Revision 14-2; Effective June 1, 2014

 

HHSC requires an applicant to provide his/her Social Security number (SSN). An exception to this requirement is for treatment of an emergency medical condition.

HHSC requires an applicant to apply for and obtain, if eligible, all other benefits to which he/she may be entitled, with some exceptions.

 

D-6100 Texas Administrative Code Rules

Revision 09-4; Effective December 1, 2009

 

§358.209. Social Security Number.

In accordance with 42 CFR §435.910, a person must give his or her social security number to the Texas Health and Human Services Commission as a condition of eligibility, except as provided in §358.205(c) of this subchapter (relating to Alien Status for Treatment of an Emergency Medical Condition).

 

§358.205. Alien Status for Treatment of an Emergency Medical Condition.

(c) An undocumented non-qualifying alien applying for Medicaid for the treatment of an emergency medical condition is exempt from providing proof of alien status or providing a Social Security number as described in 42 CFR §435.406(b).

 

§358.217. Application for Other Benefits.

To be eligible for a Medicaid-funded program for the elderly and people with disabilities, a person must apply for and obtain, if eligible, all other benefits to which the person may be entitled, in accordance with 42 U.S.C. §1382(e)(2).

 

D-6200 SSN Requirement

Revision 14-2; Effective June 1, 2014

 

As a condition of eligibility, a person must furnish HHSC with his/her Social Security number (SSN). If the person is married, the person must also provide his/her spouse's SSN.

State office uses two tape exchanges with the Social Security Administration (SSA) to verify the person’s SSN.

Sources for verification of an SSN are:

  • SOLQ or WTPY;
  • Social Security card; and
  • verification of a Medicare number with suffix A, J1, M, S or T.

The applicant should be given a reasonable opportunity to provide an SSN.

 

D-6210 When a Person Does Not Have an SSN

Revision 11-4; Effective December 1, 2011

 

Explain to the person the necessity and the procedure for obtaining a Social Security number (SSN) if the person does not have one. Document the explanation in the case record.

Give the person or authorized representative notice that an SSN must be obtained by the first redetermination. This notice can be on the eligibility letter or on Form H1020, Request for Information or Action. The person must apply for and secure an SSN by the redetermination date.

Complete Form H1106, Enumeration Referral, which is found in the Texas Works (TW) Handbook. Upon receipt of Form H1106, the Social Security Administration (SSA) processes an SSN application.

If necessary, give SSA-5, Application for a Social Security Number, to the person and assist the person in completing the SSA-5. Inform the person to forward the SSA-5 to SSA with proof of his/her age, identity and citizenship (or lawful admission to the U.S.).

Grant eligibility at application, if otherwise eligible, pending receipt of an SSN. Tell the person to inform HHSC as soon as the SSN is received. Upon receipt, enter the SSN in the system of record.

At the first redetermination, verify that the person applied for an SSN if the person cannot provide an SSN. Failure of the person or authorized representative to follow through and secure an SSN is grounds for denial at the first redetermination. Document the circumstances of the denial in the case comments.

 

D-6300 Application for Other Benefits Requirement

Revision 09-4; Effective December 1, 2009

 

Medicaid is intended to be a program of last resort. Therefore, it is important to assess the other benefits for which a person may be eligible based on the person's own activities or on indirect qualifications through family circumstances.

If a person is not receiving potential benefits, notify the person in writing of the requirement to apply for and comply with the application requirements of the other benefit(s).

A person is not eligible for Medicaid if:

  • HHSC informs the person on a written, dated notice of his/her potential eligibility for other benefits; and
  • the person does not take all appropriate steps to apply for the benefit within 30 days of receipt of such notice.

The notice informs the person or authorized representative that the person must take all appropriate steps to pursue eligibility for other benefits within 30 days of receipt of such notice. Appropriate steps include:

  • applying for the benefit; and
  • providing the other benefit source with the necessary information to determine eligibility for the benefit.

 

D-6310 Other Benefits Subject to Application Requirement

Revision 09-4; Effective December 1, 2009

 

"Other benefits" includes any payments for which a person can apply that are available to that person on an ongoing or one-time basis of a type that includes annuities, pensions, retirement benefits or disability benefits, including:

  • RSDI Title II benefits;
  • veterans' pension and compensation payments;
  • retirement benefits;
  • workers' compensation payments;
  • pensions; and
  • unemployment insurance benefits.

These benefits are common in that they:

  • require an application or similar action;
  • have conditions for eligibility; and
  • make payments on an ongoing or one-time basis.

See Section D-6340 through Section D-6380 for details regarding benefits subject to the application requirement.

 

D-6320 Other Benefits Exempt from Application Requirement

Revision 09-4; Effective December 1, 2009

 

"Other benefits" exempt from the requirement to apply for other benefits are:

  • Temporary Assistance for Needy Families (TANF);
  • general public assistance;
  • Bureau of Indian Affairs general assistance;
  • victims' compensation payments;
  • other federal (other than SSI), state, local or private programs that make payments based on need; and
  • earned income tax credits.

 

D-6330 Payments That Are Not Other Benefits

Revision 09-4; Effective December 1, 2009

 

"Other benefits" do not include:

  • payments that a person may be eligible to receive from a fund established by a state to aid victims of crime; or
  • payments such as child support, alimony and accelerated life insurance.

 

D-6340 Supplemental Security Income (SSI)

Revision 09-4; Effective December 1, 2009

 

If a person who has no income applies for Medicaid with HHSC, refer that person to the Social Security Administration (SSA) for SSI benefits. SSI eligibility will provide a greater benefit to the person by allowing the person to receive a cash benefit as well as Medicaid.

Exception: Process the application and do not refer a person who has no income to SSA for SSI if the application is for Medicaid coverage for:

  • retroactive months for a deceased person or based on an SSI application; or
  • treatment of an emergency medical condition.

 

D-6341 MEPD Eligibility Pending Adjudication of SSI Claims

Revision 11-4; Effective December 1, 2011

 

A person who has applied for Supplemental Security Income (SSI) and who appears 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 eligible for SSI, 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 in TIERS is adjusted via an interface. This is not adverse action because the person does not lose benefits.
  • If the person is younger than age 65, disability determination by the Disability Determination Unit (DDU) cannot be made unless 90 days have elapsed since the SSI file date and the Social Security Administration's (SSA) disability decision is still pending. See Section D-2500, Supplemental Security Income (SSI) Applicants and Retroactive Coverage.

DDU cannot render a disability decision for SSI applicants unless 90 days have elapsed since the SSI file date and SSA's disability decision is still pending. If SSA finds the person not to be disabled after the person has been certified for MEPD coverage, initiate denial of the MEPD case.

Once the person is eligible for SSI, the coverage in TIERS is adjusted via an interface.

  • The denial is not adverse action because the person does not lose benefits.
  • Do not send Form TF0001, Notice of Action, unless copayment is being changed.
  • For Community Living Assistance and Support Services (CLASS) and Home and Community-based Services (HCS) cases, notify DADS of the denial using the Medicaid Eligibility to DADS automated communication tool or Form H2067, Case Information.

The procedures outlined in this section are not routine procedures. Use them only in situations where there has been a delay in an SSI claim already filed. (The MEPD 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. For example, there is no existing MEPD program that provides full Medicaid coverage on an ongoing basis to community-based clients with countable income below the SSI federal benefit rate.

 

D-6350 Veterans Benefits

Revision 09-4; Effective December 1, 2009

 

The most common types of benefits from the U.S. Department of Veterans Affairs (VA) are:

  • pension;
  • compensation;
  • educational assistance;
  • aid and attendance allowance;
  • housebound allowance;
  • clothing allowance;
  • payment adjustment for unusual medical expenses;
  • payments to Vietnam veterans' children with spina bifida; and
  • insurance payments for disability insurance and life insurance.

Explore the possibility of receipt of, or potential eligibility for, a VA benefit when it appears that a person is:

  • a veteran;
  • the child or spouse of a disabled or deceased service person or veteran;
  • an unmarried widow or widower of a deceased service person or veteran; or
  • the parent of a service person or veteran who died before Jan. 1, 1957, from a service-connected cause.

A person who is potentially eligible for some VA benefits must apply for those benefits. When referring a person to the VA, recommend that the person call the VA first to obtain information on application requirements and proof the person may need to bring.

 

D-6351 VA Pension or Compensation

Revision 10-1; Effective March 1, 2010

 

Refer a person for VA pension payments (based on a nonservice-connected disability) if all of the following conditions are met:

  • The veteran or deceased service member served at least 90 days, at least one of which was during a wartime period (see Section D-6352, VA Wartime Periods).
  • The person being referred is a veteran, surviving spouse or surviving child.
  • The person has not alleged, in a signed statement, having previously applied for the Department of Veterans Affairs Improved Pension Plan (VAIP).

Refer the person for VA compensation payments if the veteran or deceased service person suffered a service-connected disability (even though minor) or died.

Refer a person for VA payment increases for medical expenses. However, do not monitor for the person’s compliance to apply for other benefits when it is to increase the VA payment for medical expenses. These VA payment increases for medical expenses are known as aid and attendance, housebound benefits or additional payments for unusual medical expenses and are considered exempt payments that do not affect eligibility or co-payment.

See the following references:

Exceptions:

  • Do not refer a person who has been eligible for a VA pension since before 1979.
  • Do not refer a person who is receiving the $90 VA pension in an institutional setting.

See the following references:

 

D-6352 VA Wartime Periods

Revision 14-1; Effective March 1, 2014

 

The wartime periods are:

War Time Periods
World War I Apr 6, 1917 to Nov 11, 1918
World War II Dec 7, 1941 to Dec 31, 1946
Korea Jun 27, 1950 to Jan 31, 1955
Vietnam (served in the Republic of Vietnam) Feb 28, 1961 to Aug 4, 1975
Vietnam (served other than in the Republic of Vietnam) Aug 5, 1964 to May 7, 1975
(Persian) Gulf War Aug 2, 1990 through a date to be set by law or presidential proclamation (per VA)
Operation Enduring Freedom (Afghanistan) and Operation Iraqi Freedom 2001 to present

Note: This war period is not yet listed on the VA's website. Refer person to VA Benefit Counselor at 1-800-827-1000.

 

D-6353 VA Payments for Dependents

Revision 09-4; Effective December 1, 2009

 

The VA may take a dependent's needs into account in determining a pension. Usually, however, the VA does not make a pension payment directly to a dependent during the lifetime of the veteran. Instead, the amount of the veteran's basic pension is increased if the veteran has dependents.

Augmented VA payment — A VA pension payment that has been increased for dependents is an augmented VA payment. For Medicaid purposes, the augmented benefit includes a designated beneficiary's portion and one or more dependents' portions.

Apportioned VA payment — A VA compensation payment made directly to the dependent of a living veteran is an apportioned payment. Apportionment is direct payment of the dependent's portion of VA benefits to a dependent spouse or child. The VA decides whether and how much to pay by apportionment on a case-by-case basis. Apportionment reduces the amount of the augmented benefit payable to the veteran or veteran's surviving spouse.

 

D-6354 Requirement to Apply for Apportionment of Augmented VA Benefit

Revision 09-4; Effective December 1, 2009

 

To be eligible for Medicaid, a dependent of a veteran must apply for apportionment (direct payment) of an augmented VA benefit if the dependent specifically:

  • is the spouse or child of a living veteran, or the child of a deceased veteran with a surviving spouse, and the veteran or surviving spouse receives VA compensation, pension or educational benefits;
  • does not reside with the designated beneficiary (that is, the veteran or the veteran's surviving spouse); and
  • has not been denied apportionment since living apart from the designated beneficiary.

Dependents who are receiving a VA benefit by apportionment do not receive automatic cost-of-living adjustments. Do not refer these individuals to the VA to request an increase.

 

D-6360 Workers' Compensation Payments

Revision 09-4; Effective December 1, 2009

 

If a person alleges either injury on the job or has what appears to be a work-related impairment, refer him/her to the appropriate agency for assistance.

 

D-6370 Private Sector Pensions

Revision 09-4; Effective December 1, 2009

 

Refer a person for a private sector pension if the person or the person's former (divorced or deceased) spouse:

  • worked for a private employer with a pension plan;
  • was age 25 or older during such employment; and
  • is not or was not already receiving a pension from the employer (or union) based on that employment.

 

D-6380 Public Sector Pensions

Revision 09-4; Effective December 1, 2009

 

Refer a person for a public sector pension if the person or the person's former (divorced or deceased) spouse, or a deceased parent if the person is a child, is not or has not received a pension based on public sector employment and meets the guidelines below:

  • Federal Civilian Employment — A person may be eligible for a federal pension if the worker did not withdraw employee contributions to the pension plan and was employed under the:
    • Civil Service Retirement System (CSRS) for a minimum of five years;
    • Federal Employees Retirement System (FERS) for a minimum of 18 months.

      Note: Often, federal employees covered under CSRS who are ill will take an extended leave of absence without pay and may apply for SSI. Such federal employees are not required to apply for a pension unless it is clear that they have terminated their job status.
  • Employment in the Federal Uniformed Services (Military) — A person may be eligible for a military service pension if the service person served a minimum of 20 years.
  • Employment by a State or Local Government — A person may be eligible for a state or local government pension if the employee:
    • was employed for a minimum of five years, or was employed (regardless of the length of time) by either a state or as a teacher in a public college or university; and
    • did not withdraw employee contributions, or withdrew employee contributions but was either a teacher in a public college or university or was employed by a state or local police/fire department.

 

D-6400 Treatment of Other Benefits

Revision 09-4; Effective December 1, 2009

 

 

D-6410 Deeming Situations

Revision 09-4; Effective December 1, 2009

 

Do not require a deemor to apply for other benefits. If a deemor applies for and receives other benefits on his/her own initiative, the amount of benefits he/she receives and/or retains is subject to the deeming policies for income and resources.

 

D-6420 Payment Options for Other Benefits

Revision 09-4; Effective December 1, 2009

 

Most of the types of benefits for which a person must apply offer choices about the method of payment. The person must apply for all other benefits payable at the earliest month and in the highest amount available based on the earliest month.

Note: Irrevocable choices and selections of benefits from pensions or retirement programs made before a person applies for Medicaid do not affect eligibility.

 

D-6421 Survivor's Benefits for Spouses and Other Dependents

Revision 09-4; Effective December 1, 2009

 

Certain pensions and retirement programs permit a person to elect survivor's benefits for dependents by electing a reduced retirement benefit. Inform the person that he/she must elect the higher current benefit to retain Medicaid eligibility. Election of the reduced retirement benefit will result in the loss of Medicaid eligibility until such time as the pension or retirement program election is changed or the option for change is no longer available.

Some pensions and retirement programs require a spouse to apply a waiver of rights to a survivor's benefit. The person is not penalized for failing to comply with the requirement to apply for other benefits if the reduced retirement benefit results from the spouse’s refusal to sign a waiver of rights to a survivor's benefit.

 

D-6422 Lump Sum or Annuity Payment Option

Revision 09-4; Effective December 1, 2009

 

If a person can choose between a lump sum or an annuity as the payment method for a benefit, inform the person that he/she must choose the annuity option.
Consider lump sum payments as follows:

  • Request for a Lump Sum Payment – If an application has been made for a lump sum payment of the monies on which a potential annuity is based and the benefit source permits the person to change the decision and apply for the annuity, the person must pursue the change to be eligible for Medicaid. If the benefit source does not permit such a change, accept the person's word that the decision is irreversible, absent evidence to the contrary.
  • Retroactive RSDI Title II Benefit Lump Sum Payment – Although filing for full retroactive RSDI Title II benefits may result in a lump sum payment, this payment represents the amount of the past due RSDI Title II benefits and is not a fund that determines future regular payments.
  • Lump Sum Only Payments – Do not require a person to apply if only a lump sum payment is available. In this situation, the payment is a resource. (This does not include a lump sum death payment under RSDI Title II.) All sources of available support (unless otherwise excluded) are considered in determining eligibility. This is true even if current needs compel a person to sacrifice future pension benefits.

For a purchased annuity, see related policy in Chapter F, Resources, and Chapter I, Transfer of Assets.

 

D-6430 Electing the Month of Entitlement

Revision 09-4; Effective December 1, 2009

 

If a person can select the month in which benefits begin, whether retroactively or prospectively, direct the person to elect the earliest month benefits can begin, regardless of the impact on other benefits from that program. Election of a later month of entitlement to qualify for higher ongoing benefits or to protect benefits paid to other individuals is cause for denying Medicaid. Election of a later month will result in the loss of Medicaid eligibility until such time as the election is changed or the option for change is no longer available.

 

D-6440 Establishing Eligibility After Denial

Revision 09-4; Effective December 1, 2009

 

If denial has occurred because of failure to pursue other benefits, establish or reestablish eligibility when:

  • the other benefit is no longer available, effective the month following the month the other benefit is no longer available; or
  • the person takes the necessary steps to obtain the other benefit, effective the earliest day in a month that the person takes appropriate steps to obtain other benefit.

 

D-6500 Exceptions to the Application for Other Benefits Requirement

Revision 09-4; Effective December 1, 2009

 

A person is eligible for Medicaid, despite failure to apply for other benefits within the 30-day period or to take other necessary steps to obtain other benefits, if there is good reason for not doing so. For example, there is good reason if:

  • the person’s guardian or authorized representative is unable to apply for other benefits because of illness; or
  • it would be useless to apply because the person had previously applied and the other program has already turned the person down for reasons that have not changed.

According to Public Law 101-508, a person is not required to accept, as a condition of eligibility, payments that a state may make as compensation to victims of crime.

When applying for or receiving benefits under a Medicare Savings Program, a person is not required to apply for SSI benefits in order to be eligible for MSP coverage.

 

D-6600 When Not to Refer for Other Benefits

Revision 09-4; Effective December 1, 2009

 

No Apparent Eligibility — If a person does not meet the basic eligibility requirements for a benefit:

  • do not refer the person to apply for that benefit; and
  • document the case record with the reason.

Prior Denial — If the person alleges having applied for other benefits previously and having been denied for reasons other than failure to pursue, accept the signed statement regarding the denial, unless there is evidence to the contrary.

Contributions Withdrawn — If a person alleges withdrawal of contributions from a public sector pension, accept the person's signed statement regarding the withdrawal unless:

  • the employee was a teacher in a public college or university or was employed by a state or local police/fire department (and no precedent exists stating that, once funds are withdrawn, no benefits are payable); or
  • there is evidence to the contrary (for example, prior knowledge indicates funds may not be withdrawn).

Application Pending — If a person alleges an application for another benefit is pending:

  • send a verification letter to the benefit source; and
  • set up a special review to monitor receipt of the benefit.

Consider the followingwhen assessing the possibility of other benefits a person may be eligible for:

  • General identification:
    • Employer's name and address.
    • Name and telephone number of the person who can supply pension information.
  • Pension plan:
    • Existence of a pension plan.
    • Statement as to whether or not employees contribute and, if they do, what happens to those contributions upon termination of employment for reasons other than retirement or disability.
    • Vesting requirements.
    • Pension plan provisions for survivors and/or dependents (including divorced spouses).
  • Union:
    • Whether or not there is a union.
    • If so, whether the union provides a pension.
    • Name, address and local telephone number of the union.
    • Conditions to qualify for the pension.
    • Union contact for additional information on the pension (including the telephone number).
  • Any other pertinent information, such as the date pension information was obtained and recorded.