Revision 16-4; Effective December 1, 2016

 

 

M-8100 Medical Effective Dates

Revision 11-4; Effective December 1, 2011

 

The eligibility begin date for MBI is the first day of the first month in which a person meets all eligibility criteria and pays the required premium, if any is required. Eligibility is established in TIERS, but eligibility is not granted until the first premium is paid. Eligibility is in a suspended status until an MBI person pays the premium. Once the premium is paid, actual eligibility is granted

 

M-8200 Prior Month's Eligibility

 

Revision 11-4; Effective December 1, 2011

 

Eligibility for three prior months to the application month is available with this program.

The coverage date is determined by the application file date and the first premium amount the person chooses to pay. Since potential eligibility is determined up to three months prior to the application file month, the person has the option of choosing the months of coverage. Payments are applied to months in reverse chronological order, beginning with the current or the following month, backwards, up to three months prior.

Payment must be for a full month. Partial month payments will be refunded to the individual. Form H0052, Medicaid Buy-In Refund Notice, will be sent to the individual stating that partial payments are not accepted. The notice also will state that it can take up to 60 days for the refund.

 

M-8300 Case Actions

 

Revision 11-4; Effective December 1, 2011

 

 

M-8310 Disposition

Revision 11-4; Effective December 1, 2011

 

Since MBI eligibility is determined in TIERS, an initial eligibility determination group (EDG) is created with a "Suspended" status. This will be used when the MBI EDG is approved for potential eligibility. The EDG status will be updated based on vendor communication. The EDG status will be updated to "Approved" when vendor communication confirms that at least one month's premium has been received. The EDG status will be updated to "Denied" when vendor communication confirms that the payment was not received by the due date. If the payment is received during the adverse action time period then the EDG is reopened.

 

M-8320 Eligibility Summary

 

Revision 16-4; Effective December 1, 2016

 

When the Medicaid Buy-In (MBI) potential eligibility EDG is disposed, Form TF0001, Notice of Case Action, is automatically sent to batch but must not be sent to the individual. Instead, the eligibility worker sends a manual Form H0053, Medicaid Buy-In Potential Eligibility Notice, containing the premium amount(s) and the premium due date. If the eligibility worker sends Form H0053 before cut-off, the premium payment is due at the end of the same month and is applied to the following month. If the individual does not make the first payment by the due date, deny the case.

On the first day of every month, TIERS automatically generates Form H0051, Medicaid Buy-In Premium Payment Notice, which is mailed directly to the individual. The notice has a coupon attached and a postage-paid envelope enclosed. The individual submits the premium payment, along with the coupon, by the due date. Failure to make the premium payment by the due date will cause the individual to be denied. Adverse action requirements pertain to MBI.

If an individual whose MBI eligibility was denied for failure to submit premium payments reapplies for MBI, the individual must pay all past due premium payments and current monthly payments to be reinstated into the program. All past due premiums and current premiums must be paid by the due date on Form H0053 sent to the individual for the reapplication.

Note: Premium payments must be received in the form of a check or a money order payable to MBI.

The premium payment address is:
Medicaid Buy-In
P.O. Box 650868
Dallas, TX 75265-9843

Once MBI receives the premium payment and the EDG is disposed, Form TF0001, Notice of Case Action, is automatically sent to batch but must not be sent to the individual. Instead, the eligibility worker sends a manual Form H0054, Medicaid Buy-In Eligibility Notice, containing the month(s) of eligibility and the corresponding premium amount(s) received.

 

M-8400 Initial Premium Due Dates

 

Revision 13-3; Effective September 1, 2013

 

The first premium payment is due based on the date of disposition.

  • If disposed before the current month's cutoff, the payment is due by the end of the disposition month.
  • If disposed after the current month's cutoff, the payment is due by the end of the following disposition month.

Example 1: Month of application: May. Prior months: April, March and February. If cutoff is May 15, and the MEPD Specialist disposes the case on May 11, the due date of all premiums for ongoing and all prior months (if the individual wants coverage for all) would be May 31,20XX. So payment is due for:

  • June – ongoing month and mandatory, must be paid first;
  • May – month of application and optional;
  • April – prior month one and optional;
  • March – prior month two and optional; and
  • February – prior month three and optional.

Note: If the individual wants those optional months, he or she must pay in reverse chronological order. This means the ongoing month must be paid first, then the previous month, then the month before that and so forth. Like the order in the example above.

Example 2: Month of application: May. Prior months: April, March and February. If cutoff is May 15, and the MEPD Specialist disposes the case on May 19, the due date of all premiums for ongoing and all prior months (if the individual wants coverage for all) would be June 30, 20XX. So payment is due for:

  • July – ongoing month and mandatory, must be paid first;
  • June – month after month of application and optional;
  • May – month of application and optional;
  • April – prior month one and optional;
  • March – prior month two and optional; and
  • February – prior month three and optional.

Note: If the individual wants those optional months, he or she must pay in reverse chronological order. This means the ongoing month must be paid first, then the previous month, then the month before that and so forth. Like the order in the example above.

 

M-8410 Ongoing Premium Due Dates

 

Revision 13-3; Effective September 1, 2013

 

Monthly premiums are due the end of each month. If payment is not received by the end of the month, the coverage will be terminated at the end of the following month.

  • If the remaining amount due is received two days prior to cutoff, then there is no interruption in coverage.
  • If the remaining amount due is received after the deadline for payment (two days before cutoff), the individual is denied and the payment will be applied to any unpaid months the individual received benefits.
  • Funds are to be applied to satisfy the ongoing month and any months premiums were not paid.
  • After 12 months from the denial for non-payment the individual can reapply without having to pay any unpaid premium.

Example 1: Payment Received Timely: The due date for the May premium is April 30, 20XX, and cutoff is May 15. If no payment is received by April 30, 20XX, the MEPD Specialist will send a manual denial notice to the individual on that date, but will NOT run eligibility (EDBC) and deny the case at that time. If payment IS received between the due date (end of previous month) and two days prior to cutoff (in this example, May 13, 20XX) there will be no disruption in coverage.

Example 2: Payment Not Received Timely: The due date for the May premium is April 30,20XX, and cutoff is May 15. If no payment is received by April 30, 20XX, the MEPD Specialist will send a manual denial notice to the individual on that date, but will NOT run eligibility (EDBC) and deny the case at that time. If payment IS NOT received by two days prior to cutoff (in this example, May 13, 20XX) the MEPD Specialist will run eligibility (EDBC) and deny the case on May 14, 20XX, and document it in case comments. No denial notice needs to be sent at this time because one was previously sent.

 

M-8411 Non-Sufficient Funds for Ongoing Cases

 

Revision 13-3; Effective September 1, 2013

 

Ongoing cases for MBI are certified or approved cases. Individuals are currently on the program as they have made premium payments. Their EDG is in approved status.

The vendor will notify the individual through written notice of non-sufficient funds (NSF) when they occur. The vendor notifies the MEPD Specialist if non-sufficient funds occur.

  • If payment is not rectified and received within the adverse action period (two days before next month's cutoff), it will be treated as a non-payment and the case denied.
  • If the individual makes a replacement payment within the adverse action period (two days before cutoff), there will be no disruption in benefits.
  • If the individual makes a replacement payment after the adverse action period (two days before cutoff) the case will be denied and the payment will be applied to any unpaid months where benefits were received. If there is any remaining payment, it will be refunded to the individual.

 

M-8412 Non-Sufficient Funds for Suspended Eligible Cases

Revision 13-3; Effective September 1, 2013

 

Suspended-eligible cases are cases where benefits have not been approved due to pending premium payments. The EDG stays in suspended status until payment is made, eligibility is determined and the case is disposed.

If the premium is not paid because of non-sufficient funds (NSF), the vendor will notify the individual through written notice of non-sufficient funds. The vendor notifies the MEPD Specialist if NSF occurs.

  • If no replacement payment is made, benefits will not be granted and the case will be denied.
    • Example – Cutoff is June 20, 20XX. The MES disposes the case on June 10, 20XX. The premium payment is due June 30, 20XX. If no premium payment is received by June 30, 20XX, the case is denied.
  • If the individual makes a replacement payment prior to the due date (end of the month) benefits will be granted.
    • Example A – Cutoff is June 20, 20XX. The MES disposes the case on June 10, 20XX. The Premium payment is due June 30, 20XX. The Premium payment received June 15, 20XX. On June 22, 20XX, vendor notifies MEPD the payment was NSF. The individual replaces/rectifies the premium on June 25, 20XX. MES approves the case and benefits granted.
    • Example B – Cutoff is June 20, 20XX. MES disposes the case on June 22, 20XX (after cutoff). The Premium payment is due July 31, 20XX. The Premium payment is received July 1, 20XX. On July 10, 20XX, the vendor notifies MEPD the payment was NSF. The individual replaces/rectifies the premium on July 15, 20XX. MES approves the case and benefits granted.
    • Note: The individual has to pay the ongoing month first, then any optional month, such as prior months, if this was an application.
  • If the individual makes a replacement payment after the due date (end of the month) benefits will be denied and payment will be refunded.
    • Example — Cutoff is June 20, 20XX. The MES disposes the case on June 10, 20XX. The Premium payment is due June 30, 20XX. The Premium payment is received June 15, 20XX. On June 20, 20XX, the vendor notifies the MEPD the payment was NSF. The individual sends a replacement premium on June 25, 20XX, but it is not received until July 5, 20XX. MES denies the case and benefits on June 30, 20XX. The monies are refunded to the individual.

Note: If the NSF notification is received after the due date (end of the month), ongoing rules will apply.

Example – Cutoff is June 20, 20XX. The MES disposes the case on June 10, 20XX. The individual received notice to pay the premium on June 20, 20XX. The premium is received on June 30, 20XX; the vendor notifies MEPD and MES approves the case. On July 4, 20XX, the vendor notifies MEPD the payment is NSF. Because the NSF notification was received after the due date – end of the month – MES must use the ONGOING policy. See M-8411,Non-Sufficient Funds for Ongoing Cases.

 

M-8420 Premium Payment Notices

 

Revision 15-3; Effective September 1, 2015

 

On the first day of every month, TIERS automatically generates Form H0051, Medicaid Buy-In Premium Payment Notice, which is mailed directly to the person. The notice has a coupon attached and a postage-paid envelope enclosed. The person submits the premium payment, along with the coupon, by the due date. Failure to make the premium payment by the due date will cause the person to be denied. Adverse action requirements pertain to MBI. A person whose MBI eligibility is denied for failure to submit premium payments must pay all past due premium payments and current monthly payments to be reinstated into the program.

Note: Premium payments must be received in the form of a check or a money order payable to MBI.

The premium payment address is:
MBI
P.O. Box 650868
Dallas, TX 75265-0868

Once MBI receives the premium payment and the EDG is disposed, Form TF0001, Notice of Case Action, is automatically sent to batch but must not be sent to the person. The eligibility worker sends a manual Form H0054, Medicaid Buy-In Eligibility Notice, containing the month(s) of eligibility and the corresponding premium amount(s) received.

 

M-8430 Presidential-Declared Emergency (PDE)

 

Revision 12-1; Effective March 1, 2012

 

A PDE hardship exemption will automatically be granted to recipients living in the declared area and premiums waived for three months. Recipients do not have to request a hardship for PDE. TIERS will send an "emergency special notice" to inform recipients at the start of the PDE period that the premiums have been waived. There is no limit to how many PDEs for which a recipient may have premiums waived; however, a recipient may only have up to three months of premiums waived once per emergency.

For MBI recipients, the waiver of premiums for a PDE begins in the month in which the emergency is declared and continues forward for a total of three consecutive months. Premiums for retroactive months will not be waived. Any premiums received and applied to a month in which a PDE is in effect will be refunded.

Example 1: A PDE is declared for March through May. Premiums may be waived for March, April and/or May. Premiums may be waived for one, two or three months, depending on the date the person is approved for MBI.

Example 2: The PDE period is declared for March through May.

March is the month in which the MBI application is received by HHSC. On April 18, the individual residing in a PDE area is approved for MBI. The individual is eligible to have monthly premiums waived for April and May.

Example 3: The PDE period may be longer than three months (e.g., declared in March, extended through July – five months).

Regardless of the length of the PDE, the recipient may only have premiums waived for three consecutive months (e.g., March, April and May), regardless of the PDE time period. In the third month for which premiums have been waived, Form H0051, Medicaid Buy-in Premium Payment Notice, which has a payment coupon attached, should be mailed no later than the 20th requesting payment for the month of June, even though the emergency period has not ended.

 

M-8500 Denial Reasons

 

Revision 11-4; Effective December 1, 2011

 

There are 11 new denial reasons for the MBI program. Use the following new denial reasons for MBI as appropriate.

1. You failed to pay your MBI premium by <the due date>.
2. Your Independence Account is a countable resource from <mmddyy> through <mmddyy> for one or more of the following reasons:
  • Money was used for non-health care or non-work related expenses.
  • Deposits exceed 50% of your earnings for the Social Security Administration qualifying quarter.
  • Deposits are from sources other than earnings or interest earned on this account.
  • Deposits include income from another individual.
3. Your countable income increased because you did not pay a designated impairment-related work expense (IRWE) with your income.
4. Your countable income increased because you did not pay a designated blind work-related expense (BWE) with your income.
5. The resources excluded as part of your Plan to Achieve Self-Support (PASS) are now countable because you have not met the goal dates in your PASS.
6. The resources excluded as part of your PASS are now countable because funds have not been set aside as agreed.
7. The resources excluded as part of your PASS are now countable because funds have not been spent as agreed.
8. The income excluded as part of your PASS is now countable because you have not met the goal dates in your PASS.
9. The income excluded as part of your PASS is now countable because funds have not been set aside as agreed.
10. The income excluded as part of your PASS is now countable because funds have not been spent as agreed.
11. You did not meet the requirements of completing a Social Security Administration Qualifying Quarter.

M-8510 Redeterminations

Revision 11-4; Effective December 1, 2011

 

Redeterminations for MBI follow regular MEPD policy for redeterminations.

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

 

M-8520 Appeals

 

Revision 13-1; Effective March 1, 2013

 

HHSC is responsible for all appeals including those concerning premiums.

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.