Revision 18-3; Effective September 1, 2018

 

General requirements. Although the person need not be currently eligible, he must prove that Medicaid requirements were met in the month of requested coverage. To meet requirements, the individual must have been:

  • aged, blind or disabled;
  • within the applicable resource limit at 12:01 a.m. on the first day of the month;
  • within the applicable income standard for the month;
  • receiving Medicaid-covered services that have not been paid or will be reimbursed by the provider; and
  • eligible according to any special criteria.

Because income eligibility will be based on the income standard for the month, determine the standard for that month.

Note: A requirement for prior coverage is unpaid or reimbursable medical bills that Medicaid could cover. See Appendix XLI, Historical Budget Reference Chart, for previous SSI FBR amounts.

To verify amounts and dates of unpaid or reimbursable services and to determine whether the provider accepts Medicaid payments, contact the provider or the provider's representative. Document the contact in the case record. The amounts and the dates of unpaid or reimbursable services may also be verified by obtaining a copy of a billing statement from the provider (dated within the last six months).

Test eligibility separately for each of the two or three prior months. Grant eligibility in whole-month increments. If approved, the person, except for Community Attendant Services recipients, receives Your Texas Benefits Medicaid card for the retroactive period.

The person should immediately give this information to providers so that claims can be filed within 90 days of the date of Medicaid certification.

 

G-7100 Prior Coverage for SSI Applicants

Revision 18-3; Effective September 1, 2018

 

The Supplemental Security Income (SSI) application asks the individual about unpaid or reimbursable medical bills in the prior three months. An affirmative response is reported to the state using the State Data Exchange (SDX) system. A person claiming unpaid or reimbursable medical expenses incurred during the three months before the date of application receives a computer-generated notice to contact the Texas Health and Human Services Commission (HHSC) if they want their eligibility for prior coverage determined.

  • Certified Recipients —For certified SSI recipients, Medicaid coverage automatically begins with the month prior to the first month of SSI payment. Prior coverage may be determined for  the preceding two months if the individual meets all Medicaid eligibility requirements.
  • Denied Applicants — For denied SSI applicants who have medical expenses, the retroactive period remains the three months prior to the SSI application month.
  • Deceased Applicants — For SSI applicants who die before the SSI eligibility decision by the Social Security Administration (SSA), and for whom SSA will not make a determination, the retroactive period is the three months prior to the receipt of an HHSC application from a bona fide agent. (see G-7210)

To apply for retroactive medical coverage, the individual must complete an HHSC application form. Use SSI program criteria when determining prior coverage eligibility.  

A person may be eligible for more than one retroactive period if the person applies for SSI more than once. Determination of eligibility on a month-to-month basis may result in non-sequential periods of eligibility.

When the eligibility determination for the open or close time-period is complete for the ME-SSI Prior, notify the individual of the decision using Form TF0001, Notice of Case Action.

 

G-7200 Prior Coverage for Medical Assistance Only (MAO) Applicants

Revision 12-3; Effective September 1, 2012

 

Applicants may be eligible for Medicaid coverage during any or all of the three months before the month of application for an ongoing MEPD program. An applicant must have unpaid or reimbursable charges or bills for Medicaid covered services during each month for which prior coverage is requested. He must meet all requirements applicable to the SSI or MEPD programs during each of the months he is eligible.

The department also explores possible three month's prior coverage based on the date of change in the individual's circumstances for an individual transferring from limited Medicaid programs, such as QMB or Community Attendant Services, to full Medicaid benefit programs.

Example: If a QMB individual entered a nursing facility on June 3, the eligibility specialist would explore possible three months prior coverage for March, April and May. The special income limit would potentially be used for June and the SSI income limit would be used for the prior months.

Note: For Title XIX facility payment only, it makes no difference whether the bill is paid or unpaid. Standards for participation mandate reimbursement if Medicaid is established.

 

G-7210 Prior Coverage for Deceased Applicants

Revision 18-3; Effective September 1, 2018

 

A bona-fide agent  may file an application with HHSC on behalf of a deceased person for Medicaid coverage for any or all of the three months before HHSC receives the application. During each month for which prior coverage is requested, the deceased person must:

  • meet all eligibility requirements applicable to the MEPD program;
  • meet SSI income and resource limits; and
  • have unpaid or reimbursable charges or bills for Medicaid-covered services.

A bona fide agent is a person who is knowledgeable of the decedent's circumstances and can report the required information for eligibility determination accurately and under penalty of perjury. If the  information does not establish a date of onset covering the period for which eligibility is being determined, request a disability determination from the HHSC Disability Determination Unit (DDU). Indicate on Form H3034, Disability Determination Socio-Economic Report, that the individual is deceased.

The time period for which eligibility is determined is the three months before the month an HHSC application is received from the decedent's bona fide agent.

When the eligibility determination is complete for the ME-SSI Prior, notify the bona fide agent of the decision using Form TF0001, Notice of Case Action.

 

 

G-7300 Emergency Coverage for Aliens

Revision 18-3; Effective September 1, 2018
 

A person ineligible for Medicaid due to undocumented status or not having an appropriate alien status to receive Medicaid may be eligible for Medicaid for an emergency episode in:

  • a three months prior period only;
  • the month of application only; or
  • the month of application and up to three prior months.

More than one episode can be reported in the above time frames.
Staff must verify the emergency episode using Form H3038, Emergency Medical Services Certification, which is completed by the medical practitioner.  
A medical practitioner is a person who holds a license to practice medicine, including the following:

  • physician (MD);
  • osteopathic medical physician (DO);
  • advance nurse practitioner (ANP); or
  • registered nurse (RN).

Note: A licensed practical nurse (LPN), a licensed vocational nurse (LVN), or a midwife do not meet the definition of medical practitioner.

For prior coverage for aliens, verification of unpaid medical bills is not required. Coverage is provided only for the duration of the emergency period as indicated on the H3038.