3-2017

Click here for a list of handbooks sharing this appendix

 

When a Medicaid for the Elderly and People with Disabilities (MEPD) Texas Integrated Eligibility Redesign System (TIERS) action is needed, complete Form H1746-A, MEPD Referral Cover Sheet.

Use the following chart to determine whether or not a new Form H1200, Application for Assistance – Your Texas Benefits, must be attached to the coversheet. If a type program does not appear in this table, submit Form H1746-A and the application, if needed.

Supplemental Security Income (SSI) Adding Any HHSC Program
TIERS Type of Assistance Program Name in TIERS MEPD Action Case Worker Action
TA08 ME – SSI State Group Home No worker intervention No application needed
No Form H1746-A needed
TP12 ME – Temp Manual SSI No worker intervention No application needed
No Form H1746-A needed
TP13 ME – SSI No worker intervention No application needed
No Form H1746-A needed
TP38 ME – SSI Nursing Facility No worker intervention No application needed
No Form H1746-A needed
TP39 ME – SSI State Hospital No worker intervention No application needed
No Form H1746-A needed
TA02 ME – SSI Waivers No worker intervention No application needed
No Form H1746-A needed

 

SSI Denial to Medicaid Waiver
TIERS Type of Assistance Program Name in TIERS MEPD Action Case Worker Action
TA02 ME – SSI Waivers Add MEPD Eligibility Determination Group (EDG) Submit Form H1200
Submit Form H1746-A

 

SSI Denials to Community Attendant Services (CAS)
TIERS Type of Assistance Program Name in TIERS MEPD Action Case Worker Action
TA08 ME – SSI State Group Home Add ME – Community Attendant EDG Submit Form H1200
Submit Form H1746-A
TP12 ME – Temp Manual SSI Add ME – Community Attendant EDG Submit Form H1200
Submit Form H1746-A
TP13 ME – SSI Add ME – Community Attendant EDG Submit Form H1200
Submit Form H1746-A
TP38 ME – SSI Nursing Facility Add ME – Community Attendant EDG Submit Form H1200
Submit Form H1746-A
TP39 ME – SSI State Hospital Add ME – Community Attendant EDG Submit Form H1200
Submit Form H1746-A
TP46 ME – SSI State Supported Living Center Add ME – Community Attendant EDG Submit Form H1200
Submit Form H1746-A
TA02 ME – SSI Waivers Add ME – Community Attendant EDG Submit Form H1200
Submit Form H1746-A

 

SSI Denials to State Supported Living Center
TIERS Type of Assistance Program Name in TIERS MEPD Action Case Worker Action
TA08 ME – SSI State Group Home Add ME – State Supported Living Center EDG Submit Form H1200-PFS, Medicaid Application for Assistance (for Residents of State Facilities) Property and Financial Statement
Submit Form H1746-A and Form H0090-I, Notice of Admission, Departure, Readmission or Death of an Applicant/Recipient of Supplemental Security Income and/or Assistance Only in a State Institution
TP12 ME – Temporary Manual SSI Add ME – State Supported Living Center EDG Submit Form H1200-PFS, Medicaid Application for Assistance (for Residents of State Facilities) Property and Financial Statement
Submit Form H1746-A and Form H0090-I, Notice of Admission, Departure, Readmission or Death of an Applicant/Recipient of Supplemental Security Income and/or Assistance Only in a State Institution
TP13 ME – SSI Add ME – State Supported Living Center EDG Submit Form H1200-PFS, Medicaid Application for Assistance (for Residents of State Facilities) Property and Financial Statement
Submit Form H1746-A and Form H0090-I, Notice of Admission, Departure, Readmission or Death of an Applicant/Recipient of Supplemental Security Income and/or Assistance Only in a State Institution
TP38 ME – SSI Nursing Facility Add ME – State Supported Living Center EDG Submit Form H1200-PFS, Medicaid Application for Assistance (for Residents of State Facilities) Property and Financial Statement
Submit Form H1746-A and Form H0090-I, Notice of Admission, Departure, Readmission or Death of an Applicant/Recipient of Supplemental Security Income and/or Assistance Only in a State Institution
TP39 ME – SSI State Hospital Add ME – State Supported Living Center EDG Submit Form H1200-PFS, Medicaid Application for Assistance (for Residents of State Facilities) Property and Financial Statement
Submit Form H1746-A and Form H0090-I, Notice of Admission, Departure, Readmission or Death of an Applicant/Recipient of Supplemental Security Income and/or Assistance Only in a State Institution
TA02 ME – SSI Waivers Add ME – State Supported Living Center EDG Submit Form H1200-PFS, Medicaid Application for Assistance (for Residents of State Facilities) Property and Financial Statement
Submit Form H1746-A and Form H0090-I, Notice of Admission, Departure, Readmission or Death of an Applicant/Recipient of Supplemental Security Income and/or Assistance Only in a State Institution

 

Qualified Medicare Beneficiaries (QMB)/Specified Low-Income Medicare Beneficiaries (SLMB) to CAS
TIERS Type of Assistance Program Name in TIERS MEPD Action Case Worker Action
TP23 MC – SLMB Add MEPD – Community Attendant EDG No application needed
Submit Form H1746-A
TP24 MC – QMB Add MEPD – Community Attendant EDG No application needed
Submit Form H1746-A

 

QMB/SLMB to Waiver
TIERS Type of Assistance Program Name in TIERS MEPD Action Case Worker Action
TP23 MC – SLMB Add MEPD EDG
Explore the impact of transfer of assets, home equity and spousal impoverishment
Submit Form H1200
Submit Form H1746-A
TP24 MC – QMB Add MEPD EDG
Explore the impact of transfer of assets, home equity and spousal impoverishment
Submit Form H1200
Submit Form H1746-A

 

QMB/SLMB to State Supported Living Center
TIERS Type of Assistance Program Name in TIERS MEPD Action Case Worker Action
TP23 MC – SLMB Add MEPD – State Supported Living Center EDG
Explore the impact of transfer of assets, home equity and spousal impoverishment
Submit Form H1200-PFS
Submit Form H1746-A and Form H0090-I
TP24 MC – QMB Add MEPD – State Supported Living Center EDG
Explore the impact of transfer of assets, home equity and spousal impoverishment
Submit Form H1200-PFS
Submit Form H1746-A and Form H0090-I

 

Qualifying Individuals (QI-1) to CAS
TIERS Type of Assistance Program Name in TIERS MEPD Action Case Worker Action
TP26 MC – QI-1 Add MEPD – Community Attendant EDG and end MC- QI-1 EDG No application needed
Submit Form H1746-A
Include a statement that the individual is willing to give up QI-1 to obtain CAS

 

QI-1 to Waiver
TIERS Type of Assistance Program Name in TIERS MEPD Action Case Worker Action
TP26 MC – QI-1 Add MEPD EDG and end MC-QI-1 EDG
Explore the impact of transfer of assets, home equity and spousal impoverishment
Submit Form H1200
Submit Form H1746-A
Include a statement that the individual is willing to give up QI-1 to obtain waiver

 

CAS to Waiver
TIERS Type of Assistance Program Name in TIERS MEPD Action Case Worker Action
TP14 ME – Community Attendant Add MEPD EDG and end MEPD – Community Attendant EDG
Determine the impact of any transfer of assets and impact of home equity and spousal impoverishment on waiver eligibility
Submit Form H1200
Submit Form H1746-A

 

Nursing Facility to Waiver
TIERS Type of Assistance Program Name in TIERS MEPD Action Case Worker Action
TP17 ME – Nursing Facility End MEPD – Nursing Facility EDG and add MEPD EDG
Determine the impact of any transfer of assets and impact of home equity on waiver eligibility
No application needed
Submit Form H1746-A
TP41 ME – Skilled Nursing Care End MEPD – Nursing Facility EDG and add MEPD EDG
Determine the impact of any transfer of assets and impact of home equity on waiver eligibility
No application needed
Submit Form H1746-A

 

Intermediate Care Facility for Individuals with an Intellectual Disability or Related Condition (ICF/IID) to Waiver
TIERS Type of Assistance Program Name in TIERS MEPD Action Case Worker Action
TA12 ME – State Group Home End appropriate ICF/IID EDG and add ME EDG Determine the impact of any transfer of assets and impact of home equity on waiver eligibility. No application needed
Submit Form H1746-A
TA26 ME – SSI Non-State Group Home End appropriate ICF/IID EDG and add ME EDG Determine the impact of any transfer of assets and impact of home equity on waiver eligibility. No application needed
Submit Form H1746-A
TP10 ME – State Supported Living Center End appropriate ICF/IID EDG and add ME EDG Determine the impact of any transfer of assets and impact of home equity on waiver eligibility. No application needed
Submit Form H1746-A
TP15 ME – Non-State Group Home End appropriate ICF/IID EDG and add ME EDG Determine the impact of any transfer of assets and impact of home equity on waiver eligibility. No application needed
Submit Form H1746-A
TP16 ME – State Hospital End appropriate ICF/IID EDG and add ME EDG
Determine the impact of any transfer of assets and impact of home equity on waiver eligibility.
No application needed
Submit Form H1746-A

 

ICF/IID to State Supported Living Center
TIERS Type of Assistance Program Name in TIERS MEPD Action Case Worker Action
TA12 ME – State Group Home End appropriate ICF/IID EDG and add ME – State Supported Living Center EDG No application needed
Submit Form H1746-A and Form H0090-I
TA26 ME – SSI Non-State Group Home End appropriate ICF/IID EDG and add ME – State Supported Living Center EDG No application needed
Submit Form H1746-A and Form H0090-I
TP10 ME – State Supported Living Center End appropriate ICF/IID EDG and add ME – State Supported Living Center EDG No application needed
Submit Form H1746-A and Form H0090-I
TP15 ME – Non-State Group Home End appropriate ICF/IID EDG and add ME – State Supported Living Center EDG No application needed
Submit Form H1746-A and Form H0090-I
TP16 ME – State Hospital End appropriate ICF/IID EDG and add ME – State Supported Living Center EDG No application needed
Submit Form H1746-A and Form H0090-I

 

Community Medical Assistance Only (MAO) to Waiver
TIERS Type of Assistance Program Name in TIERS MEPD Action Case Worker Action
TA10 ME – Waivers No change to EDG No application needed
No Form H1746-A needed
TA18 ME – Grandfathered LTC No change to EDG No application needed
No Form H1746-A needed
TP03 ME – Pickle No change to EDG No application needed
No Form H1746-A needed
TP18 ME – Disabled Adult Child No change to EDG No application needed
No Form H1746-A needed
TP21 ME – Disabled Widow(er) No change to EDG No application needed
No Form H1746-A needed
TP22 ME – Early Aged Widow(er) No change to EDG No application needed
No Form H1746-A needed
TP87 ME – Medicaid Buy In (MBI) No change to EDG No application needed
No Form H1746-A needed

 

Community MAO to State Supported Living Center
TIERS Type of Assistance Program Name in TIERS MEPD Action Case Worker Action
TA10 ME – Waivers End ME EDG and add ME – State Supported Living Center EDG
Explore the impact of transfer of assets, home equity and spousal impoverishment
Submit Form H1200-PFS
Submit Form H1746-A and Form H0090-I
TA18 ME – Grandfathered LTC End ME EDG and add ME – State Supported Living Center EDG
Explore the impact of transfer of assets, home equity and spousal impoverishment
Submit Form H1200-PFS
Submit Form H1746-A and Form H0090-I
TP03 ME – Pickle End ME EDG and add ME – State Supported Living Center EDG
Explore the impact of transfer of assets, home equity and spousal impoverishment
Submit Form H1200-PFS
Submit Form H1746-A and Form H0090-I
TP14 ME – Community Attendant End ME EDG and add ME – State Supported Living Center EDG
Explore the impact of transfer of assets, home equity and spousal impoverishment
Submit Form H1200-PFS
Submit Form H1746-A and Form H0090-I
TP18 ME – Disabled Adult Child End ME EDG and add ME – State Supported Living Center EDG
Explore the impact of transfer of assets, home equity and spousal impoverishment
Submit Form H1200-PFS
Submit Form H1746-A and Form H0090-I
TP21 ME – Disabled Widow(er) End ME EDG and add ME – State Supported Living Center EDG
Explore the impact of transfer of assets, home equity and spousal impoverishment
Submit Form H1200-PFS
Submit Form H1746-A and Form H0090-I
TP22 ME – Early Aged Widow(er) End ME EDG and add ME – State Supported Living Center EDG
Explore the impact of transfer of assets, home equity and spousal impoverishment
Submit Form H1200-PFS
Submit Form H1746-A and Form H0090-I
TP87 ME – Medicaid Buy-In End ME EDG and add ME – State Supported Living Center EDG
Explore the impact of transfer of assets, home equity and spousal impoverishment
Submit Form H1200-PFS
Submit Form H1746-A and Form H0090-I

 

Texas Works-Related Medicaid to Waiver
TIERS Type of Assistance Program Name in TIERS MEPD Action Case Worker Action
TA31 MA – Parents and Caretaker Relatives – Emergency No change to EDG. No application or Form H1746-A needed
TP02 MA – Refugee Medical Assistance (RMA) No change to EDG. No application or Form H1746-A needed
TP07 MA – Earnings Transitional No change to EDG. No application or Form H1746-A needed
TP08 MA – Parents and Caretaker Relatives No change to EDG. No application or Form H1746-A needed
TP20 MA – Spousal Support Transitional No change to EDG. No application or Form H1746-A needed
TP40 MA – Pregnant Women No change to EDG. No application or Form H1746-A needed
TP43 MA – Children Under One Year No change to EDG. No application or Form H1746-A needed
TP44 MA – Children Six to 18 Years No change to EDG. No application or Form H1746-A needed
TP45 MA – Newborn Children No change to EDG. No application or Form H1746-A needed
TP48 MA – Children One to Five Years No change to EDG. No application or Form H1746-A needed
TP70 Medicaid for the Transitioning Foster Care Youth (MTFCY) No change to EDG. No application or Form H1746-A needed
TP92 Adoption Assistance - Federal Match - With Cash No change to EDG. No application or Form H1746-A needed
TP93 Foster Care - Federal Match - No Cash No change to EDG. No application or Form H1746-A needed
TP94 Foster Care - Federal Match - With Cash No change to EDG. No application or Form H1746-A needed
TP95 Adoption Assistance - No Federal Assistance - No Cash No change to EDG. No application or Form H1746-A needed
TP96 Adoption Assistance - No Federal Assistance - With Cash No change to EDG. No application or Form H1746-A needed
TP97 Foster Care - No Federal Match - With Cash No change to EDG. No application or Form H1746-A needed
TP98 Foster Care - No Federal Match - With Cash No change to EDG. No application or Form H1746-A needed
TP99 MA - Non-AFDC Foster Care No change to EDG. No application or Form H1746-A needed

 

CAS to QI-1
TIERS Type of Assistance Program Name in TIERS MEPD Action Case Worker Action
TP14 ME – Community Attendant End MEPD – Community Attendant EDG and add MC -QI-1 EDG No application needed
Submit Form H1746-A
Include a statement that the individual is willing to give up CAS to obtain QI-1

 

Waiver to QI-1
TIERS Type of Assistance Program Name in TIERS MEPD Action Case Worker Action
TA10 ME –  Waivers End MEPD – Waiver EDG and add MC – QI-1 EDG No application needed
Submit Form H1746-A
Include a statement that the individual is willing to give up waiver to obtain QI-1

 

Waiver to CAS
TIERS Type of Assistance Program Name in TIERS MEPD Action Case Worker Action
TA10 ME – Waivers End MEPD – Waiver EDG and add MEPD – Community Attendant EDG No application needed
Submit Form H1746-A

 

Waiver to Nursing Facility
TIERS Type of Assistance Program Name in TIERS MEPD Action Case Worker Action
TA10 ME – Waivers End MEPD – Waiver EDG and add MEPD – Nursing Facility EDG No application needed
No Form H1746-A needed

 

Waiver to ICF/IID
TIERS Type of Assistance Program Name in TIERS MEPD Action Case Worker Action
TA10 ME – Waivers End MEPD – Waiver EDG and add MEPD EDG for the ICF/IID No application needed
No Form H1746-A needed

 

Waiver to State Supported Living Center
TIERS Type of Assistance Program Name in TIERS MEPD Action Case Worker Action
TA10 ME – Waivers End MEPD – Waiver EDG and add MEPD – State Supported Living Center EDG No application needed
Submit Form H1746-A and Form H0090-I

 

Medicaid Buy-In for Children to Waiver
TIERS Type of Assistance Program Name in TIERS MEPD Action Case Worker Action
TP88 ME – Medicaid Buy-In for Children End MEPD-Medicaid Buy-In for Children EDG and add MEPD EDG
Explore the impact of transfer of assets, home equity and spousal impoverishment
Submit Form H1200
Submit Form H1746-A

 

Medicaid Buy-In to State Supported Living Center
TIERS Type of Assistance Program Name in TIERS MEPD Action Case Worker Action
TP87 ME – Medicaid Buy-In End MEPD EDG and add MEPD – State Supported Living Center EDG
Explore the impact of transfer of assets, home equity and spousal impoverishment
Submit Form H1200-PFS
Submit Form H1746-A and Form H0090-I
TP88 ME – Medicaid Buy-In for Children End MEPD EDG and add MEPD – State Supported Living Center EDG
Explore the impact of transfer of assets, home equity and spousal impoverishment
Submit Form H1200-PFS
Submit Form H1746-A and Form H0090-I

 

Texas Women's Health Program to Waiver
TIERS Type of Assistance Program Name in TIERS MEPD Action Case Worker Action
TP41 Health Care – Texas Women's Health Program (TWHP) Add MEPD EDG
Coordinate efforts with Texas Works
Do not discuss the TWHP with anyone other than the certified TWHP member.
Submit Form H1200
Submit Form H1746-A
Do not discuss the TWHP with anyone other than the certified TWHP member.

 

Texas Women's Health Program to CAS
TIERS Type of Assistance Program Name in TIERS MEPD Action Case Worker Action
TP41 Health Care – Texas Women's Health Program (TWHP) Add MEPD EDG
Do not discuss the TWHP with anyone other than the certified TWHP member.
Submit Form H1200
Submit Form H1746-A
Do not discuss the TWHP with anyone other than the certified TWHP member.

 

One Type Waiver to Another Type Waiver
TIERS Type of Assistance Program Name in TIERS MEPD Action Case Worker Action
TA10 ME – Waivers Update Long-term Services and Supports Summary Screen and Medicaid Waivers/Community Attendant Screen No application needed
Submit Form H1746-A

 

Foster Care to State Supported Living Center
TIERS Type of Assistance Program Name in TIERS MEPD Action Case Worker Action
TP52 MA – State Foster Care – A Coordinate efforts with the Texas Department of Family and Protective Services (DFPS) Submit Form H1200-PFS
Submit Form H1746-A
TP53 MA – State Foster Care – B Coordinate efforts with the Texas Department of Family and Protective Services (DFPS) Submit Form H1200-PFS
Submit Form H1746-A
TP54 MA – State Foster Care – 32 Coordinate efforts with the Texas Department of Family and Protective Services (DFPS) Submit Form H1200-PFS
Submit Form H1746-A
TP57 MA – State Foster Care – D Coordinate efforts with the Texas Department of Family and Protective Services (DFPS) Submit Form H1200-PFS
Submit Form H1746-A
TP58 MA – State Foster Care – JPC Coordinate efforts with the Texas Department of Family and Protective Services (DFPS) Submit Form H1200-PFS
Submit Form H1746-A
TP88 MA – Non-AFDC Foster Care – JPC Coordinate efforts with the Texas Department of Family and Protective Services (DFPS) Submit Form H1200-PFS
Submit Form H1746-A
TP90 MA – State Foster Care Coordinate efforts with the Texas Department of Family and Protective Services (DFPS) Submit Form H1200-PFS
Submit Form H1746-A
TP93 Foster Care – Federal Match – No Cash Coordinate efforts with the Texas Department of Family and Protective Services (DFPS) Submit Form H1200-PFS
Submit Form H1746-A
TP94 Foster Care – Federal Match – With Cash Coordinate efforts with the Texas Department of Family and Protective Services (DFPS) Submit Form H1200-PFS
Submit Form H1746-A
TP97 Foster Care – No Federal Match – No Cash Coordinate efforts with the Texas Department of Family and Protective Services (DFPS) Submit Form H1200-PFS
Submit Form H1746-A
TP98 Foster Care – No Federal Match – With Cash Coordinate efforts with the Texas Department of Family and Protective Services (DFPS) Submit Form H1200-PFS
Submit Form H1746-A
TP99 MA – Non-AFDC Foster Care Coordinate efforts with the Texas Department of Family and Protective Services (DFPS) Submit Form H1200-PFS
Submit Form H1746-A

 

Adoption Assistance to State Supported Living Center
TIERS Type of Assistance Program Name in TIERS MEPD Action Case Worker Action
TP91 Adoption Assistance – Federal Match – No Cash Coordinate efforts with DFPS Submit Form H1200-PFS
Submit Form H1746-A and Form H0090-I
TP92 Adoption Assistance -Federal Match – With Cash Coordinate efforts with DFPS Submit Form H1200-PFS
Submit Form H1746-A and Form H0090-I
TP95 Adoption Assistance – No Federal Assistance – No Cash Coordinate efforts with DFPS Submit Form H1200-PFS
Submit Form H1746-A and Form H0090-I
TP96 Adoption Assistance – No Federal Assistance – With Cash Coordinate efforts with DFPS Submit Form H1200-PFS
Submit Form H1746-A and Form H0090-I

 

Shared Appendix 20

This appendix appears in the following handbooks:

Case Worker Community Care for Aged and Disabled Handbook (CW-CCAD): Appendix XXXII
STAR Kids Program Support Unit Operational Procedures Handbook (SKOPH): Appendix XVI
STAR+PLUS Program Support Unit Operational Procedures Handbook (SPOPH): Appendix V