Revision 17-2; Effective June 1, 2017

 

N-8100 Medical Effective Date

Revision 11-3; Effective September 1, 2011

 

The medical effective date (MED) for Medicaid Buy-In for Children (MBIC) cannot be before Jan. 1, 2011. This includes any prior months' eligibility for MBIC. If an application is received in which the prior months occur before January 2011, determine eligibility for other MEPD programs in those prior months. Do not automatically disregard the prior months because an MBIC application is received and the prior months occur before January 2011.

 

N-8200 Prior Months' Eligibility

Revision 17-2; Effective June 1, 2017

 

Eligibility for three prior months to the application month is available for this program. Prior months' eligibility for MBIC cannot be granted before Jan. 1, 2011.

If a premium is required, eligibility for prior months is not granted until premiums have been paid.

See Appendix XLIX, Medicaid Buy-In for Children Forms Chart. Form TF0001-MBIC, Prior Months Eligibility Notice, serves as both the eligibility notice and denial notice. If the premiums are not received by the due date, the prior months are not granted and are denied. Do not send a separate denial notice for failure to pay premium for prior months.

 

N-8300 Case Actions

Revision 11-3; Effective September 1, 2011

 

N-8310 Verification Checklist and Pending Reasons

Revision 11-3; Effective September 1, 2011

 

The following new verification checklist and pending reasons have been created for this program. These reasons will be pre-populated by TIERS on Form H1020, Request for Information or Action.

  • Send proof that you signed up for your job's health insurance.
  • Send proof that shows you get health insurance through your job.
  • Send proof that the child applying for Medicaid Buy-In for Children can't be on your job's health insurance plan.
  • Send proof that your health insurance company changed.
  • Let us know the next date you can enroll in your job's health insurance plan.
  • Send proof that your job pays at least half the premium of your health insurance.

 

N-8320 Change Action Reasons

Revision 11-3; Effective September 1, 2011

 

The following new change action reasons have been created for this program. These reasons will be pre-populated by TIERS on Form TF0001-MBIC, Change in Monthly Premium Amount or Cost-Share Limit.

  • You reached your cost-share limit for this benefit period.
  • You did not reach your cost-share limit for this benefit period.
  • Your family is making more money (income).
  • Your family is making less money (income).
  • The number of people in your family changed.
  • You have health insurance through your job
  • You don't have health insurance through your job.
  • The Health Insurance Premium Payment program (HIPP) is paying for your private health insurance.
  • The Health Insurance Premium Payment program (HIPP) isn't paying for your private health insurance.

 

N-8330 Denial Reasons

Revision 11-3; Effective September 1, 2011

 

In addition to existing MEPD denial codes, new denial reasons have been created for this program. These reasons and references will be pre-populated by TIERS on:

  • Form TF0001-MBIC, Case Action Termination;
  • Form TF0001-MBIC, Case Action Denial; and
  • Form TF0001-MBIC, Prior Months Eligibility.

Section N-8331 below outlines the reasons and references.

 

N-8331 Denial Reasons and Reference Chart

Revision 11-3; Effective September 1, 2011

 

Denial Reason Reference
It is too late to ask for benefits for these months. 1 TAC §361.115(g)
<Child's name> is married. 1 TAC §361.107
You didn't send proof that shows you get health insurance through your job. 1 TAC §361.113
You didn't send proof that shows when your job's health insurance benefits began. 1 TAC §361.113
You didn't send proof that shows your child can't be on your job's health insurance plan. 1 TAC §361.113
You didn't send proof that shows you signed up for your job's health insurance. 1 TAC §361.113
Your payment couldn't be processed. 1 TAC §361.115(a)
<Child's name> is age 19 or older. 1 TAC §361.107

 

N-8340 Redeterminations

Revision 11-3; Effective September 1, 2011

 

Redeterminations for MBIC follow regular Medicaid for the Elderly and People with Disabilities (MEPD) policy for redeterminations.

Streamlining methods and passive reviews are not allowed for an MBIC redetermination.

If a case has an MBIC eligibility determination group (EDG) and another ME EDG, the persons in the case will get both a Form H1200-MBIC and another Form H1200 for the redeterminations.

A TIERS MBIC redetermination packet will include:

  • Form H1233-MBIC, Redetermination Cover Letter;
  • Form H1200-MBIC-R, Application for Benefits – Medicaid Buy-In for Children;
  • Form H1028-MBIC, Employment Verification (Medicaid Buy-In for Children);
  • Form H0003, Agreement to Release Your Facts; and
  • Form H5017-MBIC, Items We Need from You.

 

N-8350 Appeals

Revision 13-1; Effective March 1, 2013

 

HHSC is responsible for all appeals, including those concerning premiums and cost sharing. If premium and/or cost-sharing information is needed for an appeal, refer to the MBIC business process document.

If an individual is dissatisfied with HHSC's decision concerning his eligibility for medical assistance, he has the right to appeal through the appeal process established by HHSC. In certain circumstances, the individual is entitled to receive continued benefits or services until a hearing decision is issued. Whether an individual is entitled to continued assistance is based on requirements set forth in appropriate state or federal law or regulation of the affected program. See the Fair and Fraud Hearings Handbook.