Revision 13-4; Effective December 1, 2013
The Social Security Administration (SSA) determines Medicaid eligibility for all persons who apply for SSI cash benefits. When SSA makes a determination on an application for SSI cash benefits (either approved or denied), HHSC is notified by means of the SSA/State Data Exchange System (SDX).
SSA is responsible for redetermination of SSI Medicaid eligibility. See Section H-6000, Co-Payment for SSI Cases, for other special handling of SSI eligible individuals.
When an SSI recipient enters a Medicaid facility and the SSI cash benefit will be denied because the income is greater than the reduced federal benefit rate, and:
- If contacted by the recipient/authorized representative (AR), inform the recipient/AR to notify SSA of the entry to the Medicaid facility. Send Form H1200, Application for Assistance – Your Texas Benefits, to the recipient/AR to complete and return to HHSC.
- If contacted by the Medicaid facility, inform the facility to notify SSA of the entry to the Medicaid facility. Obtain the AR's information, including mailing address, and send Form H1200 to the AR to complete and return to HHSC.
TIERS is notified by the State Data Exchange (SDX) system when SSI cash benefits have been denied because of income that is greater than the reduced SSI federal benefit rate. Once the SDX denial notice is received by TIERS, the SSI Medicaid will be denied by the system.
There is no overlay option in TIERS. Certification for MEPD benefits cannot occur until the SSI is denied. This may require delay in certification, closing and re-opening applications until the SSI is denied.
When SSI has been denied and an MEPD application has not been filed, and:
- If contacted by the recipient/AR, send Form H1200 to the recipient/AR to complete and return to HHSC.
- If contacted by the Medicaid facility, obtain the AR's information, including mailing address. Send Form H1200 to the AR to complete and return to HHSC.
Reference: See Section B-7210, Ensuring Continuous Medicaid Coverage.
After receipt of Form H1200, determine the recipient's financial eligibility for MEPD using the special income limit beginning with the first month after SSI denial. Also determine whether the recipient has an approved medical necessity or level of care and meets all other eligibility requirements. If the recipient has been denied a medical necessity or level of care but remains in the Medicaid facility (Medicare-SNF, NF or ICF/IID), or if the recipient does not remain in a Medicaid facility (Medicare-SNF, NF or ICF/IID) for 30 consecutive days, deny the MEPD application and refer the recipient back to SSI for reinstatement of full SSI benefits. If the recipient will not be reinstated for full SSI benefits, test eligibility for other Medicaid-funded programs, such as QMB, ME-Pickle, etc.
- If the MEPD application is not returned, the eligibility specialist contacts the recipient/authorized representative to attempt to obtain information to determine continued Medicaid eligibility. The eligibility specialist uses Form H1200 as a recording document, if necessary.
- Follow the procedures for SSI to MEPD transfer, unless continued SSI eligibility occurs under temporary provisions. If that situation occurs, do not process an institutional Medicaid application unless the SSI benefits are denied and the recipient is still in the facility.
Reference: See Chapter H, Co-Payment, for exceptions to reduced SSI payment standard.
When a recipient is eligible for institutional Medicaid coverage, the medical effective date (MED) is the day after the date of SSI denial, when the SSI denial is due to entry into an institution. This ensures continuous Medicaid coverage.
Note: To ensure continuous Medicaid coverage for SSI recipients who enter institutions, the coverage may be more than three months from the application file date. For example, SSI was denied March 31, 2013. The individual applied for ME-Nursing Facility on Sept. 10, 2013. The MED can go back to April 1, 2013, which is more than three months prior.
Persons who have applied for SSI and who appear to be SSI-eligible, but for whom processing of the SSI claim has been delayed, may be certified under the appropriate MEPD program pending adjudication of the SSI claim. In order to certify MEPD eligibility, however, all eligibility criteria must be met. This expedited procedure does not negate the requirement that disability be established, or the utilization of benefits, or 30 consecutive days of institutionalization, if applicable.
Consider the age of the person when temporarily certifying the person.
- If the person is age 65 or older, verify that the person has filed an application for SSI. If the person appears to be SSI-eligible, but the processing of the SSI claim has been delayed, certify the person for an appropriate MEPD program pending adjudication of the SSI claim. Once the person is eligible for SSI, the coverage is automatically adjusted in TIERS. This is not adverse action since the person does not lose benefits.
- If the person is younger than age 65, disability determination by the state office Disability Determination Unit cannot be made unless 90 days have elapsed since the SSI date of application and SSA's disability decision is still pending. See Section D-2500, SSI Applicants and Retroactive Coverage. If SSA finds the recipient not to be disabled after MEPD eligibility has been certified, procedures to deny MEPD must be initiated at that time.
Once an MEPD eligibility recipient becomes eligible for SSI, SSA will report the SSI eligibility to HHSC via the SDX system. Once the SDX information is received, TIERS will automatically deny MEPD coverage and activate the SSI coverage. This is not adverse action, since the recipient loses no benefit, so notification is not required unless co-payment is being changed. For Community Living Assistance and Support Services and Home and Community-based Services cases, notify DADS of the MEPD denial using Form H2067, Case Information, or automated communication tool.
The above is not intended as a routine procedure, but should be used only in situations where there has been a delay in an SSI claim already filed. (The eligibility specialist must verify and document that an SSI application has been filed.) The procedure also applies only to applicants who are eligible under an existing MEPD coverage group.
HHSC is responsible for processing Medicaid applications for certain residents of Medicaid facilities (Medicare SNF, NF, ICF/IID and institutions for mental diseases (IMD)). To qualify for medical assistance for institutional care, a person must:
- meet the 30-consecutive-day stay requirement (for verification and documentation requirements, see Appendix XVI, Documentation and Verification Guide);
- meet financial criteria; and
- have an approved level of care or medical necessity determination.
Reference: Section B-6300, Institutional Living Arrangement.
- initial applications from persons whose income is equal to or in excess of the reduced SSI federal benefit rate; and
- reapplications for Medicaid from persons who will be or have been denied SSI on the basis of excess income because the SSI federal benefit rate has been reduced after entry into a Medicaid facility.
State law (Chapter 242, Health and Safety Code) requires that community resource coordination groups (CRCG) be notified when a recipient under age 22 with a developmental disability enters an institutional setting. HHSC must notify the CRCG in the county of residence of the recipient's parent or guardian within three days of the recipient's admission.
The name and telephone number of the appropriate CRCG can be obtained by calling the CRCG state office at 1-866-772-2724. A CRCG list is available on the Internet at: /services/service-coordination/community-resources-...
Documentation of the notification to the CRCG should be filed in the case record.
To qualify for Medicaid facility vendor payments, a recipient must have a medical necessity for nursing facility care. The state Medicaid claims administrator (currently TMHP) is responsible for determining medical necessity for recipients in Medicaid facilities. DADS makes level of care determinations for residents in Medicaid ICF/IID facilities.
Do not approve a person for medical assistance for institutional care unless the person is (or has been) in a Medicaid facility and a level of care is assigned or medical necessity has been determined. (In a Medicare SNF, the Medicare determination of need for care is accepted as a medical necessity determination.) Form 3071, Recipient Election/Cancellation/Discharge Notice, substitutes for the medical necessity determination when hospice is elected as referenced in Section A-5200, Hospice in a Long-Term Care Facility.
Use the previous level of care or medical necessity determination if:
- a person is being reinstated for assistance (that is, the case is denied in error or a program transfer from SSI to MEPD institutional care); and
- vendor payments were made to the Medicaid facility up to the date of denial based on the previous level of care/medical necessity determination.
Use the level of care/medical necessity determination for Home and Community-Based Services waiver eligibility to transfer a Home and Community-Based Services waiver recipient admitted to an institution to the appropriate institutional care program.
If a recipient has a permanent medical necessity determination before being denied Medicaid and is not discharged from a Medicaid facility for more than 30 days, then the permanent medical necessity determination may still be used if a reapplication for assistance is filed.
If a level of care/medical necessity determination is not approved, deny the application.See Appendix XVI, Documentation and Verification Guide.
Under the utilization review procedures, facilities are required to submit medical information to the state Medicaid claims administrator (currently, TMHP) on the Minimum Data Set (MDS) assessment or to DADS on Form 8578, Intellectual Disability/Related Condition Assessment, so that medical necessity/level of care may be determined. As a part of these procedures, facilities must comply with time limits for submitting the form.
If a level of care/medical necessity determination is denied for an MEPD recipient, initiate denial procedures immediately.
A recipient may continue to be Medicaid-eligible as long as the recipient meets all eligibility criteria and:
- has a diagnosis of mental illness, intellectual disabilities or a related condition;
- no longer meets the medical necessity criteria; and
- has lived in a nursing facility for 30 months before the date medical necessity is denied and chooses to remain in the facility.
If the recipient has not been in the facility for 30 months, regular Medicaid denial procedures apply.
If an MEPD recipient in a private Medicaid facility is denied solely because of no level of care/medical necessity determination, refer the person to SSA if available income is less than the SSI full federal benefit rate. Refer SSI recipients who are denied a level of care/medical necessity determination to SSA for rebudgeting to the full federal benefit rate.
Federal regulations require that an evaluation be made of resources available to the applicant in the home, family and community. This requirement is met by sending Form H1204, Long Term Care Options, as an information cover letter for all MEPD Medicaid applications, except for state supported living centers, state hospitals and state centers. State law requires that information about all long-term services and supports be provided to applicants, authorized representatives and at least one family member so they can make an informed choice about service options.
Explain alternate care services available in the area if the applicant, authorized representative or family member(s) has questions. If the applicant or authorized representative expresses an interest in alternate care, refer the applicant to DADS staff via Form H2067, Case Information, or automated communication tool.
If a Form H1746-A, MEPD Referral Cover Sheet, has a mark in the box "LTSS Information Shared," do not send Form H1204 to the person. The agency making the referral has shared the Long Term Care Options with the person.
B-7450 Medicaid Certified Person Enters Nursing Facility or Home and Community-Based Services Waiver Program
Eligibility Systems and Payment Systems
When an active recipient with coverage Code R (either Long Term Care or Texas Works) enters a nursing facility and has a valid medical necessity and facility admission, DADS Claims Management Services/Service Authorization System Online (CMS/SASO) identifies the recipient as Service Group 1 and allows vendor payment. It also automatically assigns the recipient a Code 60 (authorization for unlimited medications), which allows all medications to be paid through the vendor drug benefit.
If a recipient has only a temporary nursing facility stay and returns home before being transferred to institutional Medicaid, there is no action required by the eligibility specialist. No retroactive coverage changes are needed. The client history can remain as it is.
Texas Works Medicaid to MEPD
If a person is on a Texas Works (Category 2) program and enters the facility for a long-term stay, the nursing facility admission information will be received by TIERS from DADS via an interface. TIERS will automatically deny the Texas Works Eligibility Determination Group (EDG) and create the MEPD EDG. The eligibility specialist then coordinates the disposition of the EDGs with Texas Works staff. There is no need for retroactive changes because vendor payment and medications are authorized through the DADS payment systems CMS/SASO).
If the eligibility specialist is notified by a facility, then the eligibility specialist should process as any other application and coordinate with Texas Works.
Community to Nursing Facility or Home and Community-Based Services Waiver Eligibility Considerations
When a Medicaid (MEPD or Texas Works) or Medicare Savings Program recipient enters a facility for a long-term stay, review information for transfer of assets, substantial home equity and other factors affecting eligibility and co-payment for services in a nursing facility or waiver. Other considerations are notification requirements regarding annuities, estate recovery and long-term care options. See Appendix XI, Reference for Client Notification Forms.