payments are countable in the co-payment budget.
Revision 09-4; Effective December 1, 2009
Workers' compensation benefits are unearned income. A portion of a person's workers' compensation may be designated for medical, legal or related expenses. Request the person to provide verification of payment and, in addition, any expense required to obtain the benefit.
A person who suffers a work-related injury or illness may be eligible for workers' compensation benefits. These benefits are administered by the Industrial Accident Board under the Texas Workers' Compensation Act. If a person dies as a result of a work-related injury or illness, his dependents or beneficiaries may be eligible for workers' compensation benefits.
Determine the monthly amount of workers' compensation benefits by multiplying the weekly benefit by 4.33. (These benefits are usually paid on a weekly basis.) Also determine the expected duration of the workers' compensation benefits.
Determine and exclude the portion, if any, of the workers' compensation that is considered an expense required to obtain the benefit.
Reference: See Section D-7400, Use of Third-Party Resources, for policies governing recovery of Medicaid payments when additional workers' compensation is received for medical expenses incurred after Medicaid eligibility began.
Verify workers' compensation benefits by one or more of the following methods:
Revision 11-4; Effective December 1, 2011
Unemployment benefits are unearned income.
A person who loses employment may be entitled to unemployment benefits through the Texas Workforce Commission (TWC). To receive unemployment benefits, a person must file an application with TWC. Determine the expected duration and the amount of the unemployment benefits per month. Unemployment benefits may be received on a weekly or biweekly schedule.
Reference: Do not use TWC's Form B-11 to verify unemployment benefits. This form does not verify the actual receipt or amount of benefits.
Verify unemployment benefits by one or more of the following methods:
Data Broker report will verify quarterly earnings and unemployment benefits. Information is obtained using the person's name and Social Security number. A match will result if the person has applied, is receiving or has received unemployment benefits with TWC. Result response time is generally immediate.
A match by name will provide the person's name, alias name, address, telephone number, Social Security number and date of birth.
Available information includes:
Revision 09-4; Effective December 1, 2009
Disability benefits are unearned income.
Some insurance policies pay benefits based on the period of time a person is disabled and not on the amount of medical expenses. These policies may be called "income maintenance" policies. Benefits from these policies are unearned income to the extent that they are not used to pay for medical expenses.
Disability benefits normally are paid to a person who has suffered injury or impairment. These payments may be from an employer, insurance or other public or private fund.
Determine the source of the benefit. If the source is covered by one of the unearned income items, such as Social Security or a private pension, use the procedures for that item.
Revision 09-4; Effective December 1, 2009
Revision 09-4; Effective December 1, 2009
Average monthly income that is predictable but varies in amount from month to month. Types of monthly income that require averaging include, but are not limited to:
Variable income can be from one source or a combination of sources.
For eligibility budgets, treatment of variable income is the same whether the person is in the community or in an institutional setting.
Treatment of variable income in co-payment budgets applies only to a person in an institutional setting (for example, a Home and Community-Based Services waiver program or a nursing facility).
There are additional treatments for variable income for the co-payment budgets that include reconciliation and restitution. See Chapter H, Co-Payment.
As specified in Section E-9000, Infrequent or Irregular Income, do not average income for the eligibility test that meets the definition of irregular or infrequent.
See Chapter G, Eligibility Budgets, for instructions on determining income eligibility. The examples in this section are for demonstration purposes only. They may not reflect the current spousal allowance amounts.
Revision 09-4; Effective December 1, 2009
| Month | Source #1 | Source #2 | Payment Received |
|---|---|---|---|
| Aug. | |||
| Sept. | $20 | X | |
| Oct. | |||
| Nov. | $20 | X | |
| Dec. | |||
| Jan. |
Revision 09-4; Effective December 1, 2009
| Month | Source #1 | Source #2 | Payment Received |
|---|---|---|---|
| Aug. | |||
| Sept. | $20 | X | |
| Oct. | |||
| Nov. | $20 | X | |
| Dec. | |||
| Jan. |
| Month | Source #1 | Source #2 | Source #3 | Payment Received |
|---|---|---|---|---|
| Aug. | $30 | X | ||
| Sept. | ||||
| Oct. | $30 | X | ||
| Nov. | ||||
| Dec. | ||||
| Jan. | $50 | X |
| Month | Source #1 | Source #2 | Source #3 | Payment Received |
|---|---|---|---|---|
| Aug. | $20 | X | ||
| Sept. | $20 | X | ||
| Oct. | $20 | X | ||
| Nov. | ||||
| Dec. | $20 | $20 | X | |
| Jan. |
| Month | Source | Payment Received |
|---|---|---|
| Aug. | $2 | X |
| Sept. | $1 | X |
| Oct. | $2 | X |
| Nov. | $5 | X |
| Dec. | $3 | X |
| Jan. | $4 | X |