Revision 15-4; Effective December 1, 2015

 

B-8100 Certificates of Insurance Coverage

Revision 09-4; Effective December 1, 2009
 

The certificate of insurance coverage is proof of a Medicaid recipient's most recent period of Medicaid coverage. The Department of State Health Services sends the certificate, a requirement of the Health Insurance Portability and Accountability Act (HIPAA) of 1996, to denied recipients. HIPAA mandates that prior health insurance coverage must be counted toward reducing or eliminating any applicable pre-existing condition exclusion period when a person enrolls in a new health insurance plan. Former Medicaid recipients may request a certificate within 24 months after their Medicaid is denied by calling 1-800-723-4789.

 

B-8200 Redetermination Cycles

Revision 15-4; Effective December 1, 2015
 

A recipient’s eligibility is redetermined:

  • when necessary because of previously obtained information indicating an anticipated change;
  • within 10 workdays after receipt of a report indicating changes that may affect eligibility or co-payment, including program transfers;
  • within 30 workdays after receipt of a report indicating changes that affect neither eligibility nor co-payment;
  • at periodic intervals not to exceed 12 months; and
  • at least every six months, if income is averaged or an incurred medical expense is budgeted. The person's income is verified and documented and past co-payment is reconciled.

For more information on redeterminations, see Section B-8430, Special Reviews, and Section B-8440, Streamlined Redetermination (Passive Redetermination).

Note: For couple cases, including cases with spouses who may be certified under different type programs, redeterminations should be synchronized to minimize the redetermination process for the recipients and the workload for the eligibility specialist. A complete redetermination of each person's eligibility must be completed at least once every 12 months.

It is a recommended practice to review community-based cases at least every three months if the recipient's countable resources are within $100 of the resources limit.

Monitor eligibility at least every three months if the person's:

  • countable resources are within $100 of the resources limit, or
  • total countable income is within $10 of the income limit.

The following information must be included in the case record documentation:

  • Whether a special review is needed
  • Date special review will be conducted
  • Method of monitoring for special review

Clearly document:

  • specific information regarding the reason a special review is set,
  • which person is affected, and
  • the eligibility area(s) subject to the review.

Example: If someone has a private pension and the pension amount is anticipated to increase in the future, a special review must be set for the anticipated change. The eligibility area will be income. Documentation must specify pension information that will need to be verified at the special review, including:

  • date on which the anticipated change is to occur,
  • type of pension,
  • source of pension, and
  • frequency of payment of pension that will need to be verified at the special review.

Use Form H1020, Request for Information or Action, and Form H1020-A, Sources of Proof, to request information from the person or authorized representative. When requesting missing information on a redetermination, allow 10 calendar days from the date the notice is mailed for the individual to provide the information. Do not deny the case for failure to furnish information before the due date listed on Form H1020.

Note: Monitor special reviews for resource or income elements through entry of the special review due date in the applicable TIERS screen.

Data Broker is not required on redeterminations, including the streamlined versions.

 

B-8300 Who May Sign a Redetermination Form

Revision 12-4; Effective December 1, 2012
 

Note: A person who may complete or sign a redetermination form for a recipient may possibly not be on the list of people to whom HHSC can release the recipient’s individually identifiable health information. See Section C-5000, Personal Representatives, for persons who may receive or authorize the release of a recipient’s individually identifiable health information under HIPAA privacy regulations.

See Section B-3220, Who May Sign an Application for Assistance, to determine who may sign a redetermination form. The requirements for signing a redetermination form are the same as the requirements for signing an application.

Note: A signature is not needed when the redetermination is passive or simplified. See Section B-8440, Streamlined Redetermination (Passive Redetermination).

 

B-8400 Procedures for Redetermining Eligibility

Revision 12-4; Effective December 1, 2012
 

When reports based on the system of record indicate a redetermination or review of eligibility is due for a recipient, the automated system will send Form H1233, Redetermination Cover Letter, a Form H1200 application series form, and Form H0025, HHSC Application for Voter Registration, to the recipient or authorized representative requesting that the application form be completed and returned along with required verification documents.

Reference: Policy and procedures found in Section B-3210, Who May Complete an Application for Assistance, and Section B-3220, Who May Sign an Application for Assistance, apply to all H1200 series application forms.

Note: Document any actions taken regarding voter registration in the Agency Use Only section of any of the H1200 series. If the recipient contacts the office declining to complete Form H0025, mail Form H1350, Opportunity to Register to Vote, to the person. See Section C-7000, National Voter Registration Act of 1993.

For redetermination involving stable institutional or community-based cases, Form H1200/H1200-A may be accepted without verifications, if information is consistent with what previously has been reported and eligibility and/or co-payment are not affected.

For redeterminations completed by the eligibility specialist because the recipient does not have an authorized representative, a contact with the recipient, facility staff or other appropriate verification sources must be made to verify all applicable eligibility points.

A minimum of one annual review, using Form H1200/H1200-A, must be made before streamlined options in Section B-8440, Streamlined Redetermination (Passive Redetermination), can be used to complete the redetermination process. This option applies to both institutional cases (except spousal impoverishment cases) and community-based cases.

Data Broker is not required on annual reviews, including the streamlined versions.

 

B-8410 Financial Management

Revision 09-4; Effective December 1, 2009
 

For redeterminations, explore financial management if there has been no activity in the person’s bank account, other than interest credited, since the last redetermination.

If a person does not report a bank account, trust fund or similar account on the 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 his checks and where, who pays his bills and how, and who keeps his money and how the funds are kept.

If the person reveals previously unreported liquid resources, 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 recipient and the person who handles the recipient’s funds.
  • Statement from a knowledgeable third party (for example, an administrator or bookkeeper in facility usually knows who receives the recipient’s benefit payments and pays the bills).

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.

 

B-8420 Notification of Changes as a Result of Redetermination

Revision 11-4; Effective December 1, 2011

 

On receipt of the completed, signed and dated H1200 series form, redetermine eligibility for MEPD. A review may result in no changes being made or one of the following situations:

  • Decrease of co-payment

    If a review results in a decrease in a recipient's co-payment, dispose of the case action and send Form TF0001, Notice of Case Action, to notify the recipient, and Form TF0001P, Provider Notice, to notify the facility. To correct co-payment for a previous period of time, complete Form H1259, Correction of Applied Income.
  • Increase of co-payment

    If a review results in an increase in the recipient's co-payment, dispose the case action and send Form TF0001 to the recipient and Form TF0001P to the facility. If the recipient does not indicate a desire to appeal by the end of the 12-day notification period, the increased co-payment remains.
  • Denial of benefits

    If a review results in a denial of benefits, send Form TF0001 to advise the recipient and Form TF0001P to notify the facility (if applicable). If the recipient does not indicate a desire to appeal by the end of the 12-day notification period, the benefits remain denied.

Note: Complete Form H1259 manually for notification if co-payment involves averaged income (raised or lowered) or incurred medical expenses. If all amounts are lower in the reconciliation shown on Form H1259, then adverse action is not required. In the above situations, ensure that if Form TF0001 and/or Form TF0001P is not sent automatically, a manual Form TF0001 and/or Form TF0001P is sent.

If there is no change in eligibility or co-payment, there is no mandate to send a notification to the recipient.

 

B-8430 Special Reviews

Revision 10-1; Effective March 1, 2010

 

A special review occurs between the annual review cycles to evaluate one or more eligibility elements without completing the annual review. The annual review (redetermination) packet is not required for a special review.

The need for a special review is based on policy, a reported change or the eligibility specialist's judgment.

Examples of when special reviews are needed for follow-up:

  • On the person's action for applying for potential benefits. An initial 30-calendar day special review is required to evaluate if the person made application after the person has been notified to do so. This may occur before the application is completed. Another special review will be needed to follow up to see if the recipient continues to be eligible.
  • When variable income and/or incurred medical expenses are averaged and projected. Special reviews are required at least every six months unless documentation substantiates an exception.
  • Within a 90-day time frame when the total countable income is within $10 of the income limit.
  • Within a 90-day time frame when the total countable resources are within $100 of the resource limit.
  • When any change is anticipated to occur.

For special reviews, document clearly the detailed reason(s) for the special review. Documentation must include:

  • specific information regarding the reason a special review is set;
  • the name of the individual who is affected; and
  • the eligibility area(s) subject to the review.

Include this information on correspondence sent to the person to request information concerning the special review. No redetermination packet is required.

For example, if someone has a private pension and the pension amount is anticipated to increase in the future, set a special review for the anticipated change. The eligibility area will be income. Documentation must specify pension information that will need to be verified at the special review. Include the:

  • date on which the anticipated change is to occur;
  • type of pension;
  • source of pension; and
  • frequency of payment of pension that will need to be verified at the special review.

Form H1020, Request for Information or Action, and Form H1020-A, Sources of Proof, are used to request information from the person or authorized representative. Include the due date on Form H1020 or H1020-A. If the recipient calls with questions, follow Appendix XVI, Documentation and Verification Guide, for acceptable verification sources.

Example:

George Black called this morning saying he received a letter requesting verification that he had applied for Veterans Affairs (VA) benefits. He stated that he had applied and was told that it would take at least six months to hear anything.

Document what Mr. Black said. Recipient declaration is acceptable verification that he has applied for additional benefits. Be sure to tell Mr. Black to call and report if he hears anything about his eligibility from the VA.

 

B-8440 Streamlined Redetermination (Passive Redetermination)

Revision 12-4; Effective December 1, 2012
 

A minimum of one annual redetermination based on procedures in Section B-8400, Procedures for Redetermining Eligibility, and using Form H1200/H1200-A, must be made before this streamlined option can be used to complete the redetermination process.

Do not use the streamlining method for the Medicaid Buy-In for Children (MBIC) program or the Medicaid Buy-In (MBI) program.

For redeterminations after the first annual redetermination, the eligibility specialist determines if Form H1200/H1200-A or Form H1200-EZ is needed based on the case criteria and this option is marked in TIERS. If it is determined the H1200-H1200-A/H1200-EZ is not needed, then the H1200-SR is sent.

The recipient is sent the H1200-SR and informed on the cover sheet that if the income and resources are the same and no changes have occurred, the redetermination form does not need to be returned. If the review packet is not returned, the redetermination will be automatically renewed using existing information in TIERS.

Use the case criteria given below to determine if Form H1200/H1200-A/H1200-EZ is needed. This option applies to both institutional cases (except spousal impoverishment cases) and community-based cases.

If the case criteria exhibits no more than the following case characteristics, the redetermination process may be streamlined:

  • SSI conversion case (SSI to MEPD institutional coverage);
  • one patient trust fund (PTF) account or one bank account;
  • excluded burial funds;
  • excluded resources;
  • income requiring no more than annual verification;
  • no variable income over $4.99;
  • no TPR or IME deduction in copayment calculation.

In addition to cases meeting the above case criteria, other stable cases (including those with variable income) may be streamlined. Regional management determines when supervisory approval is needed.

Regional management will ensure all streamlined cases meet the established criteria.

Data Broker is not required on redeterminations, including the streamlined versions.

 

B-8450 Special Reviews when Facility Contract Closure or Cancellation Occurs

Revision 11-4; Effective December 1, 2011
 

If an action by DADS against a facility results in the loss of a Medicaid contract, and the eligibility specialist has been notified by DADS or has discovered the loss of Medicaid certification, the eligibility worker begins denial procedures by sending Form TF0001, Notice of Case Action.

Ensure that the local SSA office is aware of the loss of the Medicaid contract for that facility since SSA determines SSI eligibility. See Section B-6300, Institutional Living Arrangements.

The following procedures are followed whenever a facility's contract with DADS is cancelled or the facility closes.

Step Procedure
1 HHSC receives official written notice from DADS.

The eligibility specialist sends Form TF0001 within 10 workdays after receipt of a report indicating changes that may affect eligibility or co-payment or verified discovery of the loss of Medicaid certification. See Section B-8200, Redetermination Cycles.
2 The eligibility specialist sends Form TF0001 to all Medical Assistance Only (MAO) recipients who continue to live in the uncontracted facility. See Section B-9100, Administrative Denials, and Appendix XI, Reference for Client Notification Forms.
3 If the recipient relocates to a contracted facility, or if the facility in which the recipient is living is reinstated as a contracted provider before the effective date of Medicaid denial, the denial action is cancelled and a new application is not required.
4

Ensure that the local SSA office is aware of the loss of the Medicaid contract for that facility since SSA determines SSI eligibility for the residents of the facility.