Revision 11-1; Effective March 1, 2011  

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.

 

B-7110 Continuous Medicaid Coverage After SSI Denial for Income

Revision 20-3; Effective September 1, 2020 

Certain SSI recipients are eligible for temporary Medicaid following the loss of SSI due to excess income. Medicaid eligibility is automatically extended for a short time for the following SSI recipients:

• children under 18 years old who receive waiver services; and
• people who receive an increase in Social Security Disabled Adult Children (DAC) benefits or Early Aged or Disabled Widow(er)’s benefits, who have no other income.

Recipients must return the Form H1200 and be determined eligible to continue to receive Medicaid after the short-term extended period ends.  

Recipients who do not return a Form H1200 will be denied Medicaid at the end of the extended period.  If SSA reinstates the recipient’s SSI benefits, SSI Medicaid will be reinstated.  Medicaid coverage will not be extended again at subsequent SSI denials or suspensions for the following 12 months.

Correspondence

Send the following correspondence when Medicaid is extended after the loss of SSI:

• Form H1296, Notice of SSI Medicaid Ending – to notify the person that SSI Medicaid is ending due to the loss of SSI benefits.
• Form TF0001, Notice of Case Action – to inform the person of the extended Medicaid period and that they must complete and return the Form H1200 by the due date in order to receive Medicaid after the extended period; and
• Form H1200, Application for Assistance - Your Texas Benefits.

If Form H1200 is received, determine ongoing eligibility for the appropriate type of Medicaid. Expedite processing applications received before the extended Medicaid coverage ends.  Expedited applications must be processed within 10 workdays from the date of application.

Children Receiving Waiver Services

Children who receive services through one of the following waiver programs are eligible to receive temporary ME-Waiver Medicaid for one month following the loss of SSI due to excess income:

• Medically Dependent Children Program (MDCP);
• Community Living Assistance and Support Services (CLASS);
• Home and Community-based Services (HCS);
• Youth Empowerment Services (YES); or
• Deaf Blind with Multiple Disabilities (DBMD).

Ongoing Eligibility

If Form H1200 is received, determine ongoing eligibility for ME-Waiver Medicaid.  If eligible, ME-Waiver Medicaid will remain active through the end of the month of the child’s 18th birthday.  If the child is determined not eligible under any other Medicaid type of assistance, Medicaid is denied at the end of the one-month extended period.

• Applications submitted by the child or their parent or authorized representative do not require an associated Form H1746-A, MEPD Referral Cover Sheet.  
• Applications submitted by program providers, including Managed Care Organizations (MCOs), Local Intellectual & Developmental Disability Authorities (LIDDAs) and Local Authorities (LAs), on behalf of a child receiving extended ME-Waiver Medicaid must include an associated Form H1746-A.

SSI Eligibility

If SSI benefits are reinstated while the child is active ME-Waiver Medicaid, SSI Medicaid will be suppressed, and ME-Waiver Medicaid will remain active. This is to avoid future gaps in coverage.

If SSI benefits are active when the child turns 18, ME-Waiver Medicaid will terminate and SSI Medicaid will be reinstated.

If SSI benefits are not active when the child turns 18, ME-Waiver Medicaid will remain active and will follow the regular renewal process.

Recipients of DAC or Widow/Widower Benefits

SSI recipients denied due to an increase in or receipt of RSDI disabled adult children’s benefits or widow/widower’s benefits, who do not receive income other than RSDI, are eligible to receive temporary Medicaid for two months following the loss of SSI.

• People receiving Social Security DAC benefits are eligible for ME-DAC Medicaid. (Note: People receiving SSI and QMB will receive ME-DAC and MC-QMB.)
• People receiving Social Security Early Aged or Disabled Widow/Widower’s benefits are eligible for ME-Disabled Widow(er) or ME-Early Aged Widow(er) Medicaid.

If Form H1200 is received, determine ongoing eligibility for the appropriate type of Medicaid, ME-DAC, ME-Disabled Widow(er) or ME-Early Aged Widow(er).  If the recipient is determined not eligible, Medicaid will be denied at the end of the two-month extended period.

Related Policy

Supplemental Security Income (SSI), A-2100
Disabled Adult Children (DAC), A-2310
Pickle, A-2330
Widow(er)s, A-2340
SSI Applications, B-7100
When Deeming Procedures Are Not Used, E-7200

Revision 12-3; Effective September 1, 2012  

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:

• If contacted by the recipient/authorized representative (AR), inform the recipient/AR to notify SSA of the entry to the Medicaid facility. Send Form H1200, Application for Assistance – Your Texas Benefits, to the recipient/AR to complete and return to HHSC.
• If contacted by the Medicaid facility, inform the facility to notify SSA of the entry to the Medicaid facility. Obtain the AR's information, including mailing address, and send Form H1200 to the AR to complete and return to HHSC.

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:

• If contacted by the recipient/AR, send Form H1200 to the recipient/AR to complete and return to HHSC.
• If contacted by the Medicaid facility, obtain the AR's information, including mailing address. Send Form H1200 to the AR to complete and return to HHSC.

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:

• If the MEPD application is not returned, the eligibility specialist contacts the recipient/authorized representative to attempt to obtain information to determine continued Medicaid eligibility. The eligibility specialist uses Form H1200 as a recording document, if necessary.
• Follow the procedures for SSI to MEPD transfer, unless continued SSI eligibility occurs under temporary provisions. If that situation occurs, do not process an institutional Medicaid application unless the SSI benefits are denied and the recipient is still in the facility.

Reference: See Chapter H, Co-Payment, for exceptions to reduced SSI payment standard.

 

B-7210 Ensuring Continuous Medicaid Coverage

Revision 13-4; Effective December 1, 2013

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.

Revision 19-4; Effective December 1, 2019

Persons who have applied for SSI, whose SSI application has been delayed longer than 90 days, may be certified under the appropriate MEPD program pending the SSI eligibility decision.  

Person(s) must meet all non-financial and financial MEPD criteria to be eligible including:

• establishing disability, if applicable;
• pursuing all other benefits; and
• meeting the 30 consecutive days of institutionalization, if applicable.

Consider the age of the person to determine if a disability determination is needed.

The state office Disability Determination Unit (DDU) needs a disability determination if the person is younger than 65. DDU cannot make a disability determination decision unless 90 days have passed since the SSI date of application and SSA's disability decision is still pending. If SSA finds the person is not disabled after DDU has established a disability, DDU is required to follow SSA’s decision and eligibility must be denied. Staff must set a special review for the fifth month to monitor the final SSA decision on disability.

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 an adverse action because the person does not lose benefits.

The above should be used only in situations where the processing of a SSI application has been delayed. Staff must verify and document that an SSI application has been filed.

Note: If the person is age 65 or older, no disability determination is needed. Verify that the person has filed an application for SSI.

Related Policy

SSI Applications, B-7100
Special Reviews, B-8430
Supplemental Security Income (SSI) Applicants and Retroactive Coverage, D-2500
Application for Other Benefits Requirement, D-6300
Other Benefits Subject to Application Requirement, D-6310
Other Benefits Exempt from Application Requirement, D-6320
Supplemental Security Income (SSI), D-6340

Revision 12-3; Effective September 1, 2012

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:

• meet the 30-consecutive-day stay requirement (for verification and documentation requirements, see Appendix XVI, Documentation and Verification Guide);
• meet financial criteria; and
• have an approved level of care or medical necessity determination.

Reference: Section B-6300, Institutional Living Arrangement.

HHSC processes:

• initial applications from persons whose income is equal to or in excess of the reduced SSI federal benefit rate; and
• reapplications for Medicaid from persons who will be or have been denied SSI on the basis of excess income because the SSI federal benefit rate has been reduced after entry into a Medicaid facility.

 

B-7410 Persons Under Age 22

Revision 09-4; Effective December 1, 2009

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.

 

B-7420 Level of Care/Medical Necessity

Revision 20-4; Effective December 1, 2020

To be eligible for Medicaid in an institutional setting, a person must have an approved level of care (LOC) for an intermediate care facility for persons with intellectual disabilities (ICF/IID) or an approved medical necessity (MN) with a nursing facility LOC. Texas Medicaid & Healthcare Partnership (TMHP), the state Medicaid claims administrator, is responsible for determining MN for recipients in Medicaid certified facilities.

Do not approve a person for medical assistance for institutional care unless the person has been in a Medicaid facility for at least 30 days and has an approved LOC or MN determination.

For applicants residing in a Medicare skilled nursing facility, the Medicare determination of need for care is acceptable as verification of a valid MN determination. Form 3071, Recipient Election/Cancellation/Discharge Notice, substitutes for the MN determination when hospice is elected as referenced in A-5200, Hospice in a Long-Term Care Facility.

Use the previous LOC or MN determination if:

• a person is being reinstated for assistance (a case that was denied in error or a request for a program transfer from SSI to MEPD institutional care); and
• vendor payments were made to the Medicaid facility up to the date of denial based on the previous LOC or MN determination.

Program Support Unit (PSU) staff are responsible for providing verification of an approved LOC or MN determination for a person applying for a Home and Community Based Services (HCBS) waiver program.

An approved MN determination for HCBS waiver eligibility is valid to complete a program transfer from an HCBS waiver Medicaid program to the appropriate institutional care program.

A permanent MN determination remains valid at reapplication if a denied Medicaid recipient is discharged from a Medicaid facility for not more than 30 days.

If the LOC or MN determination is still pending prior to certification and the person meets all other eligibility criteria, place the application on delay pending the approved LOC or MN. If verification of the LOC or MN is not received before the end of the delay period, deny the application for no LOC or MN. If the LOC or MN determination is denied, deny the application.

Reopen the application if verification of an approved LOC or MN is received within 90 days of the date of denial following policy in B-5000, Previously Completed Application.

Related Policy

Previously Completed Application, B-5000
Establish Processing Deadlines, R-3100
Documentation and Verification Guide, Appendix XVI

 

B-7430 Reserved for Future Use

Revision 20-4; Effective December 1, 2020

 

B-7431 Denial of Level of Care/Medical Necessity Determination

Revision 13-4; Effective December 1, 2013

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:

• has a diagnosis of mental illness, intellectual disabilities or a related condition;
• no longer meets the medical necessity criteria; and
• has lived in a nursing facility for 30 months before the date medical necessity is denied and chooses to remain in the facility.

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.

 

B-7440 Alternate Care Services

Revision 21-3; Effective September 1, 2021

Information about all available long-term services and supports must be provided to long term care recipients, their authorized representatives (ARs) and at least one family member of the recipient, if possible. This allows them to make an informed decision about service options.

Form H1204, Long Term Care Options, provides information on available long-term services and supports. It is included with the TF0001, Notice of Case Action, for all MEPD certifications, except for recipients residing in state supported living centers, state hospitals and state centers.

If an applicant, recipient, AR or family member(s) has questions about available long-term care services, refer them to 2-1-1 for current information.

Form H1746-A, MEPD Referral Cover Sheet, includes an "LTSS Information Shared" checkbox. Referring agencies will select the box to indicate that Form H1204 has been shared with the person.

 

B-7450 Medicaid Certified Person Enters Nursing Facility or Home and Community-Based Services Waiver Program

Revision 22-2; Effective June 1, 2022

Eligibility Systems and Payment Systems

Service Authorization System Online (SASO) identifies the recipient as Service Group 1 and allows vendor payment 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.

The system also automatically assigns a Code 60 (authorization for unlimited medications). This allows all medications to be paid through the vendor drug benefit.

If the nursing facility stay is temporary and the recipient returns home before being transferred to institutional Medicaid, no action is required. Retroactive coverage code changes are not needed.

Texas Works Medicaid to MEPD

If an active Texas Works Medicaid recipient enters a facility for a long-term stay, TIERS receives the nursing facility admission information from the DADS webservice interface. TIERS automatically denies the Texas Works Eligibility Determination Group (EDG) and creates a pending ME-Nursing Facility EDG. An H1200 Application for Assistance - Your Texas Benefits must be received before testing for ME-Nursing Facility Medicaid. Disposition of both EDGs must be coordinated. There is no need for retroactive coverage code changes. Vendor payment and medications are authorized through SASO.

If a facility notifies HHSC that an active Texas Work Medicaid recipient has entered the facility, staff should advise the facility that an application is required. Once the application is received, process as any other application and coordinate with Texas Works.

Community to Nursing Facility or Home and Community-Based Services Waiver Eligibility Considerations

If an active MEPD Medicaid or Medicare Savings Program recipient enters a facility for a long-term stay or requests waiver services, before completing a program transfer, staff must address all factors that may impact eligibility or co-payment. Staff must explore transfer of assets and substantial home equity and provide required information about annuities, estate recovery and long-term care options. 

Related Policy

Medicaid Estate Recovery Program Notification Requirements, B-2600
Alternative Care Services, B-7440
Notice Requirements for Application and Redeterminations, F-7250
Medicaid Coverage Issues Related to Nursing Facility Costs, H-7300
Medicare Skilled Nursing Facilities, R-1210
Notices, R-1300