Revision 18-1; Effective March 1, 2018

 

B-2100 Reporting Abuse and Neglect

Revision 09-4; Effective December 1, 2009

 

HHSC staff are mandated to report abuse or neglect that threatens the health or welfare of a child or an elderly or disabled adult. Staff must report instances of:

  • physical or mental injury;
  • sexual abuse;
  • exploitation; and
  • neglect.

Report such instances to the Department of Family and Protective Services. The toll-free number to report abuse is 1-800-252-5400.

For reports of domestic violence, abuse or neglect of adults, inform the person or his or her authorized representative of the report unless you believe informing them would place the person at risk of serious harm.

 

B-2200 Conflict of Interest

Revision 09-4; Effective December 1, 2009

 

An eligibility specialist has an obligation to avoid even the appearance of impropriety or conflict of interest when determining Medicaid eligibility. The eligibility specialist must not work on or review an ongoing case nor assist an applicant or recipient to receive benefits if the applicant or recipient is a relative (by blood or marriage), roommate, dating companion, supervisor or someone under the specialist's supervision. The specialist may not determine their eligibility for Medicaid. The specialist may provide anyone with an application for Medicaid and may inform anyone how and where to apply. The specialist may help anyone gather documents to verify eligibility and need for Medicaid, but must not take any other role in determining eligibility.

The specialist must consult with the supervisor if the applicant or recipient is a friend or acquaintance. Generally, the specialist should not work on cases or applications involving these individuals, but the degree and nature of the relationship should be taken into account.

 

B-2300 Eligibility Determination

Revision 09-4; Effective December 1, 2009

 

Verify all eligibility factors according to the verification and documentation requirements for each factor.

Document all factors of eligibility in the case record to substantiate the decisions made on all applications and redeterminations before certifying, recertifying, denying or taking any other action on a person's eligibility and/or co-payment.

 

B-2400 Documentation Standards

Revision 11-4; Effective December 1, 2011

 

Documentation standards are contained in this handbook. Specific documentation and verification standards can be found in Appendix XVI, Documentation and Verification Guide. Appendix XVI provides documentation expectations and suggested sources for obtaining information that have proven to result in quality, accurate cases.

When supervisor approval is suggested, written or documented, verbal contact is acceptable. Requirements for documenting telephone contacts are contained in Appendix XVI.

Documentation standards include the date and name/signature of the MEPD eligibility specialist on all recording documents and case actions.

See Section B-8440, Streamlining Methods.

 

B-2500 Explaining Policy vs. Giving Advice

Revision 09-4; Effective December 1, 2009

 

Explaining policy is appropriate. The law requires that Medicaid rules, policies and procedures be freely available to the public. The rules governing MEPD are contained in the Texas Administrative Code (TAC), Title 1, Part 15, Chapters 358, 359 and 360. This handbook also contains the MEPD rules, as well as policies, procedures and examples. Both the TAC and MEPD Handbook are available online. MEPD eligibility specialists act properly in explaining the rule or policy that applies to an applicant's or recipient’s situation, and in referencing the applicable rule or handbook sections.

Giving advice is contrary to HHSC policy. Giving advice includes suggesting options for how to become eligible or how to avoid Medicaid estate recovery, as well as expressing any opinion of what is preferable or more advantageous to the applicant or recipient. Giving advice is contrary to HHSC policy because it:

  • usually constitutes the unauthorized practice of law (which can subject the eligibility specialist to legal penalties);
  • encroaches on the contractual relationship that may exist between the applicant or recipient and attorney or financial advisor; and
  • can subject the eligibility specialist to personal liability for giving advice that is incorrect or that fails to take into account issues other than eligibility (attorneys and financial planners take into account other issues, such as tax laws, in giving estate planning advice relating to Medicaid eligibility).

The approach taken by MEPD eligibility specialists should be to explain policy but not to make recommendations. If an MEPD eligibility specialist is asked for advice, an appropriate response would be to provide the policy that applies to the situation, and to otherwise decline the request. The MEPD eligibility specialist should explain that agency policy prohibits giving advice, and may suggest that the applicant or recipient seek the assistance of an attorney or other estate planning professional of their own choosing.

 

Excess Income

See Appendix XVI, Documentation and Verification Guide, and Appendix XXXVI, Qualified Income Trusts (QITs) and Medicaid for the Elderly and People with Disabilities (MEPD).

If an applicant is income ineligible in an institutional living arrangement, Appendix XXXVI may be shared with applicants and their representatives to assist them in understanding the purpose of and requirements for a QIT.

To prevent allegations that MEPD staff are engaging in the unauthorized practice of law, the following instructions are provided. Use the instructions on the chart regarding the appropriate actions to take and the actions to avoid.

 

MEPD Staff

May May Not
Provide applicants or their representatives with a copy of Appendix XXXVI for informational purposes only. Tell applicants or their representatives that they need a QIT.
Provide applicants or their representatives with applicable policy and procedures. Recommend specific actions applicants or their representatives should take to become eligible for Medicaid.
Refer applicants or their representatives to the following allowable referral list:
  • local legal aid office,
  • local Area Agency on Aging,
  • National Academy of Elder Law Attorneys,
  • local bar association or lawyer referral service,
  • Advocacy Inc., or
  • State Bar of Texas for a list of attorneys who practice elder law in the area.
Tell applicants or their representatives whether or not they must have an attorney to establish a QIT.

Recommend that an applicant or representative consult with a specific attorney or organization. (See allowable referral list.)

Speak with their supervisor or regional services attorney about any questions they have regarding the use of Appendix XXXVI. Recommend that an applicant or representative call an HHSC attorney for legal advice.

 

Excess Resources

See Appendix XVI, Documentation and Verification Guide.

If excess resources can be designated as burial funds, allow the individual the opportunity to do so. See Section F-4227, Burial Funds.

If a person is determined ineligible because of excess funds in a joint account, allow an opportunity to disprove the presumed ownership of all or part of the funds. The person also must be allowed to disprove ownership of joint accounts that currently do not affect eligibility but may in the future. See Section F-4121, Joint Bank Accounts.

 

B-2600 Medicaid Estate Recovery Program Notification Requirements

Revision 18-1; Effective March 1, 2018

 

Medicaid Estate Recovery Program (MERP) is not part of the eligibility determination process for Medicaid.

MERP recovers from a Medicaid recipient’s estate the cost of Medicaid assistance paid for an individual who:

1) was age 55 or older at the time Medicaid services were received; and
2) initially applied for certain types of long-term care (LTC) services on or after March 1, 2005.

Individuals whose estate may be subject to MERP recovery include:

  • an applicant for a Medicaid program that covers these LTC services; or
  • a recipient who requests a change to a Medicaid program that covers these LTC services.

Individuals applying for or receiving these LTC services must be informed about MERP.

A signed Form 8001, Medicaid Estate Recovery Program Receipt Acknowledgement, or documentation the Form 8001 was provided, must be in the case record of each applicant whose estate is subject to MERP recovery.

 

B-2610 Types of MEPD Groups Subject to MERP

Revision 18-1; Effective March 1, 2018

 

On March 1, 2005, Texas implemented MERP in compliance with federal Medicaid and state laws. The program is managed by HHSC. Under this program, the state may file a claim against the estate of a deceased Medicaid recipient who: 1) was age 55 or older when Medicaid services were received; and 2) first applied for certain long-term care services and supports on or after March 1, 2005. The most complete, current and accurate source of information regarding MERP is the HHS website: Medicaid Estate Recovery Program. MERP Claims include the cost of Medicaid assistance paid for the following services:

  • nursing facilities;
  • intermediate care facilities for individuals with an intellectual disability or related conditions (ICF/IID), which include state supported living centers;
  • Home and Community-Based Services waiver programs. See Chapter O, Waiver Programs, Demonstration Projects and All-Inclusive Care;
  • Community Attendant Services; and
  • related hospital and prescription drug services.

Notes:

  • A person who is placed on an interest list for a Home and Community-Based Services waiver program is not considered to be an applicant.
  • As of Jan. 1, 2010, states are prohibited from recovering the value of Medicare cost-sharing paid under Medicare savings programs as a result of the Medicare Improvements for Patients and Providers Act (MIPPA) signed into law on July 15, 2008.

 

B-2620 HHSC MERP Notification Requirements

Revision 18-1; Effective March 1, 2018

 

HHSC staff must inform anyone requesting Medicaid assistance for long-term services and supports that may be subject to MERP recovery. Complete the following to document this requirement:

  • Form 8001, Medicaid Estate Recovery Program Receipt Acknowledgement, is mailed with all Form H1200 application requests received on or after March 1, 2005.
  • Ensure the signed MERP Receipt Acknowledgement (Form 8001) is imaged in the case record.
  • Include the MERP documentation with SSI monitoring requirements outlined in Section B-7100, SSI Monitoring.
  • Record information (name, address, telephone number) of any of the following individuals representing the applicant:
    • guardian of the person or guardian of the estate of the applicant;
    • agent under a durable power of attorney or a medical power of attorney;  or
    • if none of the above individuals are known, family members acting on behalf of the applicant.
  • If a signed MERP Receipt Acknowledgement form is not returned by the applicant/recipient, send Form 8001 and document in case comments that the MERP information was sent to inform the recipient about MERP and the potential for estate recovery.  Include in the documentation the date the form was sent to the recipient.

If a Form H1746-A, MEPD Referral Cover Sheet, has a mark in the box "MERP shared," do not send MERP notifications to the individual. The agency making the referral has shared MERP information with the individual.

The MERP notification requirement applies to any individual, age 55 or older, who is applying for Medicaid assistance for long-term care services and supports that are subject to MERP on or after March 1, 2005, either through an application or program transfer. Individuals transferring to long-term care services and supports subject to MERP must have documentation of Form 8001 in the case record. If there is no documentation in the case record, send Form 8001 and follow documentation guidelines outlined in this section.

Example: Mr. Andy Allen applied for a Medicare Savings Program (MSP) before Nov. 1, 2004, and was certified, but did not receive Form 8001 since Mr. Allen was on an MSP before March 1, 2005. Mr. Allen entered a nursing facility this month and requested a program transfer. Based on Section B-7450, Medicaid Certified Person Enters Nursing Facility or Home and Community-Based Services Waiver Program, the program transfer is complete, and Form 8001 is sent to Mr. Allen. Staff document in case comments the date the Form H8001 was mailed.