Revision 16-4; Effective December 1, 2016

 

 

B-6100 Face-to-Face and Telephone Interviews

Revision 10-3; Effective September 1, 2010

 

As a result of the initiative to integrate application and eligibility determination processes, a face-to-face interview or a telephone interview is not required in determining eligibility for Medicaid programs within this handbook.

At the request of the person or the person's authorized representative, conduct a face-to-face interview or an interview by telephone based on the request. Form H1246, Medicaid Eligibility Interview Guide, is optional for staff to use to record information during the interview.

Information to consider for the case documentation:

  • Whether a face-to-face or telephone interview was conducted.
  • Date of the interview and name of the person interviewed (applicant or authorized representative).
  • Relationship of the authorized representative to the applicant.
  • Reason, if an interview was requested but not conducted.

Interviews are not required for Medicaid applicants or recipients. If an appointment is scheduled and the person does not keep the appointment, do not deny based on the missed appointment.

 

B-6200 Financial Management

 

Revision 10-3; Effective September 1, 2010
 

If a person does not report a bank account, trust fund or similar account on Form H1200, Application for Assistance – Your Texas Benefits, or other application for assistance, ask the person or the authorized representative to explain how the person's financial affairs are handled. This includes determining who:

  • cashes the checks and where;
  • pays the bills and how; and
  • keeps the money and how the funds are kept.

If the person reveals previously unreported liquid resources, request verification to determine the value, ownership and accessibility according to the requirements for the resource involved.

Sources for verifying financial management are as follows:

  • Statements from the applicant and the person who handles the applicant's funds.
  • Statement from a knowledgeable third party (for example, an administrator or bookkeeper in the facility usually knows who receives the applicant's benefit payments and pays the bills).

Use Appendix XVI, Documentation and Verification Guide, for sources of needed verifications.

Include the following information in the case record documentation:

  • Where checks are cashed and how bills are paid.
  • Who handles the person's checks, pays the person's bills and maintains the person's money.
  • How much money, if any, the person or anyone else keeps.
  • How much has accumulated.
  • Source of information.

Note: If the person's bank account is dormant, financial management must be verified and documented. For applications, explore financial management if there has been no activity in a reported account during the month of application and the month before.

 

B-6300 Institutional Living Arrangement

 

Revision 13-2; Effective June 1, 2013
 

Determine the first day the applicant’s eligibility can be established under the special income limit. Form 3618, Resident Transaction Notice; Form 3619, Medicare/SNF Patient Transaction Notice; 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, are adequate verification of dates of admission to a Medicaid facility. In absence of the above-listed forms, eligibility staff may contact the administrator, bookkeeper or office manager for the date of admission.

See Section G-6000, Institutional Eligibility Budget Types. The 30-day requirement begins with confinement to one or more Medicaid-certified facilities (Medicare-SNF, NF or ICF/IID) for at least 30 consecutive days.

Eligibility under the special income limit cannot be processed or disposed in the system of record until the 30 consecutive days in an institutional setting have been met.

The date of entry to an institution is day zero. For the institution to be paid, the individual must stay overnight. This is due to the days being defined on a 24-hours basis – midnight to midnight which is explained in the DADS nursing facility requirements and licensure handbooks.

Example 1: Individual entered the nursing facility on March 27. He stayed there for 30 consecutive days – not going home, to the hospital or to another nursing facility. The earliest the specialist can certify the case is the 31st day, which is April 27.

Example 2: Individual entered the hospital on Feb. 10 and entered the nursing facility on Feb. 19. He stayed there for 30 consecutive days – not going home, to the hospital or to another nursing facility. The start of the 30 consecutive days started on Feb. 19, not Feb. 10. The earliest the specialist can certify the case is the 31st day, which is March 22.

Example 3: Individual entered the nursing facility on March 1. He went to the hospital on March 5. He returned to the nursing facility on March 10. The 30 consecutive days started on March 1 and was not interrupted by the hospital stay. The earliest the specialist can certify the case is the 31st day, which is April 1.

Example 4: Individual entered the nursing facility on May 10. The 31st day is June 10. He went home on June 1. He did not stay the required 30 consecutive days. The specialist cannot certify the case.

Example 5: Individual entered the nursing facility on April 20. The 31st day is May 21. He died on May 10. He did not stay the required 30 consecutive days; however, the specialist can certify the case if the individual meets all other eligibility requirements.

Example 6: Mr. Smith entered the hospital on Feb. 15 and then went to the nursing home on March 10. His wife continues to live in their home in the community. The 30 consecutive days starts on March 10, not Feb. 15. The earliest the specialist can certify the case is the 31st day, which is April 10th.

Note: The hospital stay in February is start date for the continuous period in an institution for the spousal resource assessment – which is different than the 30 consecutive day’s requirement.

See Chapter J, Spousal Impoverishment, regarding the resource assessment and spousal protected resource amount (SPRA). When determining the 30-day stay requirement, consider both the days in a medical facility and the days in the Home and Community-Based Services waiver setting.

Use the special income limit for the month of entry to a Medicaid-certified long-term care facility (Medicare-SNF, NF or ICF/IID) if it is anticipated that the person will remain in a Medicaid-certified facility for at least 30 days. When eligibility is based on the special income limit, finalization of the person’s eligibility cannot be processed or disposed in the system of record until the 30 consecutive days in an institutional setting have been met. See Appendix XIX, Earliest Certification Application Due Dates Chart, to determine the 31st day.

See Section G-7000, Prior Coverage.

It may be necessary to verify the living arrangement for prior months by contacting the person or authorized representative to ensure the appropriate income limit is used for determining eligibility for prior months. It may also be necessary to contact the facility, the Home and Community-Based Services waiver provider or the hospital, if a person has been discharged to a hospital, to ensure that the 30-consecutive-day requirement is met.

The following verification and documentation must be included in the case record:

  • Date the person entered the Medicaid facility.
  • Date the applicant met the 30-consecutive-day requirement (or date of death).
  • Source of verification.

See Appendix XXX, Medical Effective Dates (MEDs). Use the information under the Institutional Based area to determine the appropriate income limit for the month of application and the prior months.

The 30 consecutive day in an institutional setting requirement does not apply to a regular Medicaid recipient who:

  • is eligible for SSI, or
  • was eligible for SSI and continues regular Medicaid eligibility through one of the cost of living adjustment (COLA) disregard programs.

The COLA disregard programs are:

  • ME-Pickle
  • ME-Disabled Adult Child
  • ME-Disabled Widow(er)
  • ME-Early Aged Widow(er)

See Section B-7450, Medicaid Certified Person Enters Nursing Facility or Home and Community-Based Services Waiver Program.

 

B-6400 Processing Deadlines

 

Revision 10-3; Effective September 1, 2010
 

Make and document an eligibility decision on an application as soon as all required verification is received.

Time frame for eligibility determination:

  • Make an eligibility decision within 45 days on applications from applicants 65 years or older.
  • Make a decision within 45 days on applications from applicants under age 65 who have had disability established based on the Social Security Administration criteria for RSDI Title II or SSI Title XVI disability.
  • Make a decision within 90 days on applications from applicants who must have disability established by the HHSC Disability Determination Unit.

References:

  • See Section B-4000, Date of Application, for clarification of date of application and complete application.
  • See Section R-3100, Establish Processing Deadlines, for automation procedures to follow when applications cannot be completed within the normal 45/90-day limit and for requirements to request a delay in certification.
  • See Section D-2100, When a Medical Determination Is Not Required, and Section D-2200, When a Medical Determination Is Required, for further information regarding a medical determination for applicants under age 65.

 

B-6410 Application Due Dates

Revision 10-3; Effective September 1, 2010
 

In Section B-4000, Date of Application, several dates of application are outlined. However, for timeliness and processing purposes:

  • The timeliness count begins the date the completed and signed application for assistance was returned to a local HHSC office.
  • The date of application is day zero in the final eligibility determination of the application.

If an applicant applies for multiple programs and all requested information is provided for one program and not the other(s), make an eligibility determination for the program in which all the information has been received. Continue to collect the missing information for the other program(s) until the final due date for missing information.

Reminders:

  • The date of application is not established when DADS receives a completed and signed application form. The date of application is established when HHSC receives the completed and signed application form.
  • For applications submitted after state business hours, the date of application is the following business day.
  • If an application is denied in error, the original date of application must be protected no matter how old the date on the application for assistance. A new application processing date would need to be established.

 

B-6420 Missing Information Due Dates

Revision 14-1; Effective March 1, 2014
 

Applications

Use Form H1020, Request for Information or Action, to request missing information or verifications. The final due date for missing information for applications on Form H1020 is the:

  • 39th day from the date of application, or
  • 84th day from the date of application for a person who needs a disability determination.

Do not send a second request for missing information. Take appropriate case action based on the original request for missing information.

Delay in Certification

When there is an approved delay in certification, the 39th and 84th days are extended 90 days.

Always send notification to the applicant/authorized representative and nursing facility, using Form H1020 and Form H1247, Notice of Delay in Certification.

Use Form H1020 to indicate the needed information and the re-established due dates during the delay in certification. See Section B-6510, Failure to Furnish Missing Information.

Re-established due dates are based on the reason for the delay in certification and reasonable MEPD specialist judgment. For example, if the delay is due to the 30-day consecutive requirement not being met, the re-established due date would not automatically need to be the full 90-day extension. However, if the delay is due to the facility pending certification, the full 90-day extension may be necessary. When unsure of the re-established due dates based on the reason for the delay in certification, consult the supervisor to determine the re-established pending period. Do not send a second request for missing information during the re-established due dates based on the delay in certification. Take appropriate case action based on the Form H1247 and Form H1020 used to notify the applicant of the delay in certification and the needed verification.

Redeterminations

Use Form H1020 to request missing information or verifications. The due date for missing information or verifications for redeterminations should be 10 days from the date on Form H1020.

 

B-6500 Denials

 

Revision 11-4; Effective December 1, 2011
 

Before a person is denied for any reason during application, eligibility for QMB/SLMB must also be tested.

Examples:

  • An applicant for nursing facility coverage also must be tested for QMB coverage. If the applicant is ineligible for nursing facility coverage but eligible for QMB, certify the applicant for QMB. Indicate on the notice that the applicant is ineligible for nursing facility coverage but eligible for QMB coverage.
  • When an MQMB recipient dually eligible for nursing facility coverage leaves the nursing facility to live at home, test for continuing QMB coverage in the new living arrangement.
  • When a Community Attendant Services (CAS) recipient who is also QMB-eligible no longer has physician's orders and is ineligible for CAS, do not deny the QMB coverage unless a change in the recipient’s circumstances also results in ineligibility for QMB.

 

B-6510 Failure to Furnish Missing Information

Revision 16-4; Effective December 1, 2016

 

Applications

An individual or authorized representative must furnish verification needed to make an eligibility decision. For applications, the initial written request for verification must be initiated within 30 calendar days from the date the application is received by the Texas Health and Human Services Commission (HHSC).

Do not deny the application for failure to furnish missing information before doing the following:

  • Send the individual or the authorized representative Form H1020, Request for Information or Action, to request verification of necessary information. The Form H1020 must identify the months for which information is needed to determine eligibility, such as "three bank statements that cover the months of June, July, and August," and the verification provided by the individual must include the following information:
    • name of the financial institution;
    • account number(s); and
    • amount of the balance as of 12:01 a.m. for the appropriate month(s).
  • The Form H1020 provides a due date of when the requested information must be returned based on the application's final due date. See Section B-6420, Missing Information Due Dates, regarding applications.

Do not send a second request for missing information for applications.

Deny the application if the procedures described above are followed and the individual or authorized representative does not provide the requested information by the close of business on the final due date. See Section B-6420.

Delay in Certification

Delay in certification procedures may be necessary if the applicant or the authorized representative is attempting to obtain the information but cannot meet the deadline. For specific delay information, follow the guidelines in Section R-3100, Establish Processing Deadlines, and in Section B-6420.

Use Failure to Furnish Information when the application is denied because of failure to provide missing information.

References:

  • See Section B-4000, Date of Application, for clarification regarding date of application and complete application.
  • See Section R-3100 for automation procedures to follow when applications cannot be completed within the normal 45/90-day limit and for requirements to request a delay in certification.
  • See Section B-3310, Absence of an Authorized Representative, when a person is unable to act on his own behalf and has no authorized representative.

Redeterminations

A person or authorized representative must furnish verification needed to make an eligibility redetermination decision.

Do not deny the redetermination for failure to furnish missing information before doing the following:

  • Request in writing from the recipient or the authorized representative necessary verification using Form H1020. A copy of Form H1020 must be in the case record. The request must be specific, such as three bank statements that cover the months of June, July and August and that provide the following:
    • Name of the financial institution
    • Account number(s)
    • Amount of the balance as of 12:01 a.m. for the appropriate month(s)
  • Give a due date by when the information is to be submitted. The system-generated due date is 10 days from the date of Form H1020. See Section B-6420 regarding redeterminations.

Do not send a second request for missing information for redeterminations.

Deny the redetermination if the procedures described are followed and the information/verification is not provided by the close of business on the due date. See Section B-6420.