Revision 16-4; Effective December 1, 2016

 

Medicaid Buy-In for Children (MBIC) correspondence refers to a premium as a monthly payment.

A family may have to pay a monthly premium as a condition of eligibility. The premium amounts are based on a sliding scale, dependent upon family income and whether the applicant/recipient is covered under a parent's employer-sponsored health insurance (ESI) plan. If a parent's insurance qualifies, the Health Insurance Premium Payment Program (HIPP) can reimburse the family for the ESI premium (see D-7700, Health Insurance Premium Payment Reimbursement Program). HIPP eligibility is also a determining factor in the MBIC premium amount.

Note: The 50% rule for ESI only applies to eligibility and not to premium calculations.

Premium amounts are calculated using the gross countable family income. In the budgeting examples in Section N-6351, Examples of Budgeting Steps, the amount of gross family income used for premium calculation is the "balance of budget group income." Since the premium amount is calculated before the substantial MBIC exclusion of $85 + one-half of the remainder, 300 percent of the federal poverty level is used for the premium calculations.

Note: In TIERS, list the parent/guardian of the MBIC child as the head of household. The parent/guardian also needs to be listed as the alternate payee as well as the EDG name. This is primarily for any premium reimbursements and managed care purposes.

 

N-7100 Premiums for Alaskan Native or American Indian

Revision 11-3; Effective September 1, 2011

 

Premiums are waived if an applicant/recipient is an Alaskan Native or American Indian.

 

N-7200 Premiums in Multiple MBIC-eligible Families

Revision 11-3; Effective September 1, 2011

 

If there is more than one MBIC-eligible recipient in the family unit, there will be only one premium per family unit. Each eligibility determination group (EDG) will have a premium amount calculated; however, the lowest premium amount of all EDGs will be the premium charged.

 

N-7300 Premium Due Dates

Revision 11-3; Effective September 1, 2011

 

Premiums are due on the fifth of each month.

Premiums are not required for application month, disposition month or any month in between.

Example: Application is received in January 2011. Case is disposed in March 2011 with a medical effective date (MED) of Jan. 1, 2011. No premiums are required for January, February or March. First premium is due April 5. Premiums are required for the month following the disposition month regardless of the MED.

If premiums are required, payment of MBIC premiums is a condition of continued eligibility.

 

N-7310 Grace Period for Premiums

Revision 11-3; Effective September 1, 2011

 

An applicant/recipient is given a 60-day grace period to make a premium payment before denial occurs. If a recipient has missed making a premium payment for two consecutive months, the Texas Integrated Eligibility Redesign System (TIERS) will send Form H0062-MBIC, Late Payment Notice, and Form H0065-MBIC, Hardship Form. If a payment is not received by two days before TIERS cutoff, two months after the first missed payment, and a valid hardship is not claimed by the due date on the Form H0065-MBIC, TIERS will auto terminate the MBIC EDG(s) effective the end of that month.

Example: First missed payment is May 5, 2011. On June 5, 2011, the May payment is missed a second time. On June 7, 2011, Form H0062-MBIC, Late Payment Notice, and Form H0065-MBIC, Hardship Form, are sent to the client/authorized representative. Due date for premium payment is July 6, 2011. Due date for a hardship to be claimed is June 17, 2011 (10 days from the date of Form H0065-MBIC). Payment must be received by two days before cut-off in July 2011 or hardship claimed by June 17, 2011. If no payment is received or hardship claimed, denial is effective July 31, 2011. TIERS will auto terminate the MBIC EDG(s) effective the end of that month.

 

N-7320 Premiums and Reapplication for MBIC

Revision 11-3; Effective September 1, 2011

 

If a person is denied MBIC, but later reapplies and is eligible for MBIC, there is no requirement to pay the missed premiums from the last eligibility period before new eligibility can be granted.

 

N-7330 Coordination with the Children with Special Health Care Needs (CSHCN) Program

Revision 11-3; Effective September 1, 2011

 

If an MBIC applicant/recipient is also eligible for the CSHCN Program through the Department of State Health Services (DSHS), the state will pay the MBIC premium. There is no coordination or verification required by Medicaid for the Elderly and People with Disabilities (MEPD) specialists. Direct payment of the person's medical insurance premiums by anyone on the person's behalf is not considered as income. See Section E-1710, Medical Care and Services That Are Not Income.

DSHS will make referrals of CSHCN persons that may be potentially eligible for MBIC. Some of these people may already be eligible for the Children's Health Insurance Program (CHIP). Based on information from DSHS, there is no requirement for a CSHCN eligible person that is also eligible for CHIP to switch to MBIC. It is the person's choice. If the person chooses to remain in CHIP, document in case comments the person's choice and deny the MBIC application as a voluntary withdrawal.

 

N-7400 Premium Amounts

Revision 11-3; Effective September 1, 2011

 

Premium amounts vary based on whether the family does or does not have ESI and whether HIPP is involved or not. Premium amounts are automatically determined by TIERS.

The charts in Section N-7410, Charts for Premium Amounts, outline the premium amounts for persons with:

  • no ESI;
  • ESI and state-paid HIPP; or
  • ESI and no state-paid HIPP.

 

N-7410 Charts for Premium Amounts

Revision 14-3; Effective September 1, 2014

 

No ESI

Note: These premium amounts are current. These amounts are subject to change when FPIL limits change.

Family Income Family of 1 or 2
Premium Amount
Family of 3 or More
Premium Amount
At or below 150% FPIL $0 $0
151–200% FPIL $90 $115
201–300% FPIL $180 $230

 

ESI with State-Paid HIPP

Note: These premium amounts are current. These amounts are subject to change when FPIL limits change.

Family Income Family of 1 or 2
Premium Amount
Family of 3 or More
Premium Amount
At or below 150% FPIL $0 $0
151–200% FPIL $25 $35
201–300% FPIL $50 $70

 

ESI and No State-Paid HIPP

No premiums are required for families with ESI who are not eligible for HIPP. These families are paying their full share of the premium for ESI and are not expected to also pay a premium for MBIC.

 

N-7500 Hardship

Revision 11-3; Effective September 1, 2011

 

A hardship exemption may be granted for loss of income if the loss of income is due to:

  • termination of employment because of layoff or business closing;
  • involuntary reduction in work hours;
  • a parent leaving the household because of divorce or separation; or
  • a parent's death (the parent had to be previously residing in the same household as the MBIC applicant/recipient).

No hardship exemption is allowed to waive prior months premium(s).

Hardship exemption is only allowed once per household every 12 calendar months (regardless of how many MBIC recipients are in the household).

A hardship must be requested within 10 days from the date on Form H0065-MBIC, Hardship Form. A hardship request must be in writing; however, a verbal request is acceptable to meet the 10-day deadline. Written follow-up is required.

Example: First missed payment is May 5, 2011. On June 5, 2011, the May payment is missed a second time. On June 7, 2011, Form H0062-MBIC, Late Payment Notice, and Form H0065-MBIC, Hardship Form, are sent to the client/authorized representative. Due date for premium payment is July 6, 2011. Due date for a hardship to be claimed is June 17, 2011 (10 days from date of Form H0065-MBIC). Payment must be received by two days before cut-off in July 2011 or hardship claimed by June 17, 2011. If no payment is received or hardship claimed, denial is effective July 31, 2011. TIERS will auto terminate the MBIC EDG(s) effective the end of that month.

 

N-7510 Hardship Approval

Revision 11-3; Effective September 1, 2011

 

Approve a hardship request if one of the valid reasons is met. Do not require verification of hardship reasons. Use client's statement and signature on Form H0065-MBIC, Hardship Form, as proof of the hardship; however, if the reason is something that would potentially impact benefits (such as loss of job), verify the change for potential eligibility changes to ongoing benefits. This does not have to be done before the hardship can be approved. Notify a client/authorized representative of the hardship approval on Form TF0001-MBIC, Hardship Waiver Approved.

If approved, the hardship exemption begins on the first of the month for which a premium payment was not received and is granted for three consecutive months.

Example: Premiums were missed in May and again in June. Hardship was claimed on Form H0065-MBIC, and hardship was approved in July. Premiums are waived for May, June and July.

 

N-7511 Hardship Approval Reasons

Revision 11-3; Effective September 1, 2011

 

Form TF0001-MBIC, Hardship Waiver Approved, will be pre-populated with one of the following reasons.

  • Someone living with you was laid off their job. – OR – The place where they work closed.
  • Someone living with you has less income because they work fewer hours.
  • A parent left the house because of a divorce or separation.
  • A parent died. (This is an approval reason but this actual verbiage will not print on the TF0001.)

 

N-7520 Hardship Denial

Revision 11-3; Effective September 1, 2011

 

Deny a hardship request if:

  • none of the valid reasons are met; or
  • Form H0065-MBIC, Hardship Form, or a verbal request was not received by the due date; or
  • a hardship has been granted within the past 12 calendar months. TIERS will track the12-month period.

Notify a client/authorized representative of the hardship denial via Form TF0001-MBIC, Hardship Waiver Denied.

 

N-7521 Hardship Denial Reasons

Revision 11-3; Effective September 1, 2011

 

Form TF0001-MBIC, Hardship Waiver Denied, will be pre-populated with one of the following reasons.

  • We didn't get your "Hardship Form" (H0065-MBIC) by the due date.
  • It hasn't been 12 months since we last stopped your payments. Your payments can be stopped for three months only once in 12 months.
  • You didn't lose money from a job (income) for reasons that allow us to stop your payments.

 

N-7600 Presidential-Declared Emergency

Revision 11-3; Effective September 1, 2011

 

A presidential-declared emergency hardship exemption will automatically be granted to recipients living in the declared area and premiums will be waived for three months. Recipients do not have to request a hardship for a presidential-declared emergency. TIERS will send an "emergency special notice" to inform recipients at the start of the presidential-declared emergency period that the premiums have been waived.

For MBIC recipients, the waiver of premiums for a presidential-declared emergency is for the month of declaration and forward for a total of three months.

Hardship exemption and presidential-declared emergency periods can overlap. They do not run consecutively.

Example: A recipient has hardship exemption for January, February and March. A presidential-declared emergency is declared for March. The presidential-declared emergency hardship would normally be allowed for March, April and May. Total number of months the recipient is not required to pay premiums is five, which are January, February, March, April and May.

A presidential-declared emergency has priority over a hardship exemption if the two situations fall during the same time period. If a hardship exemption has been approved but a presidential-declared emergency is granted for the same time period, the client cannot have another hardship exemption for 12 months.

There is no limit to how many times a recipient may receive a presidential-declared emergency hardship; however, a recipient may only receive one presidential-declared emergency per disaster.

 

N-7700 Prior Months' Premiums

Revision 11-3; Effective September 1, 2011

 

MBIC correspondence refers to these as "payments for past months."

Prior months' eligibility is not granted until premiums for prior months are paid. If all prior months have a $0 premium, eligibility will be granted upon disposition. If any of the prior months have a premium, the premium is due two months after the initial premium due date.

Example: Application is filed in March, disposed on April 1.The prior months are January and February. The premiums for January and February are due on July 5 (two months after May 5, the initial premium due date).

When premiums are paid, eligibility is granted beginning with the last month of the prior month period. Months cannot be skipped, even if a month with a $0 premium falls between two months that require a premium. In the following examples, January, February and March are prior months.

Examples:

  • January is $90, February is $90 and March is $90. As premiums are paid, eligibility is granted first for March, then February, and then January.
  • January is $90, February is $0 and March is $90. March has to be paid before February is granted.

Reminder: No hardship is allowed to waive prior months' premium(s).

 

N-7800 Health Insurance Premium Payment (HIPP)

 

Revision 11-3; Effective September 1, 2011

 

If a parent gets health insurance at work, that information will be sent to the HIPP program for review. If certain standards are met, HIPP will pay the entire health insurance premium as a reimbursement to the individual.

Parents/persons who want to learn more can call 1-800-440-0493 or visit www.gethipptexas.org.

When ESI information is entered into TIERS, this information is automatically sent to HIPP. HIPP eligibility is not an MEPD specialist's responsibility; however, HIPP eligibility does impact the MBIC premium amount.

 

N-7900 Cost-Sharing

 

Revision 11-3; Effective September 1, 2011

 

Cost-sharing is the amount a person pays out of their own pocket for health care. Cost-sharing includes MBIC premiums. Recipients will receive information from the premium processing vendor regarding what expenses are included in cost-sharing.

 

N-7910 Cost-Share Limit

 

Revision 11-3; Effective September 1, 2011

 

Each recipient has a cost-share limit. TIERS will calculate a cost-share limit for each recipient and populate the cost-share limit on Form TF0001-MBIC, Initial Certification.

There is no cost-share limit for the prior months.

Cost-share limit is set at the eligibility determination group level. If there is more than one MBIC-eligible recipient in the family unit, there will be only one cost-share limit per family unit. Each EDG will have a cost-share limit calculated; however, the lowest cost-share limit of all EDGs will be used at a case level.

The cost-share limit for each family is set at:

  • 5% of countable gross annual income for a family whose countable gross annual income is at or below 200 percent of the FPIL.
  • 7.5% of countable gross annual income for a family whose countable gross annual income is 201% to 300% of the FPIL.

The amount of monthly gross countable income in the month following disposition is multiplied by 12 in order to determine the gross annual income used in calculating the cost-share limit. This is the total gross countable income prior to the MBIC exclusion of $85 + one-half.

The cost-share limit can change if there is a change in income during that initial 12-month period. Example: MBIC application is received in January 2011 and certified in March 2011. The cost-share limit is based on income budgeted for April 2011 and begins April 2011. In August 2011, a change in income is reported and case action is taken in August (cut-off is taken into consideration). A new cost share limit will begin in September 2011.

 

N-7920 Cost-Share Period

 

Revision 11-3; Effective September 1, 2011

 

A cost-share period is established for each recipient. This period begins the first day of the disposition month and lasts for 12 months. This is the period during which an MBIC recipient's medical costs and MBIC premiums can be counted toward the cost-share limit.

There is no cost-share period for the prior months.

The original cost-share period is retained for MBIC eligibility determination groups when:

  • an individual is denied in error and then reactivated; and
  • a previously certified MBIC client enters a facility (transfer) and then returns to MBIC within the same cost-share period.

A new cost-share period will be set (based on the new disposition date) when a person reapplies if an MBIC EDG is denied or terminated for any reason except for:

  • denied in error, or
  • transfer between programs.

 

N-7930 Tracking Cost-Share Expenses

Revision 11-3; Effective September 1, 2011

 

A recipient is exempt from MBIC monthly premiums for the remainder of the coverage period when the cost-share expenditures for the recipient reach the cost-share limit.

For a recipient without employer-sponsored health insurance, the premium processing vendor will determine when the MBIC premium payments reach the cost-share limit.

For a recipient with employer-sponsored health insurance and the Health Insurance Premium Payment Program, the recipient must track cost-share expenses. A form will be provided by the premium processing vendor for the recipient to report when the cost-share limit is reached. This form is entitled "Medical Costs List."

The premium processing vendor will provide a refund if a monthly premium payment is received after the cost-share limit has been met. This is automatically tracked by the premium processing vendor.