Revision 12-3; Effective September 1, 2012

 

D-3100 Related Texas Administrative Code Rules

Revision 09-4; Effective December 1, 2009

 

§358.207. Residence.

To be eligible for a Medicaid-funded program for the elderly and people with disabilities, a person must be a resident of the United States (U.S.) and the state of Texas.

(1) U.S. residence. The Texas Health and Human Services Commission (HHSC) follows 20 CFR §416.1603 in determining a person's U.S. residence.

(A) The U.S. residence requirement does not apply to:

(i) a child who is a citizen and is living with a parent who is a member of the U.S. Armed Forces assigned to permanent duty ashore outside the U.S.; or

(ii) to certain persons temporarily abroad for study.

(B) Once eligible for benefits, a person must maintain a presence in the U.S. in accordance with 42 U.S.C. §1382(f)(1). If a person has been outside the U.S. for 30 consecutive days, the person is not eligible for benefits until the person has been in the U.S. for 30 consecutive days.

(2) Texas residence. HHSC follows 42 CFR §435.403 in determining a person's state residence.

 

§358.215. Inmates of Public Institutions.

An inmate of a public institution, including a jail, prison, reformatory, or other correctional or holding facility, as defined in 42 CFR §435.1009 and §435.1010, is not eligible for Medicaid payment for Medicaid-covered services received while residing in the public institution.

 

§358.213. Resident of an Institution for Mental Diseases.

A person who lives in an institution for mental diseases must be 65 years of age or older to be eligible for a Medicaid-funded program for the elderly and people with disabilities.

 

D-3200 Eligibility

Revision 09-4; Effective December 1, 2009

 

To be eligible for Medicaid, a person must be a resident of the U.S.

To be eligible for an MEPD program under Texas Medicaid, a person must be a resident of the state of Texas. The person must have established residence in Texas and must intend to remain in Texas.

Consider a person a resident of the U.S. and Texas if the person has:

  • established an actual dwelling place within the geographical limits of the U.S. and Texas; and
  • the intent to continue to live in the U.S. and Texas.

Accept the person's statement on the application or redetermination form regarding Texas residency.

Further evidence of Texas residency is required only if Texas residency is questionable. A person can prove residency by providing document(s) that indicate a Texas address. For example, sources of evidence could be from the following:

  • Property, income or other tax forms or receipts
  • Utility bills, leases or rent payment records

 

D-3300 Maintaining Presence in the U.S.

Revision 09-4; Effective December 1, 2009

 

A Medicaid recipient is not eligible for Medicaid for any month during all of which the person is outside of the U.S. If a person is outside of the U.S. for 30 or more days in a row, the person is not considered to be back in the U.S. until the person is back for 30 days in a row. A person may again be eligible for Medicaid in the month in which the 30 days end if the person continues to meet all other eligibility requirements.

The period of absence begins with the day after the person's departure from the U.S. The period of absence ends for eligibility purposes:

  • the day before the person's return to the U.S., if the time outside the U.S. is less than 30 consecutive days; or
  • 30 consecutive days after return to the U.S., including a person newly arrived in the U.S. (that is, for the very first time), if the time outside the U.S. is 30 consecutive days or more.

Develop continuous presence in the U.S. if there is reason to believe the person has been outside the U.S. for 30 consecutive days or a full month.

If otherwise eligible, a person whose eligibility has been denied because of absence from the U.S. can be recertified effective with the day:

  • following the 30th day of continuous presence in the U.S. after the person's return, if the time outside the U.S. was 30 consecutive days or more; or
  • the person returned to the U.S., if the time outside the U.S. was a full calendar month, but less than 30 consecutive days (calendar month of February only).

 

D-3310 Exceptions to U.S. Presence

Revision 09-4; Effective December 1, 2009

 

The U.S. residence requirement does not apply to:

  • a child who is a citizen and is living with a parent who is a member of the U.S. Armed Forces assigned to permanent duty ashore outside the U.S.; or
  • to certain persons temporarily abroad for study.

 

D-3400 Change of Address

Revision 12-3; Effective September 1, 2012

 

When a recipient moves, the recipient is required to report this change within 10 days to HHSC. A permanent change of address or residence is important for the following reasons:

  • It is very important to receive and maintain current address and residence information on the recipient's record to ensure proper receipt of Medicaid. Processing a change of address (COA) or residence request promptly will help alleviate any problems affecting the recipient's Medicaid eligibility.
  • A COA or residence request may indicate that a change in circumstances has occurred which may affect continuing Medicaid eligibility. For example, there may be changes in living arrangements, marital status, in-kind support and maintenance, and resources (for example, home ownership).

When a recipient wishes to visit another address within the state for more than a month, the recipient is required to report this change within 10 days to HHSC. If this COA is temporary, a temporary COA does not impact eligibility if the visit is for no longer than three months.

See Section F-3121, Intent to Return Policy.

 

D-3500 Intent to Remain in Texas

Revision 09-4; Effective December 1, 2009

 

To be eligible for Texas Medicaid, a person must be a resident of the state of Texas; that is, the person must have established residence in Texas and must intend to remain in Texas.

 

D-3510 Intent to Return

Revision 11-4; Effective December 1, 2011

 

A visit to another state does not terminate Texas residence if the person intends to return when the purpose of the visit is completed.

If a Texas resident visits out of the state (but remains in the United States) with subsequent returns or expressions of intent to return, the person’s Texas residence is not interrupted. A recipient is responsible for requesting a temporary change of address because of an absence from the state. The recipient is also responsible for informing HHSC about the purpose, plans, date of departure and date of planned return.

If the recipient does not contact HHSC before departure, but HHSC learns about the recipient’s absence from some other source, treat this information as a reported change. Attempt to get the recipient’s out-of-state address. After receiving the out-of-state address, contact the recipient to determine whether the absence from the state is temporary, why the recipient left and when the recipient plans to return to Texas.

The length of out-of-state visits is not limited. Review the recipient’s situation every three months to determine where the recipient intends to live permanently.

If the recipient’s absence from the state is temporary and an annual review is scheduled, mail the redetermination packet directly to the recipient at the out-of-state address. If the nature of the recipient’s visit is questionable, additionally request the recipient to:

  • restate the purpose of the absence; and
  • indicate the recipient’s official permanent residence.

Review the recipient’s response on the redetermination packet as to residency and intent to remain a Texas resident. Redetermine eligibility based on the recipient’s usual living arrangement unless the recipient no longer indicates Texas residency with the intent to remain a Texas resident.

Reference: Chapter F, Resources, for treatment of a home and out-of-state property.

 

D-3520 No Intent to Return

Revision 09-4; Effective December 1, 2009

 

A recipient leaving the state with no declared intent to return, and without any evidence that would indicate plans to return, is considered to have moved from the state and Medicaid is denied immediately. If the recipient subsequently returns to the state and declares the intent to remain, Medicaid may be resumed if the recipient meets all other eligibility requirements.

 

D-3600 Interstate Issues

Revision 09-4; Effective December 1, 2009

 

 

D-3610 Interstate Requests for Assistance

Revision 09-4; Effective December 1, 2009

 

If a recipient is eligible for Medicaid in another state and receives Medicaid in that state, the person is not eligible for Medicaid from the state of Texas.

If a person is placed in an institution located in Texas by an agency of another state, the person remains a resident of the state that made the placement.

 

D-3620 Out-of-State Medicaid and Texas Medicaid Recipients

Revision 09-4; Effective December 1, 2009

 

Under certain conditions, HHSC makes vendor payment to out-of-state providers on behalf of Texas Medicaid recipients. An out-of-state provider must be contracted with Texas as a Medicaid provider in its own state to provide care or services to Medicaid recipients and the recipients must be eligible for Texas Medicaid for the time involved. No payment commitment can be made until all necessary forms have been completed.

An out-of-state provider can contact Texas' contracted Medicaid claims administrator, currently the Texas Medicaid and Healthcare Partnership (TMHP). TMHP's website for the Texas Medicaid Program is www.tmhp.com.

The provider should furnish as much information as possible about the recipient, including the recipient's full name, Texas Medicaid number, Social Security number, date of birth, date of admission and date of discharge.

Note: If the person receives SSI and intends to live in the other state, inform the person to notify the Social Security Administration immediately about the move.

 

D-3630 Texas Applicant Outside the State of Texas

Revision 09-4; Effective December 1, 2009

 

If a person from Texas wishes to apply for Medicaid while outside the state, the person should contact the other state's Medicaid agency. The other state's Medicaid agency determines whether:

  • the person plans to live or visit in that state; and
  • that state's Medicaid is available to the person.

If the other state's Medicaid agency determines that the person is not eligible for that state's Medicaid, the other state's Medicaid agency contacts HHSC.

HHSC sends the person an application to apply for Texas Medicaid.

When the completed application is returned, use the person's Texas address as the residence address and the out-of-state address as the mailing address. Consider the person as a resident of Texas for the month of application and for the retroactive coverage period if appropriate.

After eligibility is determined, a copy of the decision is sent to the other state's Medicaid agency.

 

D-3640 Applicant from Another State

Revision 09-4; Effective December 1, 2009

 

A person from another state may ask to apply for Medicaid in Texas. Although the opportunity to apply for Medicaid cannot be denied to another, ask the following questions to assist the person in determining whether an application in Texas is appropriate:

  • Is the person visiting or does the person intend to live in Texas?
  • Is the person receiving Medicaid from another state?
  • Does the person want to receive Medicaid from Texas or from the other state?
  • Has the person declared intent to live in Texas with the full knowledge that if the person is eligible for Medicaid in Texas, the person is not eligible to receive Medicaid from the other state?
  • Is the person aware that if the person declares the intent to live in Texas and is certified for Medicaid in Texas, HHSC notifies the other state?

In some instances, a person might tentatively declare intent to live in Texas but is found to be ineligible for Medicaid in Texas. Be careful to avoid action that might jeopardize a person's continued eligibility for Medicaid from another state. Although a person might at first declare intent to live in Texas, the person might decide to continue receiving Medicaid from the other state (if the person learns of ineligibility for Medicaid in Texas). Consequently, the person might revoke the declaration of intent to live in Texas and keep the person's residence in the other state.

 

D-3650 Out-of-State Recipient Visiting Texas

Revision 09-4; Effective December 1, 2009

 

If a recipient who receives a money grant (TANF, general assistance, state supplementary payments to SSI) or Medicaid, including Medicare Savings Program benefits, from another state and applies for Medicaid in Texas, determine whether:

  • the recipient intends to continue receiving the money grant or Medicaid from the other state; and
  • Medicaid benefits are available to the recipient from that state.

Declaration to continue living in the other state — If the recipient declares the intent to continue living in the other state, the recipient is not eligible for Medicaid in Texas. Contact the out-of-state Medicaid agency to determine which services are covered and how providers file claims. Have the recipient inform any Texas Medicaid provider to send any claim to the out-of-state Medicaid agency in the recipient's state of residence.

Declaration to live in Texas — If a recipient who receives a money grant from another state (TANF, general assistance, state supplementary payments to SSI) makes a declaration of intent to live in Texas, this declaration does not automatically establish eligibility. Determine eligibility according to the requirements of the Texas Medicaid Program.

Impact on the medical effective date — If the intent to live in Texas is made by the recipient and the recipient meets Texas MEPD requirements, contact the out-of-state Medicaid agency of the recipient's former state of residence to determine the last day Medicaid claims will be paid by that state. The denial effective date is the last day for which the recipient 's former state of residence will pay Medicaid claims. This is not necessarily the denial effective date on the former state's computer system. The medical effective date for the recipient in Texas is no earlier than the day following the date the recipient 's former state of residence will pay Medicaid claims.

 

D-3660 SSI Recipient Visiting in Texas

Revision 16-3; Effective September 1, 2016

 

If an out-of-state SSI recipient indicates an intent to live in Texas, refer the recipient to a Social Security Administration (SSA) office. SSA makes the SSI residence determination. SSA will modify the SSI file indicating the new address. The change in the SSI file will trigger a change in the new address for the Medicaid file.

If the SSI recipient indicates a need for medical care during the month of the move to Texas, give the recipient Form H1300, Declaration of Texas Residency, and refer the recipient to an SSA office for verification of SSI status. SSA accepts Form H1300 via fax.

When the completed Form H1300 is returned, process under ME – Nursing Facility, to begin Medicaid coverage in Texas effective the day after the last date claims will be paid in the former state. Once the application has been disposed, Form H1027-A, Medicaid Eligibility Verification, covering the recipient's residence in Texas can be issued, if needed.

Example: An SSI recipient moves to Texas on Aug. 10 and needs medical care. After receipt of confirmation of SSI status for the month of August and verification from the former state that it will pay no Medicaid claims after Aug. 9, the eligibility specialist processes the application using ME – Nursing Facility for 8/10/YYYY through 8/31/YYYY and issues Form H1027 for those dates, if needed.

Note: Remember that Medicaid coverage in Texas may begin no earlier than the day after the last date claims will be paid by the former state.

If the request for coverage of medical care received in the month of the recipient's move to Texas is made during a subsequent month (or received in the month of the move, but the application is not disposed until the following month), the procedure is the same as above except that the application is processed using ME-SSI Prior for the month of move to Texas. In this instance, the medical effective date would be the first day of the month of move and the denial date would be the last day of that month. Do not issue Form H1027 for a past month. Instead, inform the recipient that Your Texas Benefits Medicaid ID card will be sent so that receipt is within seven to 14 days. The recipient must notify all providers of the added coverage for purposes of timely claims filing.

Example: An SSI recipient moves to Texas on May 24 and receives medical care on May 26. On June 15, the recipient requests assistance for that expense. After receipt of confirmation of SSI status for the month of May and verification from the former state that it will pay no Medicaid claims after May 23, the eligibility specialist processes the application using ME-SSI Prior for 5/1/YYYY through 5/31/YYYY. Inform the recipient that Your Texas Benefits Medicaid ID card will be sent so that receipt is within seven to 14 days, which the recipient must then use to notify provider(s) of Medicaid eligibility.

TIERS Procedures

Process as a manual SSI during the month of move. The medical effective date will be the first of the month.

Note: Even though the medical effective date precedes the actual date the recipient moves into the state, Texas medical claims would not have been incurred prior to the move date.

 

D-3700 Special Situations

Revision 09-4; Effective December 1, 2009

 

In the following situations, the state in which the person resides is influenced by several factors.

  • Under age 21 and not in an institutional setting. A person under age 21 who is not residing in an institutional setting is a Texas resident if the person is:
    • living in Texas more than temporarily;
    • living in another state when Texas has legal custody of the person; or
    • living in Texas, meets the blindness or disability criteria, and is MEPD eligible.
  • Under age 21 and in an institutional setting.
    • If the parent(s) or legal guardian lives outside of Texas, the residence of an institutionalized person under age 21 is the state in which the parent or legal guardian states the institutionalized person is present, and intends to stay.
    • If the parents have abandoned the person and no legal guardian has been appointed, the person's residence is the state in which the institution is, if the authorized representative acting on behalf of the person in making an application for MEPD lives in that same state.
    • If the person is married, the person's residence is the institution's state.
  • Age 21 or over and in an institutional setting.
    • The residence of an institutionalized person age 21 or over is the state in which the person is residing with the intent to remain.
    • If the person is incapable of indicating intent, the person's residence is determined in the same way as the residence of an institutionalized person under age 21.

Interstate institutional setting issue — If a person, regardless of his/her age, is placed in an institution located in Texas by an agency of another state, the person remains a resident of the state that made the placement.

Reminder: A person who lives in an institution for mental diseases must be age 65 or older to be eligible for an MEPD program.

 

D-3800 Inmates in a Public Institution

Revision 09-4; Effective December 1, 2009

 

A public institution is an establishment that is operated or controlled by a federal or state government unit, or a political subdivision, such as the city or county. An inmate of a public institution, including a jail, prison, reformatory or other correctional or holding facility, is not eligible for Medicaid payment for Medicaid-covered services received while residing in the public institution.

Permanent release — After permanent release from a correctional facility like a jail, prison, reformatory or holding facility, a person is not considered to be under the control of that institution. If, after a permanent release from a correctional facility, a person enters a Medicaid contracted long-term care facility (Medicare, skilled nursing facility (SNF), nursing facility (NF) or intermediate care facility for persons with mental retardation (ICF/MR)), the person is not considered to be in a public institution.