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N-8310 Verification Checklist and Pending Reasons
Revision 11-3; Effective September 1, 2011
The following new verification checklist and pending reasons have been created for this program. These reasons will be pre-populated by TIERS on Form H1020, Request for Information or Action.
- Send proof that you signed up for your job's health insurance.
- Send proof that shows you get health insurance through your job.
- Send proof that the child applying for Medicaid Buy-In for Children can't be on your job's health insurance plan.
- Send proof that your health insurance company changed.
- Let us know the next date you can enroll in your job's health insurance plan.
- Send proof that your job pays at least half the premium of your health insurance.
N-8320 Change Action Reasons
Revision 11-3; Effective September 1, 2011
The following new change action reasons have been created for this program. These reasons will be pre-populated by TIERS on Form TF0001-MBIC, Change in Monthly Premium Amount or Cost-Share Limit.
- You reached your cost-share limit for this benefit period.
- You did not reach your cost-share limit for this benefit period.
- Your family is making more money (income).
- Your family is making less money (income).
- The number of people in your family changed.
- You have health insurance through your job
- You don't have health insurance through your job.
- The Health Insurance Premium Payment program (HIPP) is paying for your private health insurance.
- The Health Insurance Premium Payment program (HIPP) isn't paying for your private health insurance.
N-8330 Denial Reasons
Revision 11-3; Effective September 1, 2011
In addition to existing MEPD denial codes, new denial reasons have been created for this program. These reasons and references will be pre-populated by TIERS on:
- Form TF0001-MBIC, Case Action Termination;
- Form TF0001-MBIC, Case Action Denial; and
- Form TF0001-MBIC, Prior Months Eligibility.
Section N-8331 below outlines the reasons and references.
N-8331 Denial Reasons and Reference Chart
Revision 11-3; Effective September 1, 2011
| Denial Reason | Reference |
|---|---|
| It is too late to ask for benefits for these months. | 1 TAC §361.115(g) |
| <Child's name> is married. | 1 TAC §361.107 |
| You didn't send proof that shows you get health insurance through your job. | 1 TAC §361.113 |
| You didn't send proof that shows when your job's health insurance benefits began. | 1 TAC §361.113 |
| You didn't send proof that shows your child can't be on your job's health insurance plan. | 1 TAC §361.113 |
| You didn't send proof that shows you signed up for your job's health insurance. | 1 TAC §361.113 |
| Your payment couldn't be processed. | 1 TAC §361.115(a) |
| <Child's name> is age 19 or older. | 1 TAC §361.107 |
N-8340 Redeterminations
Revision 11-3; Effective September 1, 2011
Redeterminations for MBIC follow regular Medicaid for the Elderly and People with Disabilities (MEPD) policy for redeterminations.
Streamlining methods and passive reviews are not allowed for an MBIC redetermination.
If a case has an MBIC eligibility determination group (EDG) and another ME EDG, the persons in the case will get both a Form H1200-MBIC and another Form H1200 for the redeterminations.
A TIERS MBIC redetermination packet will include:
- Form H1233-MBIC, Redetermination Cover Letter;
- Form H1200-MBIC-R, Application for Benefits – Medicaid Buy-In for Children;
- Form H1028-MBIC, Employment Verification (Medicaid Buy-In for Children);
- Form H0003, Agreement to Release Your Facts; and
- Form H5017-MBIC, Items We Need from You.
N-8350 Appeals
Revision 13-1; Effective March 1, 2013
HHSC is responsible for all appeals, including those concerning premiums and cost sharing. If premium and/or cost-sharing information is needed for an appeal, refer to the MBIC business process document.
If an individual is dissatisfied with HHSC's decision concerning his eligibility for medical assistance, he has the right to appeal through the appeal process established by HHSC. In certain circumstances, the individual is entitled to receive continued benefits or services until a hearing decision is issued. Whether an individual is entitled to continued assistance is based on requirements set forth in appropriate state or federal law or regulation of the affected program. See the Fair and Fraud Hearings Handbook.