Revision 16-4; Effective October 1, 2016

Medical Programs

Applicants may receive Medicaid during the three-month period before the month they apply for Medicaid. See A-831, Three Months Prior Coverage, for eligibility criteria and application procedures.

Some former individuals on TP 08, TP 43, TP 44, and TP 48 remain eligible for Transitional Medicaid after their eligibility is denied. See the chart that follows for more information.

Reason for Denial	Type Program	Who Is Covered?
Alimony/Spousal support	TP 20 (A-850, Alimony/Spousal Support Transitional Medicaid Coverage)	The household
New or increased earnings	TP 07 (A-842, TP 07 Transitional Medicaid)	The household

Most adopted children receive Medicaid through the Texas Department of Family and Protective Services (DFPS). DFPS works with the Interstate Compact on Adoption and Medical Assistance (ICAMA) to facilitate the timely delivery of Medicaid coverage when a family moves or the adoption involves an interstate placement. If an adopted child is receiving Medicaid in another state, the parent must contact the originating state to coordinate and transfer Medicaid coverage information to Texas. If an adoptive parent has any questions about the adoptive child's Medicaid, advisors should inform them to contact their local DFPS office for assistance.

Medical Programs, Qualified Medicare Beneficiaries (QMB) and Specified Low-Income Medicare Beneficiaries (SLMB)

Individuals receiving some Texas Works Medicaid types of assistance may also qualify for the Medicaid for the Elderly and People with Disabilities (MEPD) Medicare Savings Program types of assistance, MC – QMB (TP 24) or MC – SLMB (TP 23), if they meet the eligibility criteria. See policy in the Medicaid for the Elderly and People with Disabilities Handbook, Q-2000, Qualified Medicare Beneficiaries (QMB) — MC-QMB.

Individuals may receive QMB and the following types of assistance:

• MA – Earnings Transitional (TP 07)
• MA – Parents and Caretaker Relatives (TP 08)
• MA – Pregnant Women (TP 40)
• MA – Children Under 1 (TP 43)
• MA – Newborn Children (TP 45)
• MA – Children 1-5 (TP 48)
• MA – Children 6-18 (TP 44)
• MA – Former Foster Care Children (FFCC) (TA 82)

The above programs cannot be dually eligible for SLMB. Even though these programs may meet SLMB eligibility requirements, the Medicare Part B premium is already paid. An individual can be dually eligible for MA – MN with Spend Down (TP 56) and SLMB.

Revision 22-3; Effective July 1, 2022

Medical Programs

Regular Medicaid eligibility begins the day a person meets all eligibility criteria. It is usually the first day of the application month if all eligibility criteria are met on that date.

The medical effective date (MED) may not be the first day of the application month in the following situations. 

The MED cannot precede:

• A newborn's date of birth.
• The date a child enters the home.
  
  Note: Assign the date of birth as the MED for a child born to a woman incarcerated in the Texas Department of Corrections at Gatesville when contacted by HHSC staff housed at the University of Texas Medical Branch (UTMB) Hospital. Document this contact in Case Comments.
   
• For the parent or caretaker relative’s Medicaid application, the newborn’s date of birth or the date a child enters the home when the newborn or entering child is the only eligible child.
  
  TP 08 Exception: TIERS assigns an earlier MED if the parent or caretaker relative has unpaid medical bills and would have been eligible for Medicaid as a pregnant woman from the first day of her infant's birth month.


• The start date of the emergency condition for aliens eligible for Emergency Medicaid.
• The date a disqualified parent or caretaker relative complies.
• The month at least one eligible dependent child is certified for Medicaid.

If the only child of a parent or caretaker relative eligible for TP 08 dies before certification, process an application for Medicaid for a deceased person. Certify coverage for the child through the date of death and for the parent or caretaker relative through the remainder of that month.

TP 40

Medicaid for a pregnant woman does not begin before the first day of the month her pregnancy begins. The applicant’s (pregnant woman's, case name's, or authorized representative's [AR's]) verbal or written statement is an acceptable source of verification for the start month, the number of expected children, and the anticipated date of delivery.

If the applicant’s (pregnant woman's, case name's or AR's) statement is not available, use one of the verification requirements to obtain the pregnancy start date and anticipated date of delivery.

If information is requested but not returned by the 15th business day from the file date, deny the application. Reopen the application if the person provides verification by the 60th day from the file date.

Exception: Do not request verification of pregnancy if the:

• application is processed after the pregnancy terminates; and
• applicant provides proof of the newborn child's birth.

A pregnant woman remains eligible through the second month following the month her pregnancy terminates if all other eligibility requirements are met and countable income is below the income limits in:

• the application month; or
• one of the three months prior to the application month if in the prior month she:
  • had unpaid Medicaid-reimbursable bills; or
  • received services from the Texas Department of State Health Services (DSHS).

Example: A pregnant woman applies for Medicaid in May 2020. Her expected delivery date is December 2020. She has unpaid medical bills in February 2020 and meets all other eligibility requirements. She does not have any unpaid medical bills in March or April 2020. Certify her for Medicaid from February 2020 through February 2020.

After determining a pregnant woman is eligible for TP 40, the woman remains eligible even if the budget group's income increases above the income limit.

Note: If a woman certified for Healthy Texas Women (HTW) reports her pregnancy, the HTW and Medicaid for Pregnant Women (TP 40) coverage may overlap because HTW does not provide prenatal or pregnancy benefits. In this situation, HTW is denied prospectively, and the woman is enrolled in TP 40 beginning the first of the month when she meets all eligibility criteria.

If a woman who was certified for expedited benefits provides postponed verifications that prove she does not meet eligibility requirements, provide advance notice of adverse action, and deny her coverage.

TP 45

Before providing initial TP 45 coverage for a newborn child, verify that the:

• mother was:
  • eligible for and received Medicaid in Texas on the day the child was born; or
  • retroactively eligible for Medicaid for the day the child was born;
• child resides in Texas; and
• mother was continuously eligible for Medicaid (or would have been eligible if pregnant) during the child's birth month.

Note: A newborn child born to a mother who received Emergency Medicaid coverage at the time of the child's birth is eligible to receive TP 45 coverage from the date of birth through the end of the month of the child's first birthday.

The MED for the initial certification is always the child's date of birth.

Before resuming coverage for a newborn who has been denied TP 45, verify that the child resides in Texas.

TP 56

Medicaid coverage for children or pregnant women with spend down begins the first day the household meets spend down.

Note: A woman certified for HTW may have overlapping coverage with TP 56 if she has unpaid medical bills related to her pregnancy because HTW does not provide full coverage benefits. 

The applicant meets spend down by submitting or having a provider submit medical bills to the Clearinghouse.

The Clearinghouse:

• determines when the person meets spend down; and
• notifies Texas Integrated Eligibility Redesign System (TIERS) via an interface. TIERS sets the MED for the certified members.

Note: The Clearinghouse may discover a discrepancy while processing a spend down EDG. Processing is put on hold and the EDG is referred to State Office Data Integrity (SODI) to research. SODI sends a memo to field staff asking for information to clear the discrepancy. Respond quickly to these requests so that the Clearinghouse can complete the spend down process.

Emergency Medicaid

Medicaid eligibility begins on the start date of the emergency medical condition verified by the attending practitioner on Form H3038, Emergency Medical Services Certification, or Form H3038-P, CHIP Perinatal – Emergency Medical Services Certification.

Related Policy

Provider Referral Process, A-125
Pregnancy, A-144.5
Medicaid Termination, A-825
Verification Requirements, A-870
How to Determine Spend Down, A-1359
Spend Down EDGs, A-1532.1
Reuse of an Application Form After Denial, B-111
Medicaid Reinstatement, B-530
Current Medicaid, Medicare (Part A or B) and Children's Health Insurance Program (CHIP) recipients, W-911
Pregnant Women, W-912

A—821 Types of Coverage

Revision 15-4; Effective October 1, 2015

Medical Programs

The type of coverage determines how recipients access Medicaid services. There are two types of coverage: fee-for-service and managed care.

A—821.1 Fee-for-Service

Revision 15-4; Effective October 1, 2015

Medical Programs

Fee-for-service, also known as Traditional Medicaid, allows access to any Medicaid provider and self-referral to specialists. The provider submits claims directly to the claims administrator for reimbursement of Medicaid-covered services.

A—821.2 Managed Care

Revision 21-1; Effective January 1, 2021

Medical Programs except TA 31, TP 32, TP 33, TP 34, TP 35, TP 36, and TP 56

Medicaid managed care is health care provided through a network of doctors, hospitals or other health care providers who contract with a managed care organizations (MCO). The state pays the MCO a capitated rate for each member enrolled, rather than paying for each unit of service. The providers submit claims directly to the MCO for reimbursement of Medicaid-covered services.

Medicaid managed care programs include:

• STAR (State of Texas Access Reform). STAR provides acute care services (like doctor visits, hospital visits and prescriptions), and each member is enrolled in an MCO and assigned a main doctor to coordinate care. People who are dually eligible for Medicare and Medicaid are excluded from this program.
• STAR Health. STAR Health provides comprehensive, coordinated health care services for children in foster care and kinship care. Each member is enrolled with a single MCO, Superior HealthPlan, and is assigned a main doctor to coordinate care. People who are dually eligible are excluded from this program.
• STAR+PLUS. STAR+PLUS provides acute care and long-term services and supports (LTSS). A key feature of this program is service coordination, or specialized care management. Each member is enrolled with an MCO, and Medicaid-only members are assigned a main doctor. STAR+PLUS serves Medicaid-only and dually eligible people, including most nursing facility residents. It is a statewide program.
• STAR Kids. STAR Kids provides acute care services and LTSS. Additionally, people eligible for Medically Dependent Children’s Program (MDCP) waiver services receive these services through STAR Kids. A key feature of this program is service coordination. Each member is enrolled with an MCO and assigned a main doctor to coordinate care. STAR Kids serves children and young adults age 20 or younger with disabilities.
• Children's Medicaid Dental Services. Children's Medicaid Dental Services provide primary and preventive dental services through managed care. Each member is enrolled in a dental maintenance organization (DMO) and has a main dental home. Most children, birth through age 20, who receive Medicaid, are eligible for dental services.

Medicaid managed care is available statewide. Information concerning the medical and dental managed care plans with contact information for each plan is located at hhs.texas.gov/services/health/medicaid-chip/provider-information/managed-care-organization-dental-maintenance-organization-provider-services-contact-information.

Texas Works Medicaid recipients must enroll in managed care. Exceptions (not comprehensive):

• STAR exceptions:
  • people who are dually eligible for Medicaid and Medicare;
  • children enrolled in the DSHS Children with Special Health Care Needs (CSHCN) Program;
  • children and adults residing in institutions (nursing facilities, Intermediate Care Facilities, and State Supported Living Centers);
  • medically-needy program participants;
  • children in foster care or kinship care;
  • adults that receive SSI; and
  • children and adults that are in a 1915(c) waiver program.
• STAR Health exceptions:
  • youth adjudicated in Texas Juvenile Justice Department (TJJD) facilities;
  • youth from other states placed in Texas, or Texas youth placed in other states; and
  • youth residing in Medicaid-paid facilities.
• STAR+PLUS exceptions:
  • a person 20 or younger who is not in the Medicaid for Breast and Cervical Cancer (MBCC) program;
  • people over the age of 21 in Former Foster Care in Higher Education (FFCHE); and
  • people over 21 who are in a 1915(c) waiver program or who reside in community home for people with Intellectual Developmental Disabilities and are dually eligible for Medicare and Medicaid.
• STAR Kids: A person over the age of 21 and a person 20 or younger without disabilities.
• Children's Medicaid Dental Services exceptions:
  • people 20 or younger who reside in an institution;
  • people in STAR Health;
  • youth placed in other states; and
  • adults 21 and older.

MAXIMUS:

• Contracts with the state to enroll recipients into Medicaid managed care.
• Mails enrollment packets that include information about the plan choices available in their county of residence to newly certified recipients.

If a recipient does not choose a plan or a main doctor by the deadline provided in the enrollment packet, MAXIMUS assigns a plan and a main doctor. They then mail the information to the recipient.

Members of federally recognized Indian tribes are exempt from mandatory enrollment in Medicaid managed care but may choose to participate voluntarily.

At all Medicaid applications and redeterminations, identify and determine if the person qualifies for this exemption. If this information is not available, do not designate the person as exempt. Do not pend the application or delay the eligibility determination for this information.

TIERS refers newly certified recipients to MAXIMUS to initiate their enrollment into managed care. MAXIMUS staff is available in some local eligibility determination offices. A recipient can call the MAXIMUS Helpline at 800-964-2777 to initiate enrollment, to request a plan change, or to disenroll from managed care if they are exempt from mandatory enrollment in Medicaid managed care.

If a recipient has difficulty accessing medical services in a managed care plan, refer the person to the Medicaid Managed Care Helpline at 866-566-8989. The Medicaid Managed Care Helpline advocates for managed care recipients who are having trouble accessing the medical and dental care they need.

Related Policy

Office of the Ombudsman, B-1420
Managed Care Plans, C-1116

A—822 Medicaid Coverage for New State Residents

Revision 15-4; Effective October 1, 2015

Medical Programs

Advisors must determine the correct MED for applicants who:

• move to Texas from another state during the application month or the three months prior to the application month, and
• are Medicaid recipients in the losing state in the month they move.

Step	Action
1	If the losing state denied the recipient's Medicaid the last day of the month the recipient moved from the state or later, then go to Step 2. If the losing state denied the recipient's Medicaid the day the recipient moved from the state, then assign an MED = date the applicant became a Texas resident.
2	Did any member of the certified group incur Medicaid-reimbursable bills after they moved to Texas? If yes, then verify the effective date of denial in the losing state. Go to Step 3. If no, then verify the effective date of denial in the losing state. Assign an MED = first day of the month after the month the losing state denied the recipient's Medicaid.
3	Will the losing state pay for the bills incurred in Texas after the day the person became a Texas resident? If yes, then assign an MED = first day of the month after the month the losing state denied the recipient's Medicaid. If no, then assign an MED = date the applicant became a Texas resident.

Note: If the applicant is unable to provide a contact person in the losing state, the advisor must contact the appropriate state Medicaid director's office. See C-1111, State Medicaid Agencies, for telephone numbers.

When a Texas Medicaid recipient moves to another state, staff from the gaining state may contact the local office about effective dates of denial and coverage of bills incurred in the gaining state. Texas Medicaid pays for Medicaid-reimbursable services provided out-of-state if the:

• recipient needs services because of a medical emergency documented by the attending physician or other provider;
• recipient's health could be jeopardized by not obtaining services; and
• provider enrolls in the Texas Medicaid Program. Out-of-state providers can obtain enrollment information by calling the claims administrator at 1-800-925-9126.

A—823 Lock-In Status

Revision 15-4; Effective October 1, 2015

Medical Programs

HHSC identifies fee-for-service and managed care individuals who:

• received duplicative, excessive, contraindicated or conflicting health services, including drugs; or
• abused, misused or committed fraudulent actions related to Medicaid benefits and services.

These clients may choose one pharmacy and/or one main doctor to be their designated provider for Medicaid services.

The duration periods of lock-in status are as follows:

• The initial period is 36 months.
• The second period is an additional 60 months.
• The third period is for the duration of eligibility and all subsequent periods of eligibility.
• The period of lock-in status for individuals arrested, indicted or convicted of, or admitting to, a crime related to Medicaid fraud differs from the time period listed for initial, second and third periods of lock-in. These individuals will be assigned lock-in status for 60 months or the duration of eligibility and subsequent periods of eligibility up to or equal to 60 months.

For individuals with enrollment lock-in status, HHSC issues a Your Texas Benefits Medicaid card printed with "Lock-in Doctor" and/or "Lock-in Drug Store" on the front of the card, along with the name of the doctor and/or drug store. If an individual with lock-in status prints a Medicaid card from the YourTexasBenefits.com, the same information is displayed.

Staff must verify current lock-in status when issuing Form H1027-A, Medicaid Eligibility Verification. To verify an individual’s lock-in status, the advisor may access the individual’s Lock-In Enrollment page from the Individual – Summary page’s hover menu. If an individual is in lock-in status, the Lock-In Enrollment page will display the provider name and begin date of the status.

Individuals are removed from lock-in status at the end of the specified period if their use of medical services no longer meets the criteria for lock-in status.

Advisors refer individuals with questions regarding their lock-in status to the HHSC Office of Inspector General (OIG) at 1-800-436-6184.

A—824 Issuance of Form H1027-A, Medicaid Eligibility Verification

Revision 15-4; Effective October 1, 2015

Medical Programs

Advisors must issue Form H1027-A, Medicaid Eligibility Verification, to an eligible Medicaid individual only if the individual:

• needs his eligibility verified to receive medical services;
• does not have access to a Your Texas Benefits Medicaid card; and
• is unable to reprint the Medicaid card from YourTexasBenefits.com.

The individual may not have a Your Texas Benefits Medicaid card if the individual:

• is newly certified and has not received it,
• lost or accidentally destroyed the card, or
• is temporarily separated from other eligible family members who have their card.

Before issuing Form H1027-A, staff must verify the individual's current eligibility, enrollment lock-in status and managed care enrollment by accessing the Individual – Summary and Individual – Medicaid History pages. If inquiry is unavailable, advisors must follow regional procedures.

Medicaid with No Enrollment Lock-in or Managed Care Coverage

Issue Form H1027-A for current eligibility if the most recent medical coverage period on the Individual – Summary and Individual – Medicaid History pages:

• is open (no close date shown), and
• reflects regular Medicaid coverage.

Enrollment Lock-in

If an individual is in enrollment lock-in status, "Yes" will display after Lock-In on the Individual – Summary page. Advisors select Lock-In Enrollment from the hover menu over the individual's client number. The Individual – Lock-In Enrollment page provides information regarding the provider(s) to which the individual is currently or was once locked in.

If an individual is currently in lock-in, advisors issue a separate Form H1027-A for the individual and print LIMITED and the name(s) of the provider(s) to which the individual is locked in. Form H1027-A generated in TIERS is printed with "LIMITED" in the "Type of Coverage" field.

Managed Care Coverage

If an individual is in a managed care service area, "Yes" will display after Managed Care on the Individual – Summary page. Select Managed Care from the hover menu over the individual's client number. Advisors select the Individual – Managed Care page to view the individual's plan to which the individual is enrolled.

Advisors must issue Form H1027-A for everyone on the case in the same managed care plan by printing the appropriate managed care program name (e.g., STAR, STAR Health, STAR+PLUS) and the name and telephone number of the plan. This information is in C-1116, Managed Care Plans.

After staff verify eligibility, enrollment lock-in status and managed care enrollment, advisors complete, sign and date Form H1027-A. The unit supervisor or other second party must approve the form indicating he verified eligibility and lock-in status.

Form H1027-A is not used if the most recent medical period:

• is closed, or
• shows institutional coverage.

Form H1027-A instructions include detailed information for completing the form.

TA 74, TA 75, TA 76, TA 83, TA 86 and TP 42

The advisor must issue Form H1027-A if the person has a completed Form H1266, Short-term Medicaid Notice: Approved, showing the date the person is approved for coverage.

Form H1027-A instructions include detailed information for completing the form.

State Paid Medicaid

TA 62

State Paid Medicaid coverage shows in the Medicaid History screen when the individual was not eligible for Medicaid and staff have issued Form H1027-A in error. State Paid Medicaid is 100 percent state-funded.

A—825 Medicaid Termination

Revision 22-2; Effective April 1, 2022

TP 08

If an application is not received by the last day of the month, an EDG is automatically denied effective the last day of the last benefit month.

Related Policy

Denial at Redetermination, A-2342

Emergency Medicaid

Eligibility for Emergency Medicaid ends the date the person's medical condition is stabilized as verified by the attending practitioner or other practitioner familiar with the patient's condition. Verification is done on Form H3038, Emergency Medical Services Certification, or Form H3038-P, CHIP Perinatal – Emergency Medical Services Certification.

A woman certified for Medicaid for Pregnant Women – Emergency (TP 36) on the day her pregnancy ends is eligible to receive TP 36 in the two-month postpartum period if she has another medical emergency.

Related Policy

Regular Medicaid Coverage, A-820

TP 40

Medicaid eligibility for a pregnant woman ends on the last day of the second month following the month the pregnancy terminates.

If the pregnancy terminates early because of molar pregnancy, abortion or premature delivery, deny the coverage effective the last day of the second month following the month the pregnancy terminated. If the pregnancy ends in a month later than expected, change the end date to reflect the new termination date.

A woman whose Medicaid for Pregnant Women coverage ends is automatically tested for other types of assistance using current case information without requiring a new application, if the EDG was not denied for the following reasons:

• voluntary withdrawal;
• death;
• move out of Texas;
• receipt of benefits in another group; or
• failure to provide postponed verification.

TIERS automatically determines eligibility for another type of assistance. If eligible, the woman receives a new certification period which begins after the TP 40 EDG ends.

TP32, TP36, TP40, and TP56

A woman certified for Medicaid (TP 32, TP 36, TP 40, TP 56) on the day her pregnancy ends, is eligible to receive the same type of Medicaid (TP 32, TP 36, TP 40, TP 56) for two months after her pregnancy ends. 
Medicaid for Pregnant Women– Emergency (TP 36) and Medically Needy with Spend Down (TP 32 and TP 56) are only provided in the two-month postpartum period if the woman meets the additional eligibility requirements for these type programs. The original budget used to certify the Medicaid coverage on the day the woman’s pregnancy ends, is the same budget used in the two-month postpartum period.

Related Policy

How to Determine Spend Down, A-1359
Denial of an Application, A-2341
Denial at Redetermination, A-2342 

TP 43, TP 44 and TP 48

A child is continuously eligible for the first six months of the 12-month certification period. If a household fails to report required information at application that causes a child to be ineligible for Medicaid, deny the EDG and send a fraud referral to the Office of the Inspector General (OIG). This does not apply if the household provides verification required by policy. For example, the household applies for Medicaid for a child, provides one pay stub, and is determined eligible. If providing more income verification would result in the child being ineligible, do not deny the Medicaid EDG. The child remains continuously eligible for the first six-months of the 12-month certification period, because policy requires only one pay stub to verify income for a child's Medicaid EDG.

EDGs with end dates do not require staff action to close the EDG when the household does not return a renewal form. These will close effective the last day of the last benefit month of the certification period.

Note: Independent children residing in state hospitals are continuously eligible for the first six months of the 12-month certification period, even if the child is released from the state hospital. If a child is released from the facility prior to the end of the six-month period, process the address change and continue coverage.

A child is eligible through the last day of the month of the child’s:

• first birthday for TP 43;
• sixth birthday for TP 48; and
• 19th birthday for TP 44.

When a child ages out of the current type of assistance during the continuous eligibility period, TIERS:

• Denies the TP 43 or TP 48 EDG through mass update and opens a new EDG for the next type of assistance for the remainder of the continuous eligibility period if the child is eligible for the next type of assistance.
• Sustains the TP 43 or TP 48 EDG if the child is not eligible for the next type of assistance.

When a child ages out of the current type of assistance during the non-continuous eligibility period, TIERS denies the TP 43 or TP 48 EDG and opens a new EDG for the next type of assistance if the modified adjusted gross income (MAGI) is equal to or below the corresponding Federal Poverty Level (FPL).

If the MAGI is more than the FPL for the next type program, the child’s eligibility for CHIP is tested.  If ineligible for CHIP, the child is referred to the Federally Facilitated Marketplace (FFM).

Exception: Children aging out of TP 44 are eligible through the last day of the month of their 19th birthday.

If a child is ineligible for the next type of assistance or turns 19, the child may continue to receive Medicaid if the child:

• is hospitalized on the child's 19th birthday;
• remains hospitalized (there is not a time limit); and
• meets all eligibility requirements except age.

Verify the child’s hospitalization and update the child’s living arrangement to “hospital” to prevent TIERS from denying the child’s coverage.

Verify the hospitalization each month and update the child’s living arrangement when the hospitalization ends.

Related Policy

Continuous Medicaid Coverage, A-832
Medical Programs Administrative Renewals, B-122.4
Processing Children’s Medicaid Redeterminations, B-123

TP 45

A child's eligibility terminates the last day of the month of the child's first birthday. Deny the TP 45 EDG before the child's first birthday if the:

• child's mother was presumptively eligible and received TP 42 at the time of the child’s birth but was not eligible for regular Medicaid at the time of the child’s birth. The child is eligible for TP 45 through the end of the birth month; or
• child no longer resides in Texas. The child is eligible for TP 45 through the month the change occurs.

Notes:

• If the child's mother met spend down and received TP 56 or TP 32 to cover the child's birth, the child is eligible for TP 45 from the date of birth until the end of the month the child turns one.
• State Office Data Integrity (SODI) terminates the newborn's coverage before the child's first birthday in situations in which the child's mother relinquishes her parental rights and information about the child's current residency and new caretaker is unknown. 

Related Policy

TP 45 Provider Referral Process, A-125
Regular Medicaid Coverage, A-820

A-825.1 Recipients of TANF and TP 08

Revision 17-2; Effective April 1, 2017

Recipients of TANF must comply with the Personal Responsibility Agreement (PRA), including cooperating with child support requirements and participating in the Choices program, unless exempt. TP 08 coverage is terminated if an individual receiving both TP 08 and TANF is sanctioned for failure to comply with the Choices PRA requirements.

Individuals certified for TP 08, but not TANF, must cooperate with medical support requirements. Failure to cooperate with the requirements result in the termination of the individual's TP 08 coverage.

Notes:

• TANF sanctions due to noncooperation with other PRA requirements do not result in termination of TP 08 coverage.
• Individuals receiving TP 08 who are not receiving TANF are not required to comply with the TANF PRA.
• The noncooperating adult may reapply for Medicaid and qualify after the identified forfeit months, with the exception of those who non-comply with child support. These individuals must comply before becoming eligible for Medicaid.

Related Policy

Sanctions for Noncooperation, A-1141
Personal Responsibility Agreement, A-2100
Choices, A-2121
Child Support, A-2122
When to Start a Full-Family Sanction, A-2141
Denial at Redetermination, A-2342

A—826 Reserved for Future Use

Revision 20-4; Effective October 1, 2020

 

A—827 Your Texas Benefits Medicaid Card

Revision 19-4; Effective October 1, 2019

Medical Programs

When a person is certified for ongoing Medicaid benefits, a Your Texas Benefits Medicaid card is mailed, which should:

• be carried and protected like a driver's license or credit card; and
• used when visiting a Medicaid provider (i.e., doctor, dentist or pharmacy).

The Your Texas Benefits Medicaid card is plastic, like a credit card, and includes the following information printed on the front:

• person’s name and Medicaid ID number;
• managed care program name (if STAR Health);
• date the card was issued; and
• billing information for pharmacies.

The back of the card includes the statewide toll-free phone number where people can get more information about the Your Texas Benefits Medicaid card.

Each person certified for Medicaid in a household receives one Your Texas Benefits Medicaid card. It is intended to be the person’s permanent card.  

If a person loses:

• Medicaid coverage but later regains coverage, the person can use the same Your Texas Benefits Medicaid card.
• Their Your Texas Benefits Medicaid card, they can request a replacement by:
  • logging on to their YourTexasBenefits.com account;
  • calling 2-1-1 (after selecting language, select Option 2, and then Option 1); or
  • calling 855-827-3748.

If a person forgets their Your Texas Benefits Medicaid card, a provider (i.e., doctor, dentist or pharmacy) can verify Medicaid coverage by:

• calling the TMHP Contact Center at 800-925-9126; or
• visiting the Texas Medicaid and Healthcare Partnership’s (TMHP's) TexMedConnect website using the person’s Medicaid ID number or one of the following combinations for the person:  
  • Social Security Number (SSN) and last name;
  • SSN and date of birth (DOB); or
  • last name, first name, and DOB. 

If a person needs quick proof of eligibility, they can;

• log in to their www.YourTexasBenefits.com account to print a temporary card; or
• go to a local benefits office to request a card. HHSC staff in the office will:
  • assist the person accessing and printing a Medicaid card from the person’s www.YourTexasBenefits.com account from the office’s lobby computer; or
  • generate a temporary Form H1027-A, Medicaid Eligibility Verification via TIERS if the person prefers not to or has trouble accessing their Medicaid card online.

Revision 13-2; Effective April 1, 2013

 

 

A—831 Three Months Prior Coverage

Revision 15-4; Effective October 1, 2015

Medical Programs except TP 40

Applicants may be eligible for Medicaid coverage during the three-month period before the month they apply for Medical Programs. Prior coverage may be continuous or there may be interrupted periods of eligibility involving all or some of the certified members.

TP 40

Medicaid for a pregnant woman does not begin before the first day of the month her pregnancy began, as explained in A-820, Regular Medicaid Coverage.

 

 

A—831.1 How to Apply for Three Months Prior Coverage

Revision 15-4; Effective October 1, 2015

Medical Programs except TP 45

A person applies for three months prior Medicaid coverage by completing Form H1113, Application for Prior Medicaid Coverage. Advisors must give this form to applicants who indicate on an application or during the application interview that the family has unpaid medical bills incurred during the three months before the application month. Exception: For Children’s Medicaid, Form H1113 is not required if the family provides enough information to determine eligibility for prior months.

Related Policy

Continuous Medicaid Coverage, A-832
TP 45 Retroactive Coverage, A-833

 

 

A—831.2 Eligibility for Three Months Prior Coverage

Revision 17-1; Effective January 1, 2017

Medical Programs except TP 40

Advisors certify the applicant for Medicaid only for the month(s) the individual meets all eligibility requirements and has:

• unpaid medical bills for Title XIX-covered services; or
• received Medicaid services from the Texas Department of State Health Services.

Advisors provide prior Medicaid coverage even if the:

• family is not currently eligible for Medical Programs; or
• person with unpaid medical bills is deceased.

TP 08

Certify a parent or caretaker relative for a prior month(s) if they are caring for a dependent child who meets all eligibility requirements in the prior month(s), but is not certified for Medicaid in the prior month(s) because the child does not have unpaid medical bills.

TP 40

Gaps do not apply to TP 40. Once eligibility is determined in one of the prior months, it continues even if there are no unpaid medical bills in a subsequent prior month.

 

 

A—831.2.1 Reopening Three Months Prior Applications

Revision 21-3; Effective July 1, 2021

Medical Programs

Applications for prior Medicaid coverage may be reopened for one or more month(s) in the three-month prior period when:

• the person requests the application be reopened within two years after the application file date; and
• Medicaid eligibility (certification with or without spend down) for the person or month(s) of coverage requested was not previously established.

Verify a previous application was filed. Use any application filed by the household within the past two years as a basis for determining eligibility for prior Medicaid coverage, even if the application did not request ongoing Medicaid, prior months’ Medicaid coverage or claim unpaid medical bills. Medicaid eligibility can only be established within two years after the application file date whether or not the request was processed due to agency or applicant error.

Note: Do not reopen an application for prior Medicaid for a month that Medicaid eligibility (certification with or without spend down) was established, even if the spend down was closed by the Clearinghouse.

 

 

A—831.3 Income Computation

Revision 15-4; Effective October 1, 2015

Medical Programs

Staff must determine eligibility for each month in which there are unpaid medical bills using the income and verification rules explained in A-1300, Income

The needs and income of people who would have been considered in the client’s MAGI household composition for each month the client’s MAGI household composition has unpaid medical bills are included.

 

 

A—831.4 Determining the Appropriate Type Program for the Prior Month

Revision 15-4; Effective October 1, 2015

Medical Programs

Use the following chart to determine the type program to use for eligibility in the prior month:

If the type program is …	and the modified adjusted gross income for the prior month is …	then …
TP 08,	less than or equal to the FPIL amount for TP 08 and there is no gap in coverage,	certify the application for the prior month.
TP 08,	less than or equal to the FPIL amount for TP 08 and: there is a gap in coverage, or the individual is not currently eligible,	certify the application for the prior month(s).
TP 08,	more than the FPIL amount for TP 08,	do not certify the application for the prior month in this type program. Check eligibility for another type program.
TP 40, TP 43, TP 44, or TP 48,	less than or equal to the FPIL amount for that program,	certify the application for the prior month.
TP 40, TP 43, TP 44, or TP 48,	more than the FPIL amount for that program,	do not certify the application for the prior month in this type program. Check eligibility for TP 56.
TP 45,	not applicable,	these applicants are always eligible back to the date of birth.
TP 56,	more than the medically needy income limit (MNIL),	determine if the household has enough medical expenses to meet spend down for the prior month. If yes, then certify the children or pregnant woman. If no, then deny the application for prior coverage.
TA 31, TP 33, TP 34, TP 35, or TP 36,	less than or equal to the FPIL amount for that program,	certify the applicant for the prior month only for the dates of the emergency medical condition verified on Form H3038, Emergency Medical Services Certification, or Form H3038-P, CHIP Perinatal – Emergency Medical Services Certification.
TP 32	above the income limits as stated above (applies only to children [under age 19] and pregnant women),	determine if the household has enough medical expenses to meet spend down for the prior month. If yes, then certify the child or pregnant woman. If no, then deny the application for prior coverage.

Note: Applicants are considered for eligibility in Medicaid for Former Foster Care Children (TA 82) and Medicaid for Transitioning Foster Care Youth (TP 70) before TP 08.

 

 

A—831.5 Medical Eligibility Date for Three Months Prior Coverage

Revision 13-2; Effective April 1, 2013

Medical Programs

The MED for a month of prior coverage begins the earliest day in the month the individual met all eligibility criteria. It is the first day of the month unless all eligibility criteria were not met.

Related Policy

Regular Medicaid Coverage, A-820

 

 

A—831.6 Applications Based on Incapacity

Revision 15-4; Effective October 1, 2015

TP 08 and TA 31

If the applicant claiming incapacity meets the other eligibility requirements for prior Medicaid coverage, the advisor must document information according to A-1080, Disability Verification.

 

 

A—832 Continuous Medicaid Coverage

Revision 19-1; Effective January 1, 2019

TP 40

Staff provide continuous Medicaid coverage without an application or an interview for a pregnant woman through the second month after the pregnancy terminates regardless of income increases if she:

• received Medicaid on a program other than TP 40 and was ineligible because of income;
• provides verification that she was pregnant in the month she becomes ineligible for Medicaid; and
• received Medicaid within 11 months prior to the application month.

Note: Accept the individual's (pregnant woman's, case name's or AR's) verbal or written statement of pregnancy as verification. The statement must include the name of the woman who is pregnant, pregnancy start month, number of expected children and anticipated date of delivery. The individual also may provide Form H3037, Report of Pregnancy, or another document containing information specified on Form H3037.

Note: Staff provide continuous Medicaid coverage to a pregnant woman who was denied with an administrative denial reason (such as, but not limited to, failure to keep appointment and voluntary withdrawal) if her Medicaid would have been denied because of income if the income had been reported.

The continuous coverage policy applies to women who were receiving benefits from the following programs:

• SSI or MEPD. Note: When an SSI Medicaid recipient is denied, TIERS sends Form H1296, Notice of SSI Medicaid Ending, informing the recipient that she may be potentially eligible for other Medical Programs within HHSC.
• A caretaker certified on TP 08 who is not eligible for TP 07 or TP 20.
• A caretaker or child certified on TP 07 or TP 20.
• A child certified on TP 44.

TP 43, TP 44 and TP 48

A child under age 19 receives a 12-month certification period. The child is continuously eligible for Medicaid for six months or through the month of the child’s 19th birthday, whichever is earlier. The second six months of coverage is non-continuous, and changes may impact the child’s eligibility.

Exceptions:

• During the continuous eligibility period, if a household reports that a sibling has moved into the household and requests Medicaid for the sibling, the sibling is added to the current case. TIERS aligns the end of the new Medicaid-eligible child’s certification period with the end of the existing child’s certification period.
• A child is not eligible for continuous coverage if a household fails to report required information at application that causes a child to be ineligible for Medicaid. See A-825, Medicaid Termination.

If the household is eligible in the application month, process month, or ongoing month, the child is eligible for continuous coverage beginning the first month the household meets the eligibility criteria. Note: This includes situations where the household is eligible in the application or process month, but not in an ongoing month.

If the household is eligible only in a month prior to the application, certify the child for the prior month only. The child is not eligible for continuous coverage.

Note: Explore TP 56 for the child if the individual indicates the child has unpaid bills in a month of ineligibility.

Related Policy
Medicaid Termination, A-825
What to Report, B-621

 

 

A—833 TP 45 Retroactive Coverage

Revision 15-4; Effective October 1, 2015

TP 45

Advisors must provide retroactive TP 45 coverage for newborn children without requiring an application or an interview with the child's mother if all of the following conditions are met:

• There are unpaid Title XIX bills for the newborn child.
• The mother of the child is unwilling, unable or refuses to apply for current benefits for the child, or the child is not eligible for current benefits.
• The advisor has verification of the following eligibility factors for the newborn child:

Eligibility Factor	Eligibility Requirement
Age	Coverage must be initiated within one year of the child's birth. The child's coverage cannot continue after the child becomes 13 months old.
Residence	Child must be residing in Texas.
Natural mother's Medicaid coverage dates	Child's mother must be eligible for and receiving Medicaid on the day the child is born. The mother's eligibility can be determined retroactively. See A-820, Regular Medicaid Coverage.

The file date is the day the advisor is notified about the unpaid bills for the child.

TIERS will allow a:

• file date as late as the month of the child's first birthday, and
• medical effective date as early as the child's date of birth.

 

 

A—834 Retroactive Medicaid Coverage for Abandoned Children

Revision 18-1; Effective January 1, 2018

Medical Programs

If a newborn or child is abandoned at an acute care hospital, or at a psychiatric hospital while receiving inpatient services, DFPS requests a court order for custody. Once the court order is obtained, DFPS provides Medicaid coverage from the day in which custody is granted. The MED is the date DFPS takes conservatorship. This may result in the newborn or child having unpaid medical bills if DFPS takes conservatorship after the date of birth or the date of admission to the hospital and the date DFPS takes conservatorship.

A designated DFPS representative completes Form H1113, Application for Prior Medicaid Coverage, requesting coverage on behalf of the abandoned child and forwards the request to a designated Texas Works advisor within Centralized Benefit Services (CBS) at cbs_ffche-mtfcy@hhsc.state.tx.us.

For children abandoned in a psychiatric hospital, DFPS will only submit applications to request retroactive Medicaid for a child receiving inpatient treatment.

CBS advisors provide retroactive Medicaid coverage only during the following situations:

• A newborn is taken into foster care conservatorship after the date of birth but before the child is released from the hospital, creating a gap in coverage from the date of birth through the day before the foster care conservatorship date.
• A child of any age is taken into foster care conservatorship while in the hospital, but after the admission date, creating a gap in coverage from the date of admission to the day before the foster care conservatorship date.

Note: The MED for a child (not a newborn) cannot precede the date of admission into the hospital.

Revision 02-6; Effective July 1, 2002

A—841 General Eligibility Information

Revision 15-4; Effective October 1, 2015

TP 07

Some TP 08 household members may be eligible for transitional Medicaid, TP 07.

An eligibility determination for TP 07 is based on whether a parent or caretaker relative is certified for TP 08, Parents and Caretaker Relatives Medicaid, in Texas for three of the six months before the first month of ineligibility. If a parent or caretaker relative certified for TP 08 coverage is eligible for transitional Medicaid, his or her children will be eligible as well. Each individual will be certified on an individual transitional Medicaid EDG for the duration of the certification period.

Example: The household composition consists of mother, father, and two mutual children. The mother and father each are certified on an individual TP 08 EDG in Texas for three of the six months before the month of ineligibility and each child on an individual Children's Medicaid EDG. The father has an increase in income that makes him ineligible for TP 08. The father is then certified on an individual TP 07 EDG. The mother and the two children will be certified on individual TP 07 EDGs, each with the same certification period as the father.

When a TP 07 EDG has been created, other eligible household members receive a new TP 07 EDG. See A-846.1, Parents and Caretaker Relatives Enter or Already Live in the Home, and A-846.2,Child Enters or Already Lives in the Home.

A household member is not eligible for TP 07 if the member was ineligible for TP 08 because the individual committed fraud during any of the six months before the TP 07 EDG was opened. The fraud must be determined by a court or through a hearing. If the TP 07 EDG was opened before the fraud determination was known:

• the household member is disqualified using advance adverse action notice procedures, and
• transitional child care staff must be notified that the member should not have received transitional benefits because of Medicaid fraud.

TP 08 households denied for any reason (such as failure to keep an appointment) may request TP 07 during the adverse action time frame and have their eligibility determined. For example, a household who failed to keep their appointment because of a new job may be eligible for TP 07.

Individuals may request Medicaid on TP 08 any time after denial. These individuals and their household members may also request TP 07 if they become employed.

The number of months of transitional coverage is 12 months.

A—841.1 Multiple Changes That Cause TP 08 Ineligibility

Revision 15-4; Effective October 1, 2015

TP 08

If two or more changes (when one is new or increased earned income) cause the income to increase from less than the FPIL for TP 08 to more than the FPIL for TP 08 for the same month, and the household has not been notified that members are eligible for TP 07, advisors follow the steps below:

Step	Action
1	If all other case factors remain the same, is the household income increased to above the FPIL for TP 08 because of new or increased earnings? Yes. The family is eligible for TP 07 if members meet the other eligibility requirements. No. Go to Step 2.
2	Is the income increased to above the FPIL for TP 08 as a result of a change other than new or increased earnings? Yes. The family is not eligible for TP 07. Go to Step 3. No. Go to Step 4.
3	Does the family meet the income limits for the Medical Program EDGs for which they are certified? Yes. Continue current Medical Program coverage. No. Deny the Medical Program EDG(s) for which the individual is no longer income eligible.
4	Is the income increased to above the FPIL for TP 08 when all changes are considered? Yes. The family is eligible for TP 07 if the members meet the other eligibility requirements.

Changes reported in a timely manner do not stop the denial of the TP 08 EDG and creation of the TP 07 after the household is notified of transitional Medicaid eligibility, even when both changes affect the same month.

Exceptions: The EDG is denied if the household:

• moves out of Texas;
• no longer meets the household composition requirement as specified in A-841.3, Eligibility Criteria During Transitional Medicaid Coverage; or
• reports a change that makes the household ineligible before the first month of transitional Medicaid eligibility.

A—841.2 Notice to Clients

Revision 15-4; Effective October 1, 2015

TP 08

When TIERS denies a TP 08 EDG and creates a TP 07, TIERS generates Form TF0001, Notice of Case Action, to notify the household:

• that their TP 08 and their children on associated TP 43, TP 44 and TP 48 EDGs are denied;
• the date their TP 07 benefits will end; and
• about the transitional Medicaid eligibility and reporting requirements. Note: If the individual is in the office, the advisor may explain the reporting requirements.

A—841.3 Eligibility Criteria During Transitional Medicaid Coverage

Revision 15-4; Effective October 1, 2015

TP 07

Certified members remain eligible for transitional Medicaid if the:

• household continues to live in Texas, and
• EDG meets one of the following household composition requirements.

The transitional EDG includes an eligible child. Note: For transitional Medicaid, an eligible child is a child who meets all of the following requirements: citizenship, Social Security number (SSN), age, relationship, and domicile.

OR

A parent or caretaker relative cares for a child who receives: SSI; adoption assistance payments; or federal, state or local foster care payments; or Medicaid (TP 07, 20, 40, 43, 44, 45, or 48.

The noncomplying adult who is certified for TP 07 is denied when the advisor receives notice that the legal parent failed to cooperate with third-party resource (TPR) requirements or has been found guilty of a Medicaid intentional program violation.

If another-related caretaker failed to cooperate with TPR requirements or was found guilty of a Medicaid intentional program violation, the advisor must:

• change the status to payee, or
• deny the transitional Medicaid EDG if the other-related caretaker is the only person on the EDG.

The advisor must not:

• count unearned income of household members when determining continued eligibility for households certified for transitional Medicaid; or
• deny a transitional Medicaid EDG because of new or increased income of a household member, unless reported in the seventh or tenth month Medicaid Status Report.

A—842 TP 07 Transitional Medicaid

Revision 15-4; Effective October 1, 2015

TP 08

TP 08 certified members are eligible for TP 07 if:

• at least one of the group members was eligible for and received TP 08 in Texas for three of the six months before the first month of ineligibility; and
• the denial is because:
  • a certified parent, certified caretaker relative, or disqualified legal parent began receiving or had an increase in gross earned income; or
  • of the earnings of a new or returning absent parent who is added to the certified group because the household meets incapacity or deprivation criteria.

A—842.1 Determining the First Month of TP 07 Medicaid

Revision 15-4; Effective October 1, 2015

TP 08

The first TP 07 month is the month the change is effective (when reported and acted on timely) when new or increased earnings cause a certified parent or caretaker relative on TP 08 to be over the FPIL for TP 08.

Determine the first month of TP 07 eligibility using the following chart:

Step	Action
1	The first month of TP 07 is the first month after adverse action expires when the change is reported, verified, and processed timely (or should have expired if the change was not reported, verified, or processed timely). Note: The first month can be no later than the first month of overpayment as described in B-752.1.2, Errors After Certification, but may be earlier based on the date the notice of adverse action expires (as described in A-2343.1, How to Take Adverse Action if Advance Notice Is Required).
2	Was at least one household member eligible for and did that member receive TP 08 in Texas for at least three of the six months prior to the month identified in Step 1? (See A-842.2, Determining the Three of Six Months Eligibility Requirement.) If yes, continue to Step 3. If no, deny the EDG.
3	Designate the month from Step 1 as the first month of TP 07 eligibility.

Individuals who appeal the advisor's decision to deny the TP 08 EDG often receive TP 08 while the appeal is pending. If the hearing officer sustains the advisor's decision, the months the client received continued benefits during the appeal process are counted as TP 07 months.

A—842.2 Determining the Three of Six Months Eligibility Requirement

Revision 20-1; Effective January 1, 2020

TP 08

Advisors must determine whether at least one household member was eligible for and received TP 08 in Texas for three of the six months before the first month of ineligibility.

Advisors must count any month when at least one household member was eligible for and received benefits. Advisors must include any month that someone in the household received TP 08.

Advisors must not count any month benefits were:

• issued but the household was not eligible;
• not issued;
• received in another state;
• prior Medicaid coverage; or
• Medicaid only for the application month due to certification in a later month.

TP 08 with Other Household Members on a Medical Program

Advisors must determine whether at least one TP 08 household member was eligible for and received Medicaid in Texas for three of the six months before the first month the income increase is effective.

Advisors must count any month when at least one household member was eligible for and received Medicaid through:

• TP 08, TP 20, TP 40, TP 43, TP 44, TP 45, TP 48, or TP 56 and spend down was met;
• SSI, including SSI Medicaid only;
• federal, state, or local foster care; or
• adoption assistance.

Advisors must not count any months Medicaid benefits were:

• certified but the household member was not eligible;
• received in another state; or
• prior Medicaid benefits.

A—842.3 Automatic Denial of TP 07

Revision 15-4; Effective October 1, 2015

TP 07

Recipients terminated from TP 07 must be retested for eligibility for any other Medical Programs, as explained in A-2342.1, Retesting Eligibility.

A—843 Reserved for Future Use

Revision 20-2; Effective April 1, 2020

A—844 Transitional Medicaid Reporting Requirements for TP 07

Revision 15-4; Effective October 1, 2015

TP 07

Individuals receiving TP 07 coverage are required to report the following changes during the 4th, 7th and 10th months of the transitional period:

• Changes in the household members' gross monthly earnings, and
• Changes in the household composition.

Form H1146, Medicaid Report, is computer-generated and is sent to the household at cutoff in the 3rd, 6th and 9th months. Form H1146:

• informs the household of the availability of continuing transitional coverage,
• provides information about the change reporting requirements, and
• provides a way to report the required information.

Advisors use Form H1146-M, Medicaid Report (Manual), to replace TIERS-generated forms that the household reports are lost or destroyed.

Advisors must not require verification for the transitional Medicaid EDG. Exception: Advisors must require appropriate verifications to determine whether a new household member is eligible to be added to the EDG. See A-846.1, Parents and Caretaker Relatives Enter or Already Live in the Home, and A-846.2, Child Enters or Already Lives in the Home.

Note: If the household does not return Form H1146, no action is required.

A—844.1 Staff Action on the Fourth Month Medicaid Report

Revision 21-1; Effective January 1, 2021

TP 07

Use the following procedures to process Form H1146-M, Medicaid Report, for the fourth month. Take action on the household members' other EDGs and cases if the reported information affects those benefits.

If the household returns Form H1146 and Form H1146 indicates …	then …
the household still meets the household composition requirements in A-841.3, Eligibility Criteria During Transitional Medicaid Coverage,	take no action on the transitional Medicaid case.
a child who is not receiving TP 43, TP 44, TP 45, TP 48, or transitional Medicaid is in the home,	see A-846.2, Child Enters or Already Lives in the Home.
a child left the home,	see A-846.3, Household Member Leaves the Home.
a returning absent parent or stepparent,	see A-846.1, Parents and Caretaker Relatives Enter or Already Live in the Home.
a household member certified for TP 07 reports a pregnancy,	explore TP40 eligibility for the pregnant household member.
the household no longer meets the household composition requirements in A-841.3,	deny the EDG, and send Form TF0001, Notice of Case Action.
there are no earnings by the parent or caretaker relative in at least one of the three report months, and there is no good cause for the lack of earnings; or the average monthly gross earnings of the household members* exceeds the applicable income limit for the household size,	shorten the transitional Medicaid coverage to end after the sixth month. Note: If the medical coverage is shortened because the parent or caretaker relative did not have earnings for a complete month, inform the household that they can show good cause. They must show good cause within 13 days. (See A-844.4, Good Cause Determinations.)

* See A-844.3, 185% FPIL Test, for budgeting policies.

Related Policy
Eligibility Criteria During Transitional Medicaid Coverage, A-841.3
185% FPIL Test, A-844.3
Good Cause Determinations, A-844.4
Parents and Caretaker Relatives Enter or Already Live in the Home, A-846.1
Child Enters or Already Lives in the Home, A-846.2
Household Member Leaves the Home, A-846.3

A—844.2 Staff Action on the Seventh and Tenth Month Medicaid Reports

Revision 21-1; Effective January 1, 2021

TP 07

Use the following procedures to process Form H1146-M, Medicaid Report, for the seventh and tenth months. Take action on the household members' other EDGs and cases if the reported information affects those benefits.

If the household returns Form H1146 and Form H1146 indicates …	then …
the household no longer meets the household composition requirements in A-841.3, Eligibility Criteria During Transitional Medicaid Coverage,	deny the EDG and send Form TF0001, Notice of Case Action.
there are no earnings by the parent or caretaker relative in at least one of the three report months, and there is no good cause for the lack of earnings; or the average monthly gross earnings of the household members* exceeds the applicable income limit for the household size,	deny the EDG using the appropriate denial reason; open a new EDG for the appropriate Medical Program if applicable; and send Form TF0001 to the household. If the EDG is denied and the household is not eligible for another type of Medical Program, send Form H1010, Texas Works Application for Assistance – Your Texas Benefits, along with Form TF0001. HHSC must act on received information (earnings) that makes the household ineligible for transitional Medicaid even if the information is received outside of the reporting period (i.e., changes); however, eligibility can only be terminated at the end of the seventh or tenth month. Note: If the denial is because the parent or caretaker relative did not have earnings for a complete month, inform the household that they can show good cause. They must show good cause within 13 days. (See A-844.4, Good Cause Determinations.)
the household continues to be eligible,	take no action.
a child who is not receiving TP 43, TP 44, TP 45, TP 48, or transitional Medicaid is in the home,	see A-846.2, Child Enters or Already Lives in the Home.
a child left the home,	see A-846.3, Household Member Leaves the Home.
a returning absent parent or stepparent,	see A-846.1, Parents and Caretaker Relatives Enter or Already Live in the Home.
a household member certified for TP 07 reports a pregnancy,	explore TP40 eligibility for the pregnant household member.

* See A-844.3, 185% FPIL Test, for budgeting policies.

Note: A denial notice (Form TF0001) will be sent to the household at the end of their 12 months of transitional Medicaid.

Related Policy
Eligibility Criteria During Transitional Medicaid Coverage, A-841.3
Good Cause Determinations, A-844.4
Parents and Caretaker Relatives Enter or Already Live in the Home, A-846.1
Child Enters or Already Lives in the Home, A-846.2
Household Member Leaves the Home, A-846.3

A—844.3 185% FPIL Test

Revision 15-4; Effective October 1, 2015

TP 07

Advisors use the following policies and procedures to determine whether the household's earnings are at or below the 185 percent FPIL when processing Medicaid reports.

Advisors must include all members of the individual’s MAGI household composition when determining the MAGI income.

Exceptions:

• Advisors must not count the earnings of a child who is exempt according to A-1341, Income Limits and Eligibility Tests.
• See A-240, Medical Programs, and A-1341 for exceptions to household composition and countable income.
• When a person is disqualified because of failure to cooperate with child/medical support or TPR requirements, or is found guilty of a Medicaid intentional program violation, the person is not included in the household size.

If the person who fails to cooperate is …	then …
a certified legal parent,	count the person’s earnings.
an "other relative" caretaker who is the parent or stepparent of a child on the case,	count the person’s earnings.
an "other relative" caretaker who is not a parent or stepparent to a child on the case,	do not count the person’s earnings.

A—844.4 Good Cause Determinations

Revision 15-4; Effective October 1, 2015

TP 07

Good cause for the caretaker relative not having earnings in one or more of the report months includes:

• involuntary loss of employment,
• illness,
• actively looking for work but unable to find a job, and
• other reasons beyond the household's control.

A—845 Reinstatement of Denied Transitional Coverage

Revision 15-4; Effective October 1, 2015

TP 07

Certain households whose transitional Medicaid EDGs are denied before the end of their original eligibility period may have transitional Medicaid coverage reinstated. Advisors must reinstate eligible household members for the remainder of their original transitional Medicaid period if:

• the original transitional Medicaid end date has not expired;
• the TP 07 was denied — for example, members:
  • were recertified for TP 08; or
  • moved out of Texas;
• the household does not want to apply for TP 08 or is not eligible for TP 08 (at application, review, or change); and
• there is a dependent child in the household certified for Medicaid.

Note: Individuals requesting reinstatement of TP 07 transitional Medicaid must have remained continuously eligible for transitional Medicaid during the months the TP 07 EDG was denied. Exception: A household that moved out of Texas must meet all of the eligibility criteria except residence.

A—845.1 Advisor Action on Reinstatements

Revision 15-4; Effective October 1, 2015

TP 07

Advisors must count the months of absence from transitional Medicaid as if the family had actually received transitional Medicaid.

Advisors use the following table to determine the MED:

If the member ...	then enter the day ...
remained in Texas during the transitional Medicaid denial period and did not receive other Medicaid coverage,	following the denial date.
moved out of the state,	the member returned to Texas and was no longer eligible for Medicaid in another state (see A-822, Medicaid Coverage for New State Residents).
was certified for TP 08 or another Medical Program,	following the denial date on the other TP 08 or other Medicaid EDG.

To reinstate denied transitional Medicaid, advisors must:

• Determine which mode to use. If the case status is denied and there is:
  • no active EDG, use Reopen mode.
  • an active EDG, use Complete Action mode.
• On the Program Summary page, select Reactivation from the Program Action drop-down menu.
• On the Program Details page, enter the Reactivation Date and select the appropriate Reactivation Reason.
• From the Program – Individuals Summary display, select the person(s) requesting aid.
• Change Aid Requested to Yes. Note: The Date Requested is defaulted to the previous date for individuals who were on the EDG when it was terminated.
• Continue through Data Collection.
• In Disposition, choose Administrative TMA Reinstatement as the reason for eligibility.

Notes:

• Advisors must not open a new application. If a new application was created, it is denied as filed in error.
• When processing the reinstatement, any members who are no longer in the household are removed.
• Advisors send Form TF0001, Notice of Case Action, to notify the household of their continued eligibility.

Advisors must obtain information on household composition and earnings for the months the household did not receive TP 07 and is required to report on Form H1146, Medicaid Report.

If the household missed the …	then obtain information on months …
fourth month Medicaid report,	one, two, and three.
seventh month Medicaid report,	four, five, and six.
tenth month Medicaid report,	seven, eight and nine.

If the household was …	then …
certified for Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF), or any of the Medical Programs,	use case information, requesting additional information from the household only if necessary.
not certified,	obtain the necessary information.

Advisors determine whether the individual was continuously eligible for TP 07 Medicaid using:

• A-844.1, Advisor Action on the Fourth Month Medicaid Report, for the fourth-month Medicaid Report;
• A-844.2, Advisor Action on the Seventh and Tenth Month Medicaid Reports, for the seventh- and tenth-month Medicaid Reports; and
• A-844.4, Good Cause Determinations, to determine good cause for no earnings.

A—846 Special Household Composition Policies for Transitional Medicaid

Revision 13-2; Effective April 1, 2013

A—846.1 Parents and Caretaker Relatives Enter or Already Live in the Home

Revision 15-4; Effective October 1, 2015

TP 07

Advisors must follow the procedures below if the household requests TP 07 benefits for a caretaker, returning absent parent, stepparent, or second parent in the home.

Advisors must add the member to the case and open a new TP 07 EDG for the individual, or change an ineligible member to eligible if the person is a caretaker or second parent who:

• was disqualified on the TP 08 or transitional EDG but has complied with the eligibility requirement for which he was disqualified (for example, TPR);
• is a returning absent parent/second parent in the home; or
• is a stepparent caretaker because the legal parent has a disability and is unable to care for the children.

A—846.2 Child Enters or Already Lives in the Home

Revision 15-4; Effective October 1, 2015

TP 07

Advisors follow the procedures in the chart below:

• when the TP 07 household reports that a child who is not receiving TP 07, TP 43, TP 44, TP 45, or TP 48 is in the home;
• when denying a TP 08 EDG and opening a TP 07 EDG; and
• upon review of another Medical Program EDG for a child who lives with a TP 07 recipient.

An other-related child's separate Medical Program EDG continues unless the caretaker needs Transitional Child Care services for the child.

If a child who is not receiving TP 43, TP 44, TP 45, TP 48, or transitional Medicaid …

then …

is a newborn, moves in, or already lives in the home,

obtain the appropriate information/verifications and determine if the child meets all of the following requirements: citizenship, SSN, age, relationship, and domicile. Use information/verifications from other case records when the child is currently or has been a TANF/Medical Program or SNAP recipient. Do not consider the following criteria: deprivation, and income. Note: Obtain information regarding a child's earned income when processing the seventh and tenth month Medicaid reports if the child's earnings are counted, following Medical Programs policy explained in A-1341, Income Limits and Eligibility Tests. If the child is eligible, then send Form TF0001, Notice of Case Action, to the household to inform the household of the child's eligibility. If the child is not eligible or the household does not provide the information/verification, then: send Form TF0001 to the household; inform the household that: their TP 07 EDG will continue; but the child cannot be added to the case, stating the reason the child cannot be added; and take no action on the case.

If a child who is added to the case has unpaid medical bills for any of the three months prior to the month the request is received to add the child, advisors must:

• determine and document three months prior eligibility according to Medical Programs policies and procedures in A-830, Medicaid Coverage for the Months Prior to the Month of Application; and
• assign the child an MED beginning the first prior month the child met all TP 07 eligibility requirements.

The child's MED cannot precede the:

• first month the household was eligible for TP 07 (advisors must determine a child's eligibility for another Medical Program if the individual applies for prior coverage that precedes the first month the household is eligible for TP 07); or
• date the child entered the household.

A—846.3 Household Member Leaves the Home

Revision 15-4; Effective October 1, 2015

TP 07

Follow the procedures in the chart below when the transitional Medicaid household reports that a child leaves the household.

If a child leaves the household and the …	then …
child was part of the transitional certified group, and household continues to meet the household composition requirements in A-841.3, Eligibility Criteria During Transitional Medicaid Coverage,	send Form TF0001, Notice of Case Action, to the household informing the household that the child will no longer receive Medicaid, and deny the child’s TP 07 EDG.
household no longer meets the household composition requirements in A-841.3,	send Form TF0001 to the household, and deny the TP 07 EDGs that no longer are eligible.

Advisors follow normal procedures to remove a parent or caretaker relative when the household reports the person is no longer in the home.

A—846.4 Minor Parents Certified as Children

Revision 15-4; Effective October 1, 2015

TP 07

See A-240, Medical Programs, for household composition rules.

A—847 Other EDG Actions

Revision 13-2; Effective April 1, 2013

A—847.1 Changes Affecting Transitional Medicaid EDGs

Revision 21-1; Effective January 1, 2021

TP 07

For TP 07 EDGs, only take action for the following changes:

• A household member reports a pregnancy. Explore TP 40 eligibility for the pregnant household member.
• A child is born, moves in, or is already living with the certified group. Add the child to the case and open a TP 07 EDG following procedures in A-846.2, Child Enters or Already Lives in the Home.
• A parent or caretaker relative moves in or otherwise becomes eligible. Add the member to the case and open a TP 07 EDG following procedures in A-846.1, Parents and Caretaker Relatives Enter or Already Live in the Home.
• A member included in a TP 07 EDG leaves the household. Remove the member from the case following procedures in A-846.3, Household Member Leaves the Home.
• A household member is no longer eligible. Remove the member from the case. For example:
  • A child no longer meets the Medical Programs age criteria.
  • A child moves out of state.

Related Policy  
Parents and Caretaker Relatives Enter or Already Live in the Home, A-846.1
Child Enters or Already Lives in the Home, A-846.2
Household Member Leaves the Home, A-846.3

A—847.2 Reapplication for TP 08

Revision 15-4; Effective October 1, 2015

TP 07

A household receiving TP 07 may reapply for TP 08 by submitting an application. If the household is eligible, TIERS will:

• deny the TP 07;
• certify the parent/caretaker relative on a TP 08 EDG and the child on the appropriate Children’s Medicaid EDG; and
• send Form TF0001, Notice of Case Action, to the household.

Related Policy
Minor Parents Certified as Children, A-846.4

Revision 16-4; Effective October 1, 2016 

A—851 Eligibility Criteria for Medicaid when Receiving Alimony or Spousal Support

Revision 21-2; Effective April 1, 2021

TP 20

People denied TP 08 because of new or increased alimony or spousal support may be eligible for TP 20. TP 20 eligibility determinations are based on a parent or caretaker relative  certified for TP 08. Household members are eligible for TP 20 for four months following the last month of TP 08 eligibility if:

• the modified adjusted gross income before receipt of alimony or spousal support was at or below the income limit for TP 08;
• new or increased alimony or spousal support income caused the person’s MAGI household income to exceed the income limit for the household's size; and
• at least one TP 08 household member was eligible for and received Medicaid in Texas for three of the six months before the first month of ineligibility.

If the household is eligible, a separate transitional Medicaid EDG will be created for each parent or caretaker relative and each child.

When a change in new or increased alimony or spousal support is reported, verified, and processed timely, the first month a person may receive TP 20 is the month after the adverse action period expires (or should have expired if the change was not reported, verified, or processed timely). 

A person may receive less than four months of TP 20 coverage if the change of new or increased alimony or spousal support is not reported or processed timely.

Note: If a divorce or separation agreement that includes alimony was executed or last modified after Dec. 31, 2018, alimony received is not counted in the person’s household budget.

Related Policy

Determining the First Month of TP 07 Medicaid, A-842.1
Determining the Three of Six Months Eligibility Requirement, A-842.2 
Alimony (Spousal Support) Received, A—1326.17 
Changes Decreasing Benefits, B-643 

A—851.1 Multiple Changes That Cause TP 08 Ineligibility

Revision 15-4; Effective October 1, 2015

TP 08

If two or more changes (when one is new or increased spousal support) cause the income to increase above the Federal Poverty Income Limits (FPIL) for TP 08 for the same month, and the household has not been notified that members are eligible for TP 20, advisors follow the steps below:

Step	Action
1	If all other case factors remain the same, is the household income increased to above FPIL for TP08 because of new or increased alimony/spousal support?	Yes. The household is eligible for TP 20 if members meet the other eligibility requirements. No. Go to Step 2.
2	Is the income increased to above FPIL for TP 08 as a result of a change other than new or increased alimony/spousal support?	Yes. The household is not eligible for TP 20. Go to Step 3. No. Go to Step 4.
3	Does the household meet the income limits for the Medical Program EDGs for which they are certified?	Yes. Continue current Medical Program coverage.   No. Deny the Medical Program EDG(s) for which the family member is no longer income eligible.
4	Is the income increased to above the FPIL for TP08 when all changes are considered?	Yes. The household is eligible for TP 20 if the members meet the other eligibility requirements.

Changes reported in a timely manner do not stop the denial of the TP 08 EDG and creation of the TP 20 after the household is notified of transitional Medicaid eligibility, even when both changes affect the same month.

Exceptions: The EDG is denied if the household

• moves out of Texas;
• no longer meets the household composition requirement as specified in A-841.3, Eligibility Criteria During Transitional Medicaid Coverage; or
• reports a change that makes the household ineligible before the first month of TP 20 eligibility.

Related Policy

Multiple Changes that Cause TP 08 Ineligibility, A-841.1

A—852 Eligibility Criteria During Transitional Medicaid Coverage

Revision 16-4; Effective October 1, 2016

TP 20

Certified members remain eligible for Medicaid if the household continues to:

• live in Texas; and
• receive alimony/spousal support.

The legal parent who is certified for TP 20 when the advisor receives notice that the legal parent failed to cooperate with child/medical support or TPR requirements or has been found guilty of a Medicaid intentional program violation is denied.

A—853 Automated Process

Revision 16-4; Effective October 1, 2016

TP 08

If the Office of the Attorney General (OAG) receives a new or increased alimony/spousal support collection that is greater than the TP 08 income limits, TIERS determines whether the TP 08 EDG should be denied and a TP 20 opened, or whether the TP 08 EDG should be denied. If either is appropriate, TIERS notifies the individual on Form TF0001, Notice of Case Action.

A—854 Denial of TP 20

Revision 16-4; Effective October 1, 2016

TP 20

Recipients terminated from TP 20 must be retested for eligibility for any other Medical Programs, as explained in A-2342.1, Retesting Eligibility.

A—855 Reinstatement of Denied TP 20 Coverage

Revision 16-4; Effective October 1, 2016

TP 20

Certain households whose TP 20 EDGs are denied before the end of their eligibility period has expired may have transitional Medicaid coverage reinstated. Reinstate eligible household members for the remainder of the original TP 20 Medicaid period if:

• their original transitional Medicaid end date has not expired;
• their TP 20 EDG was denied because the members moved out of Texas; and
• they:
  • do not wish to apply for other medical coverage; or
  • are not eligible for other medical coverage.

Follow procedures in A-845, Reinstatement of Denied Transitional Coverage, to reinstate TP 20 coverage.

A—856 Special Household Composition Policies for Transitional Medicaid

Revision 16-4; Effective October 1, 2016

A—856.1 Parents and Caretaker Relatives Enter or Already Live in the Home

Revision 16-4; Effective October 1, 2016

TP 20

Advisors follow the procedures below if the household requests TP 20 benefits for a caretaker, returning absent parent, stepparent, or second parent in the home.

Advisors must add the member to the case and open a new TP 20 EDG for the individual if the person is a caretaker relative or second parent who:

• was disqualified on the TP 08 or transitional EDG but has complied with the eligibility requirement for which the member was disqualified (for example, child/medical support, TPR); or
• is a returning absent parent/second parent in the home.

A—856.2 Child Enters or Already Lives in the Home

Revision 16-4; Effective October 1, 2016

TP 20

Advisors follow the procedures in the chart below:

• when the TP 20 household reports that a child who is not receiving TP 20 or TP 43, TP 44, TP 45, or TP 48 is in the home;
• when denying a TP 08 EDG and creating a TP 20 EDG; or
• upon review of another Medical Program case for a child who lives with a TP 20 recipient.

Advisors must continue an other-related child's separate Medical Program EDG.

If a child who is not receiving TP 43, TP 44, TP 45, TP 48 or TP 20 …

then …

is a newborn, moves in, or already lives in the home,

obtain the appropriate information/verifications and determine if the child meets all of the following requirements: citizenship, SSN, age, relationship, and domicile. Use information/verifications from other case records when the child is currently or has been a TANF/Medical Program or SNAP recipient. Do not consider the following criteria: deprivation, and income. If the child is eligible, then: send Form TF0001, Notice of Case Action, informing the household of the child's eligibility for TP 20; and add the child to the case and open a new TP 20 EDG for the child. If the child is not eligible or the household does not provide the information/verification, then: send Form TF0001 to the household; inform the household: their TP 20 EDG will continue; but the child cannot be added to the case, stating the reason the child cannot be added; and take no action on the case.

A—856.3 Minor Parents Certified as Children

Revision 16-4; Effective October 1, 2016

TP 20

See A-240, Medical Programs, for household composition rules.

A—857 Reapplication for TP 08

Revision 16-4; Effective October 1, 2016

TP 20

A household receiving transitional Medicaid may reapply for TP 08. If the household is eligible, the advisor must:

• deny the TP 20 EDG;
• create the applicable Medical Program EDG; and
• send Form TF0001, Notice of Case Action, to the household.

Revision 15-4; Effective October 1, 2015

Medical Programs

A TPR is a source of payment for medical expenses other than the recipient or Medicaid. TPR include payments from private and public health insurance and from other liable third parties that can be applied toward the recipient's medical expenses. Title XIX (Medicaid) funds are to be used for the payment of medical services only after all available third-party resources have been used, except for medical services from the following:

• Texas Department of Assistive and Rehabilitative Services;
• Texas Commission for the Blind;
• Texas Kidney Health Care Program;
• Muscular Dystrophy Association;
• Children with Special Health Care Needs;
• Texas Band of Kickapoo Equity Health Program;
• Maternal and Child Health (Title V);
• State Legislative Impact Assistance Grant (SLIAG);
• Crime Victims Compensation Program; and
• adoption agencies or adoptive parents with medical obligations to the recipient.

Income maintenance insurance policies not related to actual medical expenses are not third-party resources unless the policy is assignable to a hospital or other medical provider.

When an applicant has health insurance, the advisor must instruct the individual to tell medical providers about the health insurance. The provider then bills the insurance company rather than or before billing Medicaid.

Individuals must cooperate:

• in identifying and pursuing any third party who may be liable for medical support payments, including absent parents who pay cash medical support;
• in reimbursing HHSC for medical expenses paid by Medicaid from:
  • court settlements, and
  • liability, casualty, or health insurance payments, and
• with HHSC and its Health Insurance Premium Payment (HIPP) contractor by:
  • providing information about available health insurance coverage;
  • enrolling in their employer's health insurance program; and
  • providing proof of their premium payments.

Individuals who refuse to cooperate without good cause are denied.

The denied legal parent is included in the household composition.

 

A—861 Third-Party Resources (TPR) and Accidents

Revision 15-4; Effective October 1, 2015

Medical Programs

The advisor must instruct individuals to report any accident-related injuries requiring medical care or accident-related unsettled legal claims within 60 days.

 

A—861.1 Reporting the Accident to the Third-Party Resources (TPR) Unit

Revision 15-4; Effective October 1, 2015

Medical Programs

If a recipient reports an injury requiring medical treatment for which liability/casualty insurance (the individual's own or someone else's) may provide payment, the advisor must determine the details of the accident and any legal action involved and forward the information by memorandum to:

HHSC/OIG/TPR Unit
MC 1354
P.O. Box 85200
Austin,Texas78708-5200

Advisors must include in the report:

• individual-identifying information;
• the date and nature of the accident and resulting injuries;
• information regarding the liable or potentially liable third party, including the liability insurance policy number and the name and address of the insurance adjuster, if available;
• dates, types, and sources of medical services related to the injury; and
• the status or plans for any legal action, including the name and address of any attorney involved, if available.

 

A—861.2 Responding to Third-Party Resources (TPR) Unit Noncooperation Notices

Revision 15-4; Effective October 1, 2015

Medical Programs

When the TPR Unit becomes aware of a possible accident through information included on a Medicaid claim form, the TPR Unit contacts the individual to obtain information about the accident.

 

A—861.3 Third-Party Resources (TPR) Reimbursements

Revision 15-4; Effective October 1, 2015

 

A—861.3.1 Client-Initiated Reimbursements

Revision 15-4; Effective October 1, 2015

Medical Programs

When a recipient reimburses HHSC for medical expenses from a court settlement or from a liability, casualty, or health insurance payment, the reimbursement should be by personal check, cashier's check, or money order payable to the Texas Department of Health and Human Services.

Advisor action:

1. Give the individual Form H4100, Money Receipt.
2. Send the reimbursement and a copy of Form H4100 to ARTS at P.O. Box 149044, Austin, Texas 78714.
3. Enter the type(s) and date(s) of the medical service(s) in the "For" section of the form.
4. If unsure what medical services were involved, complete a memorandum giving as much information as is known concerning the reimbursement.
5. Attach a copy of any information identifying the nature of the payment, such as a statement from the insurance company, to Form H4100.

The actual claim paid by Medicaid is verified in state office, and the individual is reimbursed if the payment made is in excess of the Medicaid payment. The advisor is notified of the reimbursement. Advisors must consider the reimbursement as possible TANF and/or TP 08 income.

 

Related Policy

Lump-Sum Payments, A-1331
Reimbursements, A-1332

 

A—861.3.2 Reporting Non-Reimbursement to the Third-Party Resources (TPR) Unit

Revision 15-4; Effective October 1, 2015

Medical Programs

When an advisor becomes aware that a recipient received a reimbursement for medical expenses paid by Medicaid and failed to reimburse HHSC, the advisor reports the non-reimbursement to the TPR Unit. The advisor must include any available information about the accident and the payment in the report.

The TPR Unit investigates the claim and reports back. The advisor uses the guidelines in A-861.4, Responding to Third-Party Resources (TPR) Unit Recovery Requests, upon receipt of a memo from the TPR Unit confirming the non-reimbursement.

 

A—861.4 Responding to Third-Party Resources (TPR) Unit Recovery Requests

Revision 15-4; Effective October 1, 2015

Medical Programs

Advisors use the following chart in responding to TPR Unit recovery requests.

When the TPR Unit becomes aware that an individual received a private insurance payment and has not made any payments to the Medicaid provider, the TPR Unit sends a memo to the regional director. The memo includes the amount of:

• Medicaid paid; and
• the private insurance payment, if known.

The advisor must use the following procedures after receiving the memo:

Step	Action
1	Send Form H1020, Request for Information or Action, to the caretaker, requesting that the individual: provide verification of the amount of the private insurance payment, and contact the advisor about reimbursing HHSC. If the individual does not respond, then go to Step 2. If the individual does respond, then go to Step 3.
2	Send Form TF0001, Notice of Case Action, to initiate action to disqualify the legal parent from the certified and/or budget group. Process a referral for intentional program violation if the Medicaid payment was $100 or more. To report waste, abuse or fraud to the OIG/TPR Unit, use the online reporting form https://oig.hhsc.state.tx.us/wafrep/ or call toll-free 1-800-436-6184.
3	Collect the lesser of the: Medicaid payment, or private insurance payment. Note: If the private insurance payment is greater than the Medicaid payment, count the difference as lump-sum payments for TANF, SNAP and Medical Programs. Refer to A-1200, Resources, and A-1300, Income, for policy on how to count the payments. If the individual does not make a full payment, then go back to Step 2. If the individual makes full payment, then go to Step 4.
4	When the individual makes a payment: ensure the payment is made by personal check, cashier's check or money order payable to the Texas Department of Health and Human Services; give the individual Form H4100, Money Receipt. Annotate the form with "TPR/TMHP Insurance Recovery”; and send a copy of Form H4100 with the payment to Fiscal Division, State Office, E-411.

 

A—861.5 Remitting Cash Medical Support Payments to the Third-Party Resources (TPR) Unit

Revision 15-4; Effective October 1, 2015

Medical Programs

After certification, Medicaid recipients must remit to the TPR Unit any cash medical support payments received for a certified child. The advisor gives the individual sufficient copies of Form H1710, Payment Identification, and TPR self-addressed envelopes, if payments are being made or might be made. The advisor instructs the individual upon receipt of a cash medical support payment from an absent parent after certification of the requirement to:

• write on the check or money order "Deposit Only - State Treasury" and to not endorse the check or money order;
• include Form H1710 with the check or money order; and
• send it to the HHSC/OIG/TPR Unit, MC 1354, P.O. Box 85200, Austin, TX 78708-5200.

If the individual turns in cash medical support payments to the local office, the advisor must:

• forward the payment(s) to the HHSC/OIG/TPR Unit; and
• give the individual a copy of Form H4100, Money Receipt.

Upon becoming aware that an individual did not remit a cash medical support payment, advisors must follow policy in B-700, Claims, and process a claim for the month(s) of unreported income, if required.

Related Policy

TANF, A-1124
Medical Support Payments, A-1326.2.3

 

A—862 Third-Party Resources (TPR) Reporting System

Revision 15-4; Effective October 1, 2015

Medical Programs

The application asks applicants and individuals whether any household members have health insurance. Form H1028, Employment Verification, asks employers to verify if health insurance is available, and whether the employee is enrolled. When an individual reports a new job or a change in employers, the advisor determines whether there is any new or potential private health insurance coverage for certified household members during the eligibility interview or application processing.

If information from the individual, the employer or other source indicates ...	then report ...
Medicaid-eligible household members have private health insurance coverage,	information about the private health insurance in the Third Party Resources logical unit of work of the case the individual is a member of in TIERS.
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 in the Third Party Resources logical unit of work of the case the individual is a member of in TIERS. The TPR Unit will use the information to initiate an inquiry about HIPP Program eligibility.

To contact the TPR Unit about TPR questions or problems:

• advisors may call 1-800-846-7307.
• clients may call the Client Medicaid Hotline at 1-800-252-8263.

 

A—863 Health Insurance Premium Payment (HIPP) Program

Revision 17-1; Effective January 1, 2017

Medical Programs

The Health Insurance Premium Payment (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 that 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 their 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.

HHSC's TPR Unit refers Form H1039 to the current state Medicaid contractor, Texas Medicaid and Healthcare Partnership (TMHP). If TMHP determines it is cost-effective for Medicaid to pay the recipient's employer-sponsored health insurance premiums, then TMHP sends:

• a letter to the recipient and requests verification of the employer-sponsored insurance plan and premium payments; and
• a premium reimbursement to the recipient upon receipt of complete documentation and proof of the premium payment.

Note: Do not consider an incurred medical deduction for the reimbursed premium for individuals 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 HIPP program, see HHSC's website: http://hhs.texas.gov/services/financial/insurance/health-insurance-premium-payment-hipp, or contact the Medicaid HIPP program at MCD_HIPP_Program@hhsc.state.tx.us.

Individuals may call 800-440-0493 for more information.

Related Policy

Reimbursements, A-1332

Revision 20-2; Effective April 1, 2020

Medical Programs

Verification is required for the following:

• Spousal support to establish eligibility for TP 20
• Unpaid medical bills for three months prior coverage. Exception: Refer to A-831.2, Eligibility for Three Months Prior Coverage, for TP 40 prior coverage
• Income for each of the three months prior to coverage. Note: For Children's Medicaid, do not request more income verification for prior Medicaid coverage than what is required for ongoing eligibility. See A-1371, Verification Sources, for Children's Medicaid.
• An application was filed when reopening an application for prior month coverage according to A-831.2.1, Reopening Three Months Prior Applications
• Gross earnings and the date the person received the earnings for TP 07. Exception: If verification is not readily available, accept the person's statement unless questionable. If the household provides earnings information sufficient to determine eligibility for TP 07 but does not provide verification of the earnings, deny the TP-08 EDG and create a TP 07 EDG if the person meets the eligibility requirements in A-842, TP 07 Transitional Medicaid.
• When a household requests continuation of Medicaid for children aging out of TP 44, verify the child:
  • is hospitalized on the child's 19th birthday;
  • remains hospitalized (there is not a time limit); and
  • meets all other criteria according to policy in A-825, Medicaid Termination.
• Third-Party Resource (TPR).  Report to the TPR Unit any household member who:
  • has private medical insurance; or
  • is not enrolled in group medical coverage that is available to him.

Emergency Medicaid

Verify the emergency medical condition by using Form H3038, Emergency Medical Services Certification, or Form H3038-P, CHIP Perinatal – Emergency Medical Services Certification. These forms are the only acceptable sources that can be used to verify an emergency medical condition. A licensed practitioner must complete and sign Form H3038 or Form H3038-P.

Note: An original or a faxed copy of Form H3038 or Form H3038-P is acceptable to verify the emergency medical condition.

TP 40

See A-144.5, Pregnancy, for policy relating to verification of pregnancy.

Related Policy

Pregnancy, A-144.5
Regular Medicaid Coverage, A-820
Verification Requirements, A-1370
A Household with Members on TANF, TANF-State Program (SP), TP 07, TP 08 and TP 20, B-480
Questionable Information, C-920
Providing Verification, C-930

Revision 21-2; Effective April 1, 2021

Medical Programs

Document:

• Verification of income and unpaid medical bills for the three months prior coverage.
• Medical insurance other than Medicaid.
• Method of income computation.
• Eligibility for transitional Medicaid.
• Reason for assigning less than the maximum transitional Medicaid coverage.
• Denial of TP 20 because spousal support payments stopped.
• Reason for action on a Medicaid EDG.
• Gross earnings and the dates the person received the earnings.
• Cost of health insurance premium for the child(ren) before certifying for CHIP.
• Name and phone number of state hospital employee.

If the household requests continuation of Medicaid for children aging out of TP 44, follow policy in A-825, Medicaid Termination, and document that the child:

• is hospitalized on their 19th birthday;
• remains hospitalized through the end of their eligibility period; and
• meets all other criteria according to A-825 .

If providing prior coverage for more than three months, follow policy in A-831.2.1, Reopening Three Months Prior Applications, and document that:

• there was an application on file to cover any of the prior months; and
• the file date on the application was used to cover these months.

TP 40

Document the pregnancy verification method and the anticipated delivery date.

Related Policy
Medicaid Termination, A-825 
Reopening Three Months Prior Applications, A-831.2.1 
Third-Party Resources, A-860 
Documentation Requirements, A-950
Documentation, C-940