Revision 19-4; Effective September 9, 2019

 

15100 Research Preventing Dual Enrollment

Revision 19-4; Effective September 9, 2019

 

The local intellectual and developmental disability authority (LIDDA) must determine if a person is already enrolled in another waiver program. A person cannot be enrolled in more than one waiver at a time, as determined by Texas Health and Human Services Commission (HHSC) and Appendix I, Mutually Exclusive Services. The LIDDA will:

  • access the Service Authorization System Online (SASO) to determine if the person is currently enrolled in an HHSC program or a Medicaid waiver.
    • Enter the person’s Medicaid number or Social Security number;
    • Click “Service Authorizations” on the left side of the screen;
    • Look for the number indicated under “Group”;
    • The service dates for each program are listed under beginning and end date;
    • Identify the active services;
    • Look for the service group code number; and
    • Using the chart below, determine if the person is enrolled in an HHSC Program or Medicaid Waiver.
       
      Service Group Description
      1 Nursing Facility
      2 CLASS
      4 SSLC
      5 ICF/IID-State Operated
      6 ICF/IID Non-State Operated
      7 CCAD
      8 Hospice
      9 LTC
      10 Swing Bed
      11 PACE
      12 HCS
      13 HCS-O
      14 LIDDA TCM
      15 TxHmL
      16 DBMD
      18 MDCP
      19 STAR+PLUS Waiver
  • check Appendix I to determine if the HHSC program is mutually exclusive to the waiver program being offered.
  • inform the person or legally authorized representative (LAR) of the requirement to choose either program that the person is currently enrolled in or the program that the LIDDA is offering.
  • discuss and compare the services with the person and LAR, using the Long Term Services & Supports document.
  • coordinate with the person’s current case manager or service coordinator to coordinate termination and enrollment to avoid gaps in services, if the person accepts the offer for Home and Community-based Services (HCS) or Texas Home Living (TxHmL) and the person is currently enrolled in a mutually exclusive program.

 

15200 Persons Enrolled in STAR+PLUS Waiver (SPW)

Revision 19-4; Effective September 9, 2019

 

If a person is enrolled in the SPW program (service group 19) and chooses to enroll in Home and Community-based Services (HCS) or Texas Home Living (TxHmL), the local intellectual and developmental disability authority (LIDDA) will:

  • inform the person and legally authorized representative (LAR) that disenrollment from SPW is required to enroll in HCS or TxHmL.
  • ensure the person's Individual Plan of Care (IPC) begin date is on the first day of the month.   
  • complete data entry of all HCS or TxHmL enrollment screens in the Client Assignment and Registration (CARE) System no later than the 20th day of the month preceding the enrollment date to enable disenrollment from SPW prior to the last day of the month. This will ensure there is no break or overlap in services to the person.
    Note: If CARE data entry is not completed by the 20th day, the LIDDA must change the "service begin date" so the person's enrollment in SPW will continue for one more month.
  • contact the managed care organization (MCO) service coordinator to coordinate the transition from SPW to HCS or TxHmL. Health and Human Services Commission (HHSC) Intellectual or Developmental Disability (IDD) Program Eligibility and Support (IDD-PES), Eligibility Verification and Program Support Unit (EVPS) staff will communicate with HHSC Health Plan Operations (HPO) staff to request the SPW disenrollment.
  • for delayed enrollments, or if the person or LAR has changed their mind about enrolling in HCS/TxHmL, the LIDDA must contact HHSC IDD-PES/EVPS immediately to coordinate with HHSC HPO staff.

 

15300 Determine if the Person is a Medicare Beneficiary    

Revision 19-4; Effective September 9, 2019

 

The US Government site for Medicare is Medicare.gov.

The local intellectual and developmental disability authority (LIDDA) will:

  • check to see if a person is a Medicare recipient and:
    • verify that the person is enrolled in a Medicare-sponsored prescription drug plan; and
    • assist the person in applying for extra help using the SSA-1020 form.
      Note: The person must enroll in a Medicare drug plan to receive prescription medications.
  • inform the person that upon enrollment in a waiver or an intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID) program, he or she will be auto-enrolled into a Medicaid drug plan, which may or may not be the drug plan that is most beneficial. Medicaid will pay for a limited list of drugs that Medicare will not.
  • inform the person that if they are enrolling in Home and Community-based Services (HCS), the program provider can assist them with changing drug plans and filing an exception, appeal or grievance with the drug plan.
  • inform the person that if they are enrolling in Texas Home Living (TxHmL), the LIDDA service coordinator can assist them with changing drug plans and filing an exception, appeal or grievance with the drug plan.

 

15400 Financial Eligibility

Revision 19-4; Effective September 9, 2019

 

Texas Health and Human Services Commission (HHSC) requires all persons to meet financial eligibility for enrollment in the Home and Community-based Services (HCS) and Texas Home Living (TxHmL) waiver program. After enrollment, financial eligibility must be maintained for the person to continue participation in the program. Persons eligible for certain types of Medicaid coverage are financially eligible for the program; however, not all types of Medicaid coverage ensure eligibility.

 

15410 Financial Eligibility at Pre-Enrollment

Revision 19-4; Effective September 9, 2019

 

The local intellectual and developmental disability authority (LIDDA) checks the Client Assignment and Registration (CARE) System screen C63, Medicaid Eligibility Search. The screen displays the Medicaid eligibility information for a person as it appears in the Texas Integrated Eligibility Redesign System (TIERS).

Note: The LIDDA must enter the person’s Social Security number and Medicaid number exactly as they appear in the C63 screen later during enrollment when entering CARE screen L09, Register Client Update.

If a person does not currently have Medicaid, or the type of Medicaid the person has is not acceptable for Home and Community-based Services (HCS) or Texas Home Living (TxHmL) enrollment, the LIDDA must determine whether the person should apply for Supplemental Security Income (SSI) benefits through the Social Security Administration (SSA) or apply for Medicaid through Texas Health and Human Services Commission (HHSC).  

Note: There are monthly income limits that can affect Medicaid eligibility.

If the person’s monthly income does not exceed the Medicaid income limit, the LIDDA should assist the person with completing an application for SSI benefits through the SSA. If a person is determined eligible for SSI benefits, the person is categorically eligible for SSI Medicaid, which is acceptable for HCS and TxHmL.

If the person’s monthly income exceeds the Medicaid income limit, the LIDDA should assist the person in completing an application for Medicaid through HHSC. The LIDDA must complete Form H1746-A, MEPD Referral Cover Sheet, and fax it, along with Form H1200, Application for Assistance – Your Texas Benefits, to the HHS Document Processing Center at 877-236-4123.

If Form 8578, Intellectual Disability/Related Condition Assessment, and Form 3608, Individual Plan of Care (IPC) – HCS/CFC, (for HCS), or Form 8582, Individual Plan of Care – TxHmL/CFC, (for TxHmL), have been completed, the LIDDA should include a copy of these forms with the application. If Form 8578, Form 3608 (for HCS), and Form 8582 (for TxHmL) have not been completed, proceed with submitting Form H1200 and Form H1746-A. Form 8578, Form 3608 and Form 8582 can be submitted later. Do not wait for these forms to be completed before submitting Form H1200.

If the person or legally authorized representative (LAR) prefers to submit Form H1200 himself or herself, the LIDDA must still complete Form H1746-A. After the person or LAR submits Form H1200, the LIDDA submits the completed Form H1746-A with a note in the comments section stating that Form H1200 was submitted separately.

Do not submit both an SSI application and a Medicaid application. HHSC Medicaid for the Elderly and People with Disabilities (MEPD) will not process a Medicaid application for the person if the SSA is processing an application for SSI.

Note: The process outlined above does not apply to persons leaving an intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID), state hospital or state supported living center (SSLC) to enroll in the HCS Waiver.

 

15420 Persons Leaving an ICF/IID, State Hospital or SSLC to Enroll in HCS

Revision 19-4; Effective September 9, 2019

 

When a person is discharged from an intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID), state hospital or state supported living center (SSLC) to enroll in Home and Community-based Services (HCS), a Texas Health and Human Services Commission (HHSC) Program Enrollment advisor submits a request for a Medicaid “program transfer” to HHSC Medicaid for Elderly and People with Disabilities (MEPD). [Example: D14 to R14 or I14 to R14.]

Note: The Program Enrollment advisor cannot request a “program transfer” until all of the HCS Client Assignment and Registration (CARE) System enrollment screens (L01, Consumer Enrollment; L23, IDRC Assessment; L02, Individual Plan of Care; L03, Enrollment Packet Checklist; L09, Register Client Update; and L05, Provider Choice) have been entered in CARE by the local intellectual and developmental disability authority (LIDDA). Also, a program transfer request cannot be submitted to HHSC prior to the HCS enrollment date.

For persons receiving Supplemental Security Income (SSI) benefits, CARE screen C63, Medicaid Eligibility Search, will show the person’s Medicaid coverage code and program type as D13 or I13. The representative payee must contact the Social Security Administration (SSA) to notify it of the person’s discharge from the facility and provide a current address for the person before the Program Enrollment advisor can request the program transfer to R13 for HCS enrollment. If the program transfer is not completed timely, the person may be denied SSI Medicaid and must reapply.

For persons being discharged from an ICF/IID, state hospital, or SSLC who have lost Medicaid eligibility, or do not have an acceptable type of Medicaid for HCS enrollment, the LIDDA must determine whether the person should apply for SSI benefits through the SSA or apply for Medicaid through HHSC.

Note: There are monthly income limits that can affect Medicaid eligibility.

If the person’s monthly income does not exceed the Medicaid income limit, the LIDDA should assist the person with completing an application for SSI benefits through the SSA. If a person is determined eligible for SSI benefits, the person is categorically eligible for SSI Medicaid, which is acceptable for HCS and Texas Home Living (TxHmL).

If the person’s monthly income exceeds the Medicaid income limit, the LIDDA should assist the person with completing an application for Medicaid through HHSC. The LIDDA must complete Form H1746-A, MEPD Referral Cover Sheet, and fax it, along with Form H1200, Application for Assistance – Your Texas Benefits, to the HHS Document Processing Center at 877-236-4123.

If Form 8578, Intellectual Disability/Related Condition Assessment, and Form 3608, Individual Plan of Care (IPC) – HCS/CFC, (for HCS), or Form 8582, Individual Plan of Care – TxHmL/CFC, (for TxHmL), have been completed, the LIDDA should include a copy of these forms with the application. If Form 8578, Form 3608 (for HCS), and Form 8582 (for TxHmL) have not been completed, proceed with submitting Form H1200 and Form H1746-A. Form 8578, Form 3608 and Form 8582 can be submitted later. Do not wait for these forms to be completed before submitting Form H1200.

If the person or legally authorized representative (LAR) prefers to submit Form H1200 himself or herself, the LIDDA must still complete Form H1746-A. After the person or LAR submits Form H1200, the LIDDA submits the completed Form H1746-A with a note in the comments section stating that Form H1200 was submitted separately.

Do not submit both an SSI application and a Medicaid application. HHSC MEPD will not process a Medicaid application for the person if the SSA is processing an application for SSI.

 

15500 Chart of Acceptable Types of Medicaid for HCS and TxHmL

Revision 19-4; Effective September 9, 2019

 

The following chart indicates the acceptable Medicaid coverage code and type program to enroll in Home and Community-based Services (HCS) and Texas Home Living (TxHmL). If a person does not have the proper Medicaid, the local intellectual and developmental disability authority (LIDDA) must determine if the person needs to apply for Supplemental Security Income (SSI) through the Social Security Administration (SSA) or Medicaid.

Note: Q24 and B23 are not applicable for HCS or TxHmL enrollment.

Required Medicaid Codes and Type Program
Coverage Code Type Program HCS TxHmL Coverage Code Type Program HCS TxHmL
R or P 01 Yes Yes R or P 21 Yes Yes
R or P 02 Yes Yes R or P 22 Yes Yes
R or P 03 Yes Yes R or P 29 Yes Yes
R or P 07 Yes No R or P 37 Yes No
R or P 08 Yes Yes R or P 40 Yes Yes
R or P 09 Yes Yes R or P 43 Yes Yes
R or P 10 Yes Yes R or P 44 Yes Yes
R or P 11 Yes Yes R or P 45 Yes Yes
R or P 12 Yes Yes R or P 47 Yes Yes
R or P 13 Yes Yes R or P 48 Yes Yes
R or P 14 Yes No R or P 51 Yes No
R or P 15 Yes Yes R or P 55 Yes Yes
R or P 18 Yes Yes R or P 61 Yes Yes
R or P 19 Yes Yes R or P 82 Yes Yes
R or P 20 Yes Yes R or P 87 Yes Yes

 

15600 Appointment of an Authorized Representative

Revision 19-4; Effective September 9, 2019

 

A person may allow someone else to be his or her authorized representative and help with the benefits case at Texas Health and Human Services Commission (HHSC). The person can complete Form H1003, Appointment of an Authorized Representative, and designate an authorized representative for a specific period of time. The person may only have one other person acting on his or her behalf as an authorized representative.

Form H1003 is submitted to HHSC by using Form H1746-A, MEPD Referral Cover Sheet. Complete Form H1746-A and check the “Supporting Documents” box under the section titled “Action.” Fax Form H1746-A and Form H1003 together. HHSC will add the authorized representative information to the person’s case information.

 

15700 Medicaid Forms

Revision 19-4; Effective September 9, 2019

 

 

 

15710 Form H1746-A, MEPD Referral Cover Sheet

Revision 19-4; Effective September 9, 2019

 

Form H1746-A, MEPD Referral Cover Sheet, is completed by the local intellectual and developmental disability authority (LIDDA) to share case information and supporting documentation with MEPD staff.

Form H1746-A is a “smart form” (an electronic form with capabilities beyond a traditional paper form). Do not photocopy this form. You may print the form in bulk from a personal computer.

If Form H1746-A is not included with Form H1200, Application for Assistance – Your Texas Benefits, Form H1200, the MEPD worker may not know that the application should be tested for Medicaid Waivers. This may result in denial of Medicaid for some persons. When Form H1200 is submitted for a person, Form H1746-A must be included. The form should be the first document in the packet.

Form H1746-A and Form H1200 should be faxed to the Document Processing Center at 1-877-236-4123. If mailing, send to Document Processing Center, P.O. Box 149024, Austin, TX 78714-9968.

Note: Medicaid for the Elderly and People with Disabilities (MEPD) staff may not reject Form H1746-A and Form H1200 if the forms are submitted by LIDDAs. MEPD staff must accept Form H1746-A and Form H1200 as if both were received from a local HHSC office.

 

15720 Completing Sections on Form H1746-A, MEPD Referral Cover Sheet

Revision 19-4; Effective September 9, 2019

 

Applicant/Person Information

  • The Texas Integrated Eligibility System (TIERS) number does not have to be filled in if the local intellectual and developmental authority (LIDDA) is submitting Form H1746-A, MEPD Referral Cover Sheet. Leave this field blank if you do not know the TIERS case number. Do not enter the person’s Social Security number or Medicaid number in this field.
  • The Individual Number is the same as the Medicaid Number.
  • Always fill in the ZIP Code, County, Social Security Number, Individual Number, Individual Last Name, Individual First Name and Date of Birth. It is important that this information be completed on the form.

Action

  • For pending enrollments, the LIDDA should mark “Application.”
  • When requesting coverage for a gap, the LIDDA should mark “Redetermination.”
  • Be sure to review the instructions for Form H1746-A for details on using the other action statuses.

Program

  • The LIDDA should select either Home and Community-based Services (HCS) or Texas Home Living (TxHmL). If TxHmL is selected, additional comments are required.

Information for MEPD Worker

  • Leave this section blank.

Sender

  • Select “MRA.”
  • Always complete the Date, From, Telephone, City, County and Fax information, as this is the LIDDA representative MEPD staff will contact should they have any questions or require additional information/documentation.

Additional Comments

  • If the person or legally authorized representative (LAR) submitted the application to Texas Health and Human Services Commission (HHSC) separately, the LIDDA should indicate this. Example: “Person submitted Form H1200 separate from this form.” HHSC will link Form H1200, Application for Assistance – Your Texas Benefits, with Form H1746-A.  
  • Enter a statement in this section that includes:
    • the name of the waiver program (HCS or TxHmL);
    • the date the service will begin, as identified on Form 3608, Individual Plan of Care (IPC) – HCS/CFC, (for HCS), or Form 8582, Individual Plan of Care – TxHmL/CFC, (for TxHmL) begin date;
    • the person’s current address; the name of the person’s guardian (if applicable);
    • the name and contact information of the person’s waiver program provider; and
    • an email address for the LIDDA’s representative.
  • If the program is TxHmL, write “Please test for all Retirement Survivor and Disability Insurance (RSDI) Exclusion Programs.”

Submission of Forms

  • Form H1746-A should always be on top when faxing or mailing the application packet.
  • The LIDDA should include a copy of Form 8578, Intellectual Disability/Related Condition Assessment, and Form 3608 (for HCS), or Form 8582 (for TxHmL), with each application. This will help avoid delays in processing the application. However, do not wait for Form 8578, Form 3608 or Form 8582 to be completed before submitting Form H1200.
  • Either fax or mail. Do not fax and mail the same documents, as this will cause confusion. Fax to the Document Processing Center at 1-877-236-4123. If mailing, send to Document Processing Center, P.O. Box 149024, Austin, TX 78714-9968.

Follow-up

  • HHSC MEPD may take up to 45 days to process a Medicaid application once all required documentation is received.
  • The LIDDA must document the date the application was submitted to HHSC.
  • If assistance from HHSC is needed while the application is being processed, the LIDDA, person or LAR can call 2-1-1, the Medicaid Hotline or the HHSC Ombudsman Office.
  • If financial eligibility has not been determined within 50 days after submission of the application and attempts to receive a status update from HHSC have been unsuccessful, the LIDDA can contact the Intellectual or Developmental Disability (IDD) Program Eligibility and Support (IDD-PES), Eligibility Verification & Program Support Unit (EVPS) for assistance at 512-438-2484.

 

15800 Financial Eligibility After Enrollment - HCS and TxHmL

Revision 19-4; Effective September 9, 2019

 

Persons must maintain financial eligibility to remain eligible for the waiver program. If a person loses Medicaid eligibility, it is the responsibility of the representative payee to contact the appropriate entity to determine necessary action to reinstate benefits.

If the Home and Community-based Services (HCS) Program provider is the representative payee, the provider is responsible for ensuring action is taken to reestablish Medicaid eligibility.

If the person or family is the representative payee, the local intellectual and developmental disability authority (LIDDA) service coordinator will assist, if requested.

 

15810 Medicaid Redetermination

Revision 19-4; Effective September 9, 2019

 

Texas Health and Human Services Commission (HHSC) requires persons to submit a Medicaid redetermination packet to HHSC at least annually. HHSC mails the redetermination packet to the person’s mailing address on file in the Texas Integrated Eligibility Redesign System (TIERS) 60 days in advance of the redetermination due date. It is important that the packet be completed and returned to HHSC before the due date; otherwise, Medicaid eligibility will be denied.

Local intellectual and developmental disability authorities (LIDDA) can review the Client Assignment and Registration (CARE) System screen C63, Medicaid Eligibility Search, to determine a person’s review date. This information is displayed in the “Periodic Review Date” field in this screen.

Note: Persons who receive Supplemental Security Income (SSI) Medicaid are not required to submit a redetermination packet because their eligibility is based on their SSI eligibility. The Social Security Administration (SSA) reports SSI recipient information directly to TIERS for these persons.

 

15820 Reestablishing Medicaid

Revision 19-4; Effective September 9, 2019

 

Loss of Medicaid for Elderly and People with Disabilities (MEPD) Medicaid

If a person loses financial eligibility, it is the responsibility of the person or legally authorized representative (LAR) to reestablish financial eligibility as soon as possible. It is also in the provider’s best interest to assist the person or LAR with reestablishing the person’s financial eligibility to prevent an interruption in services and payment. The local intellectual and developmental disability authority (LIDDA) may provide assistance. LIDDAs should offer assistance to persons who have chosen Consumer Directed Services (CDS).

Loss of Supplemental Security Income (SSI) Medicaid

If a person loses SSI benefits, the person will also lose SSI Medicaid. It is the responsibility of the person or their representative payee to contact the Social Security Administration (SSA) to determine the necessary action to reinstate SSI benefits. If the provider is the representative payee, the provider is responsible for ensuring immediate action is taken to reestablish financial eligibility. The LIDDA may assist a person or the representative payee. If SSI benefits will not be reinstated, the person must submit a Medicaid application to Texas Health and Human Services Commission (HHSC). Adults who lose SSI benefits because they became eligible for Retirement, Survivors and Disability Insurance (RSDI) benefits, and their income is now over the income limit for SSI benefits, may be eligible for Disabled Adult Children’s Medicaid. It is in the provider’s best interest to assist the person or LAR with submitting the Medicaid application to HHSC to prevent interruption in services and payment. The provider must include a completed Form H1746-A, MEPD Referral Cover Sheet. The LIDDA may provide assistance, if requested by the person. LIDDAs should offer assistance to persons who have chosen CDS.

Loss of Department of Family and Protective Services (DFPS) Medicaid

When a person “ages out” of DFPS conservatorship, the person will lose Medicaid. The person must submit an application to the SSA for SSI benefits or a Medicaid application to HHSC. It is in the provider’s best interest to assist the person or LAR, if any, with reestablishing financial eligibility to prevent interruption in services and payment. The LIDDA may provide assistance, if requested by the person. LIDDAs should offer assistance to persons who have chosen CDS.