Revision 18-1; Effective March 1, 2018

 

Section §1915(c) of the Social Security Act allows states to determine eligibility for certain persons seeking home or community-based medical assistance as if they were living in an institution. Without this medical assistance, these persons are likely to require care provided in a hospital, nursing facility or intermediate care facility for persons with intellectual disabilities (ICF/IID). Persons can only enroll in one waiver program at a time, but may be on various interest lists. See the HHS website at https://hhs.texas.gov/about-hhs/records-statistics/interest-list-reduction.

Deeming from parents/spouses and support and maintenance are not considered for Home and Community-Based Services waiver programs. Persons are not eligible for waiver services if they are subject to a transfer of assets penalty or have substantial home equity.

Persons may be required to share the cost of care (co-payment). Examples of co-payment worksheets for the various waiver living arrangements are contained in Appendix XXII, Home and Community-Based Services Waiver Program Co-Payment Worksheets. See Section O-5000, Waiver Programs and 30 Consecutive Days, for information related to Medicare coverage and Medicaid coverage codes.

See Section O-1100, Application for Waiver Programs.

 

O-1100 Application for Waiver Programs

Revision 18-1; Effective March 1, 2018

 

Waiver eligibility determination involves two components:

  • Waiver eligibility component
  • Financial Medicaid eligibility component

HHSC is responsible for the waiver eligibility component criteria of and for the financial Medicaid eligibility component criteria of the eligibility determination for most waivers.

Intake for a waiver is also through HHSC or an HHSC contracted provider. The HHSC designee will assist with determining appropriate program services and will assist the person in the financial Medicaid eligibility component, if necessary.

In general, HHSC is responsible for ensuring that specific criteria for the waiver eligibility component have been met and that the person:

  • is or will be residing in the community;
  • meets the age requirement of the waiver, if applicable;
  • has either a medical necessity (MN) or appropriate level of care (LOC) determination, as applicable;
  • has an approved plan of care or service plan; and
  • has a service begin date no later than 30 days from certification.

HHSC is normally responsible for financial Medicaid eligibility component criteria.

The financial Medicaid eligibility component criteria for most waivers are met if the person is a Supplemental Security Income (SSI) recipient or has full Medicaid coverage under another group in the Texas State Medicaid Plan.

Potentially, the financial Medicaid eligibility component criteria for most waivers are met if the person is a:

  • Medicaid recipient certified under a Medicaid group within the Texas State Medicaid Plan. MEPD examples include ME – Pickle, ME – Disabled Adult Child and ME – Early Aged Widow(er);
  • Medicaid recipient certified using the special income limit (see Appendix XXXI, Budget Reference Chart);
  • Community Attendant Services (CAS) recipient; or
  • Medicaid recipient based on a Texas Works Medicaid program.

Financial Medicaid eligibility for most waivers will require a review of the person's situation specifically relating to transfer of assets and substantial home equity. See Chapter I, Transfer of Assets, and Chapter F, Resources.

To meet the financial Medicaid eligibility component, if the person is not already a Medicaid recipient under another Texas Medicaid program or an SSI recipient, the person must apply for:

  • SSI if the monthly income is less than the SSI income limit; or
  • another Medicaid program under the Texas Medicaid program, such as an MEPD program.

See Section B-4000, Date of Application, for more information about the file date of an application and accepting an application.

The financial Medicaid eligibility component for the Texas Home Living (TxHmL) Program is not completed using the special income limit. More specifically, to be eligible for the TxHmL Program, the person must already be receiving Medicaid. HHSC will not certify a person for Medicaid as a condition of the TxHmL Program.

Under the financial Medicaid eligibility component criteria when determining eligibility for waivers using special income limit, a person:

  • must meet nonfinancial criteria outlined in Chapter D, Non-Financial;
  • must meet resource criteria outlined in Chapter F, Resources, with specific consideration given to:
  • must meet income criteria outlined in Chapter E, General Income, with the understanding that:
    • deeming procedures are not used; and
    • support and maintenance is not counted as income; and
  • must meet financial eligibility and payment plan budget requirements outlined in Chapter G, Eligibility Budgets, with specific consideration given to:
    • Section G-6000, Institutional Eligibility Budget Types;
    • Appendix XXII, Home and Community-Based Services Waiver Program Co-Payment Worksheets; and
    • Chapter F, Resources, for qualified income trust (QIT).

A medical effective date can be established when all the criteria are met for both the:

  • waiver eligibility component; and
  • financial eligibility component.

See Section R-1200, Medical Effective Date. For waiver eligibility, the medical effective date is one of the following:

  • The first day of the month of entry into a nursing facility, ICF/IID or state supported living center if the applicant filed a Medicaid application during that month, then requested a program transfer before being certified and met all eligibility criteria.
  • The first day of the month if the applicant met all waiver eligibility component and financial Medicaid eligibility component criteria.
  • The day after the effective date of SSI denial, for recipients transferred from SSI assistance to an MEPD program (excluding any Medicare Savings Program).

 

Notes:

  • Consider potential three months prior to the date of application if the person entered a nursing facility, ICF/IID or state supported living center and then transitioned into a waiver setting before being certified. See O-5000, Waiver Programs and 30 Consecutive Days.
  • Consider potential three months prior to the date of application if the person received waiver services in the prior months period and lost waiver eligibility due to failure to return a redetermination application. See R-1200, Medical Effective Date, for examples of these situations.
  • The TxHmL Program requires that the person already be eligible for Medicaid before placement in the TxHmL Program. Persons cannot be determined eligible for this waiver under the special income limit.

In addition, to comply with the federally approved waiver, co-payment must be considered for waiver recipients whose eligibility is determined under the special income limit. See Appendix XXII, Home and Community-Based Services Waiver Program Co-Payment Worksheets, for the sequence in which deductions are allowed. Allow deductions indicated on the appropriate co-pay worksheet. For many waiver recipients, the co-payment will be $0. Notify HHSC of the co-payment amount using the Medicaid Eligibility to HHSC automated communication tool.

When the person is married and applying for waiver eligibility, use spousal impoverishment policy for consideration of resources. See Chapter J, Spousal Impoverishment. Spousal impoverishment policy is not used in the TxHmL Program.

 

Denied SSI Due to Earned Income Impact on Waiver Eligibility

Sometimes an SSI denial is short term and an SSI recipient is reinstated. There might be a gap in SSI and Medicaid coverage. This might happen when the eligibility is based on earned weekly income, normally with four paychecks. When five paychecks are received in one month, income ineligibility might occur whether based on a recipient’s earnings or deemed income that includes weekly earnings. Even though Medicaid eligibility might be established retroactively using the special income limit to cover the gap month, Medicaid waiver services may be interrupted during the gap month.

When notified that a person receiving Medicaid waiver services is being denied SSI due to income ineligibility from the receipt of an extra paycheck, send an application to the Medicaid waiver person.

Once the application is obtained, determine eligibility for the Medicaid waiver person using the special income limit. If all eligibility criteria are met, certify the Medicaid waiver person under ME-Waivers.

After receipt of the first application, it may be used for up to 12 months. A new application must be obtained yearly and processed as a redetermination.

 

O-1200 Community Based Alternatives (CBA) Program

Revision 14-4; Effective December 1, 2014

 

The CBA program ended Sept. 1, 2014, when it was fully transitioned into STAR+PLUS. For information on STAR+PLUS, see Section O-3200, STAR+PLUS Waiver (SPW), or visit hhsc.texas.gov/doing-business-hhs/provider-portals/long-term-care-providers/long-term-provider-resources/medicaid-managed-care-expansion.

 

O-1300 Community Living Assistance and Support Services (CLASS)

Revision 18-1; Effective March 1, 2018

 

CLASS provides home and community-based services to persons with intellectual disability-related conditions as a cost-effective alternative to intermediate care facility for persons with intellectual disabilities (ICF/IID) institutional placement. People with related conditions are people who have a disability, other than mental illness or an intellectual disability, that affects their ability to function in daily life. Some examples of related conditions include muscular dystrophy, cerebral palsy, spina bifida, etc.

See Section O-1100, Application for Waiver Programs.

 

Waiver Eligibility Component

HHSC is responsible for determining if the person meets the criteria specific to CLASS for the waiver eligibility component and will communicate to HHSC that the person has:

  • an ICF/IID-RC VIII level of care (LOC), which establishes that the onset of the developmental disability was before age 22;
  • an approved plan of care or service plan; and
  • a service begin date no later than 30 days from certification.

HHSC will determine if the person is or will be residing in the community.

If HHSC determines that the person is not residing in the community. HHSC will take appropriate action.

 

Financial Medicaid Eligibility Component

HHSC is responsible for determining if the person meets the criteria specific to CLASS for the financial Medicaid eligibility component. If the person is already eligible for Medicaid through another program under the Texas State Medicaid Plan, the financial Medicaid eligibility component for this waiver has already been met.

When determining financial Medicaid eligibility for CLASS, give special consideration to the following:

  • Receipt of a signed and dated application. See Section O-1100, Application for Waiver Programs, and Section B-4000, Date of Application.
  • Age of the person. If the person's age is less than 65 and the person does not receive a Social Security Administration (SSA), SSI or Railroad Retirement (RR) disability benefit, a disability determination by HHSC is required even if the person has received an LOC under the waiver eligibility component criteria.
  • Post-DRA transfer of assets. The person is ineligible until the transfer does not appear during the look-back period. See Chapter I, Transfer of Assets, for calculation of penalty period.
  • Post-DRA substantial home equity. A person with a home whose equity interest in the home exceeds the established limit is not eligible for waiver services unless the person's spouse, child or disabled adult child is also living in the home.
  • Support and maintenance and deeming. Even if the person receives support and maintenance, do not develop this as income. If the person is living with parents or spouse, do not deem.
  • Income limit. Use the special income limit – 300% cap limit. See Appendix XXXI, Budget Reference Chart.
  • Co-payment calculation. Always determine the co-payment calculation for CLASS at initial application. Reference the appropriate worksheet from Appendix XXII, Home and Community-Based Services Waiver Program Co-Payment Worksheets, to check the calculations.
  • Spousal impoverishment resources. If married, consider spousal impoverishment for a waiver. See Chapter J, Spousal Impoverishment.
  • Spousal co-payment. See the appropriate worksheet from Appendix XXII to determine the spousal diversion or the dependent allowance.

 

Multiple Program Processing

If there is a delay in certifying the waiver services because the waiver eligibility component criteria has not been met or there is no available waiver slot, certify the person for other benefits for which the person may be entitled, such as QMB or SLMB, as soon as eligibility can be determined. If the application is due, delay of certification procedures should be used for the ME – Waiver EDG.

This allows the application to remain open for an additional 90 days.

HHSC notifies MEPD by completing and sending Form H1746-A, MEPD Referral Cover Sheet, to the Midland Data Processing Center. MEPD continues to notify HHSC of eligibility status using the MEPD communication tool (http://dadsview.dads.state.tx.us/me-to-dads/).

When all pending waiver eligibility component criteria have been met and there is an available slot, complete a disposition of the ME – Waiver EDG.

If the delay of certification period is expiring, and the waiver eligibility component criteria have not been met or there is still no available slot, proceed with denial of the ME – Waiver EDG. The MEPD specialist informs HHSC of the denial using the MEPD automated communication tool.

When a person is already a Medicaid recipient, review the case. See Section O-1100, Application for Waiver Programs, before processing a program transfer directly to the CLASS program.

 

Instructions for Processing the Program Transfer

  • After reviewing the case, if the person is eligible for a waiver and is already an institutional (ME – Non-State Group Home, ME – State Hospital, or ME – Nursing Facility) or CAS (ME – Community Attendant) MEPD Medicaid recipient, process a program transfer directly to ME – Waivers. The QMB or SLMB coverage must be continued if the person continues to meet the QMB/SLMB eligibility criteria.
  • When a program transfer for a noninstitutional MEPD Medicaid recipient is processed to ME – Waiver and waiver services have been authorized/received before the program transfer effective date, request a force change to ensure retroactive coverage of the waiver services.
  • See Appendix XLV, Program Transfer with Form H1200 Guide, to determine if a Form H1200 is needed. Verify resources and income including transfer of resources and substantial home equity. If there is a community spouse, verify all income and resources and treat according to spousal policy.

 

Notices

When the financial Medicaid eligibility component is determined, follow established procedures on notifications.

If the applicant does not meet the financial Medicaid eligibility component criteria for CLASS Medicaid, send the appropriate denial notice to the person with a copy to the HHSC designee. Continue to send notices regarding QMB, SLMB, MQMB and MSLMB eligibility to the person with a copy to the HHSC designee.

The financial Medicaid eligibility component redeterminations follow an annual schedule. When a recipient fails to return the review form, HHSC will communicate to the designee that the recipient may be denied.

 

Co-Payment

To comply with the federally approved waiver, co-payment must be calculated for any person in a waiver whose eligibility is determined under the special income limit. See Appendix XXII, Home and Community-Based Services Waiver Program Co-Payment Worksheets, for the sequence in which deductions are allowed. Allow deductions indicated on the appropriate co-payment worksheet. For CLASS, the co-payment usually will be $0 unless a QIT is involved. Notify the designee of the co-payment amount using the Medicaid Eligibility to the automated communication tool, even if the co-payment is $0 at initial application. For redeterminations and reported changes, notify HHSC only if the co-payment amount changes.

See Section O-5000, Waiver Programs and 30 Consecutive Days, for information related to Medicare coverage and Medicaid coverage codes.

 

Medical Effective Date (MED)

An MED can be established when all the criteria are met for both the:

  • waiver eligibility component, and
  • financial eligibility component.

See Section R-1200, Medical Effective Date. For waiver eligibility, the effective date for medical assistance is either:

  • the first day of the month of entry to a nursing facility, ICF/IID or state supported living center if the applicant filed a Medicaid application during that month, then requested a program transfer before being certified, and met all eligibility criteria;
  • the first day of the month if the applicant met all waiver eligibility component and financial Medicaid eligibility component criteria. See Section O-1100, Application for Waiver Programs; or
  • the day after the effective date of SSI denial for persons transferred from SSI assistance to a MEPD program (excluding any Medicare Savings Program).

 

Notes:

  • Remember to consider eligibility for QMB and SLMB, including prior coverage for SLMB, and prior coverage if the person was in a nursing facility, ICF/IID or state supported living center before the waiver.
  • A person can also be eligible under Category 2 for CLASS through Texas Works Medicaid or through the foster care program. Assist in verifying Medicaid eligibility coverage and take no further action on these cases.
  • A Medicaid recipient is still eligible for Texas Health Steps until age 21.
  • Restitution and reconciliation policy does not apply.

When eligibility is determined by accepting a person's statement for income and resources, obtain Form H1200 when transferring to a program that requires verification of income and resources. Note: The purpose of obtaining Form H1200 is to make sure all eligibility elements are addressed. If all eligibility elements have been verified before the program transfer is completed, receipt of Form H1200 is not an eligibility requirement.

Note: Verify all elements including transfer of assets and substantial home equity. If there is a community spouse, verify all elements for spousal treatment.

 

O-1400 Youth Empowerment Services (YES)

Revision 14-4; Effective December 1, 2014

 

HHSC and the Texas Department of State Health Services (DSHS) received approval from the Centers for Medicare & Medicaid Services (CMS) to implement a Home and Community-Based Services Medicaid waiver, Youth Empowerment Services (YES). Section 1915(c) of the Social Security Act allows states to determine eligibility for certain persons seeking home or community-based medical assistance as if they were living in an institution. The YES waiver allows more flexibility in the funding of intensive community-based services and supports for children with serious emotional disturbances and their families. The YES waiver began Sept. 1, 2009. To find out where YES is available for individuals, go to http://hhsc.texas.gov/doing-business-hhs/vendor-contractor-informati....

See Section O-1100, Application for Waiver Programs.

 

Waiver Eligibility Component

DSHS is responsible for determining if the person meets the criteria specific to YES for the waiver eligibility component and will communicate to HHSC that the person has:

  • an approved level of care (LOC)/medical necessity (MN) determination,
  • an approved individual plan of care (IPC), and
  • a service begin date no later than 30 days from certification.

HHSC will assume that DSHS has determined that the person:

  • is or will be residing in the community; and
  • is at least age 3, but under age 19.

If HHSC determines that the person is not residing in the community or does not meet the age requirement, communicate the discrepancy to DSHS. DSHS will take appropriate action and communicate back to HHSC.

Because Supplemental Security Income (SSI) parental deeming ends when a person reaches age 18, refer to the Social Security Administration (SSA) for an SSI determination. If certified for SSI, deny ME–Waivers. Notify the recipient of the change. Notify DSHS of the change. If the recipient never applies for SSI based on this referral, do not deny the Medicaid based on failure to apply for other benefits.

 

Financial Medicaid Eligibility Component

HHSC is responsible for determining if the person meets the criteria specific to YES for the financial Medicaid eligibility component and will communicate to DSHS that the person has met all eligibility factors. If the person already is eligible for Medicaid through another program under the Texas State Medicaid Plan, the financial Medicaid eligibility component for this waiver already has been met. The Disabled Adult Child (DAC) program is an exception that requires a transfer to a Medicaid waiver.

Note: Even though the DAC program is in the Texas Medicaid State Plan, the YES waiver does not recognize this Medicaid program. If a recipient currently is certified for DAC and YES services have been requested, complete a program transfer and change the recipient from DAC to ME–Waivers in the Texas Integrated Eligibility Redesign System (TIERS). Reminder: A person must be age 18 to be eligible for DAC, and YES waiver eligibility ends at age 19. Flag the case to restore DAC benefits once the YES waiver ends, if the recipient continues to meet all other eligibility requirements.

When determining financial Medicaid eligibility for YES, give special consideration to the following:

  • Receipt of a signed and dated application. See Section O-1100, Application for Waiver Programs, and Section B-4000, Date of Application.
  • The child must be age 3 to 18. If the person is under age 65 and does not receive an SSA, SSI or Railroad Retirement (RR) disability benefit, a disability determination by HHSC is required, even if the person has received an LOC determination under the DSHS waiver eligibility component criteria.
  • Post-DRA transfer of assets. The person is ineligible until the transfer does not appear during the look-back period. See Chapter I, Transfer of Assets, for calculation of the penalty period.
  • Post-DRA substantial home equity. A person with a home whose equity interest in the home exceeds the established limit is not eligible for waiver services unless the person's adult child with a disability, spouse or child is also living in the home.
  • Support, maintenance and deeming. Even if the person receives support and maintenance, do not develop this as income. If the person is living with parents or a spouse, do not deem.
  • Income limit. Use the special income limit — 300 percent cap limit. See Appendix XXXI, Budget Reference Chart.
  • Co-payment calculation. Always determine the co-payment calculation for YES at the initial application. Reference the appropriate worksheet from Appendix XXII, Home and Community-Based Services Waiver Program Co-Payment Worksheets, to check the calculations made in TIERS.
  • Spousal impoverishment resources. If the person is married, consider spousal impoverishment for a waiver. See Chapter J, Spousal Impoverishment.
  • Spousal co-payment. See the appropriate worksheet from Appendix XXII to determine the spousal diversion or the dependent allowance.

 

Multiple Program Processing

If there is a delay in certifying the waiver services because the person does not meet the DSHS waiver eligibility component criteria or there is no available waiver slot, certify the person for other benefits for which the person may be entitled, such as QMB or SLMB, as soon as eligibility can be determined. If the application is due, use delay of certification procedures for the ME-Waiver eligibility determination group (EDG).

This allows the application to remain open for an additional 90 days.

DSHS notifies MEPD by completing and sending Form H1746-A, MEPD Referral Cover Sheet, to the centralized mailbox (yeswaiver@dshs.state.tx.us). MEPD continues to notify DSHS of eligibility status using the Medicaid Eligibility to DSHS centralized mailbox (yeswaiver@dshs.state.tx.us).

When the person meets all pending DSHS waiver eligibility component criteria and there is an available slot, complete a disposition of the ME-Waiver EDG.

If the delay of certification period is expiring and the person still does not meet the DSHS waiver eligibility component criteria or there is still no available slot, proceed with denial of the ME-Waiver EDG. The MEPD specialist informs DSHS of the denial using the Medicaid Eligibility to DSHS centralized mailbox (yeswaiver@dshs.state.tx.us).

 

Instructions for Processing the Program Transfer

  • After reviewing the case, if the person is eligible for a waiver and is already an institutional (ME-Non-State Group Home, ME-State Hospital or ME-Nursing Facility) or CAS (ME-Community Attendant) and DAC MEPD Medicaid recipient, process a program transfer directly to ME-Waivers. The QMB or SLMB coverage must be continued if the person continues to meet the QMB/SLMB eligibility criteria.
  • When a program transfer for a noninstitutional MEPD Medicaid recipient is processed to ME-Waivers and waiver services have been authorized/received before the program transfer effective date, submit a help desk ticket to override existing coverage, such as DAC, to ensure retroactive coverage of the waiver services.
  • See Appendix XLV, Program Transfer with Form H1200 Guide, to determine if Form H1200, Application for Assistance — Your Texas Benefits, is needed. Verify resources and income, including transfer of resources and substantial home equity. If there is a community spouse, verify all income and resources and treat according to spousal policy.

 

Notices

When determining the financial Medicaid eligibility component, follow established notification procedures between the HHSC Office of Eligibility Services (OES) and DSHS.

If the applicant does not meet the financial Medicaid eligibility component criteria for YES Medicaid, send the appropriate denial notice to the person with a copy to the DSHS designee. Continue to send notices regarding QMB, SLMB, MQMB and MSLMB eligibility to the person with a copy to the DSHS designee.

Redeterminations of the financial Medicaid eligibility component follow an annual schedule. If a recipient fails to return the review form, HHSC will communicate to the DSHS designee that the recipient may be denied.

 

Co-Payment

To comply with the federally approved waiver, HHSC must calculate a co-payment for any person in a waiver whose eligibility is determined under the special income limit. See Appendix XXII, Home and Community-Based Services Waiver Program Co-Payment Worksheets, for the sequence in which HHSC allows deductions. Allow deductions indicated on the appropriate co-payment worksheet. For YES, the co-payment usually will be $0 unless a QIT is involved. Notify the DSHS designee of the co-payment amount using the Medicaid Eligibility to DSHS centralized mailbox (yeswaiver@dshs.state.tx.us), even if the co-payment is $0 at the initial application. For redeterminations and reported changes, notify DSHS only if the co-payment amount changes.

 

Medical Effective Date (MED)

An MED can be established when the person meets all of the criteria for both the:

  • waiver eligibility component, and
  • financial eligibility component.

See Section R-1200, Medical Effective Date.

For waiver eligibility, the medical effective date is one of the following:

  • The first day of the month of entry to a nursing facility, ICF/IID or state supported living center if the applicant filed a Medicaid application during that month, requested a program transfer before being certified, and met all eligibility criteria.
  • The first day of the month if the applicant met all waiver eligibility component criteria and financial Medicaid eligibility component criteria. See Section O-1100, Application for Waiver Programs.
  • The day after the effective date of SSI denial for people transferred from SSI assistance to an MEPD program (excluding any Medicare Savings Program).

 

Notes:

  • Remember to consider eligibility for QMB and SLMB, including prior coverage for SLMB, and prior coverage if the person was in a nursing facility, ICF/IID or state supported living center before the waiver.
  • A person also can be eligible under Category 2 for YES through Texas Works Medicaid. Assist in verifying Medicaid eligibility coverage and take no further action on these cases.
  • A Medicaid recipient is still eligible for Texas Health Steps until age 21. Refer the person to SSI at age 18. If the recipient becomes SSI-eligible, HHSC notifies DSHS YES staff via the Medicaid Eligibility to DSHS centralized mailbox (yeswaiver@dshs.state.tx.us) that the recipient's coverage is being transferred to SSI. HHSC must then terminate ME-Waivers coverage to allow SSI eligibility to process.
  • Restitution and reconciliation policy does not apply.

 

O-1500 Deaf Blind with Multiple Disabilities (DBMD)

Revision 18-1; Effective March 1, 2018

 

This program serves persons who, in addition to deafness and blindness, have one or more other disabling conditions that result in impairment to independent functioning. Eligible persons receive home and community-based services as an alternative to institutional care.

See Section O-1100, Application for Waiver Programs.

 

Waiver Eligibility Component

HHSC is responsible for determining if the person meets the criteria specific to DBMD for the waiver eligibility component and will communicate to HHSC that the person has:

  • an ICF/IID-RC VIII level of care (LOC);
  • an approved plan of care or service plan; and
  • a service begin date no later than 30 days from certification.

HHSC will determine that the person is or will be residing in the community.

If HHSC determines that the person is not residing in the community, HHSC will take appropriate action and communicate back to the appropriate person.

 

Financial Medicaid Eligibility Component

HHSC is responsible for determining if the person meets the criteria specific to DBMD for the financial Medicaid eligibility component and will communicate to the appropriate representative that the person has met all eligibility factors. If the person is already eligible for Medicaid through another program under the Texas State Medicaid Plan, the financial Medicaid eligibility component for this waiver has already been met.

When determining financial Medicaid eligibility for DBMD, give special consideration to the following:

  • Receipt of a signed and dated application. See Section O-1100 and Section B-4000, Date of Application.
  • Age of the person. If the person's age is less than 65 and the person does not receive a Social Security Administration (SSA), SSI or Railroad Retirement (RR) disability benefit, a disability determination by HHSC is required even if the person has received an LOC under the HHSC waiver eligibility component criteria.
  • Post-DRA transfer of assets. The person is ineligible until the transfer does not appear during the look-back period. See Chapter I, Transfer of Assets, for calculation of penalty period.
  • Post-DRA substantial home equity. A person with a home whose equity interest in the home exceeds the established limit is not eligible for waiver services unless the person's spouse, child or disabled adult child is also living in the home.
  • Support and maintenance and deeming. Even if the person receives support and maintenance, do not develop this as income. If the person is living with parents or spouse, do not deem.
  • Income limit. Use the special income limit – 300% cap limit. See Appendix XXXI, Budget Reference Chart.
  • Co-payment calculation. Always determine the co-payment calculation for DBMD at initial application. Reference the appropriate worksheet from Appendix XXII, Home and Community-Based Services Waiver Program Co-Payment Worksheets, to check the calculations made in TIERS.
  • Spousal impoverishment resources. If married, consider spousal impoverishment for a waiver. See Chapter J, Spousal Impoverishment.
  • Spousal co-payment. See the appropriate worksheet from Appendix XXII to determine the spousal diversion or the dependent allowance.

 

Multiple Program Processing

If there is a delay in certifying the waiver services because the waiver eligibility component criteria has not been met or there is no available waiver slot, certify the person for other benefits for which the person may be entitled, such as QMB or SLMB, as soon as eligibility can be determined. If the application is due, delay of certification procedures should be used for the ME – Waiver EDG.

This allows the application to remain open for an additional 90 days.

HHSC notifies MEPD by completing and sending Form H1746-A, MEPD Referral Cover Sheet, to the Midland Data Processing Center. MEPD continues to notify HHSC of eligibility status using the Medicaid Eligibility communication tool (http://dadsview.dads.state.tx.us/me-to-dads/).

When all pending waiver eligibility component criteria have been met and there is an available slot, complete a disposition of the ME Waiver EDG.

If the delay of certification period is expiring, and the waiver eligibility component criteria have not been met or there is still no available slot, proceed with denial of the ME – Waiver EDG. The MEPD specialist informs HHSC of the denial using the Medicaid Eligibility automated communication tool.

When a person is already a Medicaid recipient, review the case. See Section O-1100, Application for Waiver Programs, before processing a program transfer directly to the DBMD program.

 

Instructions for Processing the Program Transfer

  • After reviewing the case, if the person is eligible for a waiver and is already an institutional (ME – Non-State Group Home, ME – State Hospital or ME – Nursing Facility) or CAS (ME – Community Attendant) MEPD Medicaid recipient, process a program transfer directly to ME – Waivers. The QMB or SLMB coverage must be continued if the person continues to meet the QMB/SLMB eligibility criteria.
  • When a program transfer for a noninstitutional MEPD Medicaid recipient is processed to ME – Waivers and waiver services have been authorized/received before the program transfer effective date, request a force change to ensure retroactive coverage of the waiver services.
  • See Appendix XLV, Program Transfer with Form H1200 Guide, to determine if a Form H1200 is needed. Verify resources and income including transfer of resources and substantial home equity. If there is a community spouse, verify all income and resources and treat according to spousal policy.

 

Notices

When the financial Medicaid eligibility component is determined, follow established HHSC Office of Eligibility Services (OES) procedures.

If the applicant does not meet the financial Medicaid eligibility component criteria for DBMD Medicaid, send the appropriate denial notice to the person with a copy to the HHSC designee. Continue to send notices regarding QMB, SLMB, MQMB and MSLMB eligibility to the person with a copy to the designee.

The financial Medicaid eligibility component redeterminations follow an annual schedule. When a recipient fails to return the review form, HHSC will communicate to the designee that the recipient may be denied.

 

Co-Payment

To comply with the federally approved waiver, co-payment must be calculated for any person in a waiver whose eligibility is determined under the special income limit. See Appendix XXII, Home and Community-Based Services Waiver Program Co-Payment Worksheets, for the sequence in which deductions are allowed. Allow deductions indicated on the appropriate co-payment worksheet. For DBMD, the co-payment usually will be $0 unless a QIT is involved. Notify the HHSC designee of the co-payment amount using the Medicaid Eligibility automated communication tool, even if the co-payment is $0 at initial application. For redeterminations and reported changes, notify HHSC only if the co-payment amount changes.

 

Medical Effective Date (MED)

An MED can be established when all the criteria are met for both the:

  • waiver eligibility component, and
  • financial eligibility component.

See Section R-1200, Medical Effective Date. For waiver eligibility, the effective date for medical assistance is either:

  • the first day of the month of entry to a nursing facility, ICF/IID or state supported living center if the applicant filed a Medicaid application during that month, then requested a program transfer before being certified, and met all eligibility criteria;
  • the first day of the month if the applicant met all waiver eligibility component and financial Medicaid eligibility component criteria. See Section O-1100, Application for Waiver Programs; or
  • the day after the effective date of SSI denial for persons transferred from SSI assistance to a MEPD program (excluding any Medicare Savings Program).

 

Notes:

  • Remember to consider eligibility for QMB and SLMB, including prior coverage for SLMB, and prior coverage if the person was in a nursing facility, ICF/IID or state supported living center before the waiver.
  • A person can also be eligible under Category 2 for DBMD through Texas Works Medicaid or through the foster care program. Assist in verifying Medicaid eligibility coverage and take no further action on these cases.
  • A Medicaid recipient is still eligible for Texas Health Steps until age 21.
  • Restitution and reconciliation policy does not apply

 

O-1600 Home and Community-based Services (HCS)

Revision 18-1; Effective March 1, 2018

 

This Medicaid waiver provides various community services to people with a diagnosis of mental retardation who would otherwise be inappropriately placed in institutional facilities. Persons may apply and have their eligibility determined while residing in an institution, but must be living in the community to begin receiving waiver services.

See Section O-1100, Application for Waiver Programs.

 

Waiver Eligibility Component

HHSC is responsible for determining if the person meets the criteria specific to HCS for the waiver eligibility component and will communicate to HHSC that the person has:

  • an ICF/IID-RC VIII level of care (LOC);
  • an approved plan of care or service plan; and
  • a service begin date no later than 30 days from certification.

HHSC will determine that the person is or will be residing in the community.

If HHSC determines that the person is not residing in the community HHSC will take appropriate action and communicate back to necessary parties.

 

Financial Medicaid Eligibility Component

HHSC is responsible for determining if the person meets the criteria specific to HCS for the financial Medicaid eligibility component and will communicate to any necessary parties that the person has met all eligibility factors. If the person is already eligible for Medicaid through another program under the Texas State Medicaid Plan, the financial Medicaid eligibility component for this waiver has already been met.

When determining financial Medicaid eligibility for HCS, give special consideration to the following:

  • Receipt of a signed and dated application. See Section O-1100, Application for Waiver Programs, and Section B-4000, Date of Application.
  • Age of the person. If the person's age is less than 65 and the person does not receive a Social Security Administration (SSA), SSI or Railroad Retirement (RR) disability benefit, a disability determination by HHSC is required even if the person has received an LOC under the waiver eligibility component criteria.
  • Post-DRA transfer of assets. The person is ineligible until the transfer does not appear during the look-back period. See Chapter I, Transfer of Assets, for calculation of penalty period.
  • Post-DRA substantial home equity. A person with a home whose equity interest in the home exceeds the established limit is not eligible for waiver services unless the person's spouse, child or disabled adult child is also living in the home.
  • Support and maintenance and deeming. Even if the person receives support and maintenance, do not develop this as income. If the person is living with parents or spouse, do not deem.
  • Income limit. Use the special income limit – 300% cap limit. See Appendix XXXI, Budget Reference Chart.
  • Co-payment calculation. Always determine the co-payment calculation for HCS for initial applications. Reference the appropriate worksheet from Appendix XXII, Home and Community-Based Services Waiver Program Co-Payment Worksheets, to check the calculations made in TIERS.
  • Spousal impoverishment resources. If married, consider spousal impoverishment for a waiver. See Chapter J, Spousal Impoverishment.
  • Spousal co-payment. See the appropriate worksheet from Appendix XXII to determine the spousal diversion or the dependent allowance.

 

Multiple Program Processing

If there is a delay in certifying the waiver services because the waiver eligibility component criteria has not been met or there is no available waiver slot, certify the person for other benefits for which the person may be entitled, such as QMB or SLMB, as soon as eligibility can be determined. If the application is due, delay of certification procedures should be used for the ME – Waiver EDG.

This allows the application to remain open for an additional 90 days.

HHSC notifies MEPD by completing and sending Form H1746-A, MEPD Referral Cover Sheet, to the Midland Data Processing Center. MEPD continues to notify HHSC of eligibility status using the MEPD communication tool (http://dadsview.dads.state.tx.us/me-to-dads/).

When all pending waiver eligibility component criteria have been met and there is an available slot, complete a disposition of the ME – Waiver EDG.

If the delay of certification period is expiring, and the waiver eligibility component criteria have not been met or there is still no available slot, proceed with denial of the ME – Waiver EDG. The MEPD specialist informs HHSC of the denial using the MEPD communication tool.

When a person is already a Medicaid recipient, review the case.

See Section O-1100, Application for Waiver Programs, before processing a program transfer directly to the HCS program.

 

Instructions for Processing the Program Transfer

  • After reviewing the case, if the person is eligible for a waiver and is already an institutional (ME – Non-State Group Home, ME – State Hospital or ME – Nursing Facility) or CAS (ME – Community Attendant) MEPD Medicaid recipient, process a program transfer directly to ME – Waivers. The QMB or SLMB coverage must be continued if the person continues to meet the QMB/SLMB eligibility criteria.
  • When a program transfer for a noninstitutional MEPD Medicaid recipient is processed to ME – Waivers and waiver services have been authorized/received before the program transfer effective date, request a force change to ensure retroactive coverage of the waiver services.
  • See Appendix XLV, Program Transfer with Form H1200 Guide, to determine if a Form H1200 is needed. Verify resources and income including transfer of resources and substantial home equity. If there is a community spouse, verify all income and resources and treat according to spousal policy.

 

Notices

When the financial Medicaid eligibility component is determined, follow established procedures from the HHSC Office of Eligibility Services (OES) on notifications.

If the applicant does not meet the financial Medicaid eligibility component criteria for HCS Medicaid, send the appropriate denial notice to the person with a copy to the proper designee. Continue to send notices regarding QMB, SLMB, MQMB and MSLMB eligibility to the person with a copy to the proper designee.

The financial Medicaid eligibility component redeterminations follow an annual schedule. When a recipient fails to return the review form, the recipient may be denied.

 

Co-Payment

To comply with the federally approved waiver, co-payment must be calculated for any person in a waiver whose eligibility is determined under the special income limit. See Appendix XXII, Home and Community-Based Services Waiver Program Co-Payment Worksheets, for the sequence in which deductions are allowed. Allow deductions indicated on the appropriate co-payment worksheet. For HCS, the co-payment usually will be $0 unless a QIT is involved. Notify the HHSC designee of the co-payment amount using the MEPD communication tool, even if the co-payment is $0 at initial application. For redeterminations and reported changes, notify HHSC only if the co-payment amount changes.

 

Medical Effective Date (MED)

An MED can be established when all the criteria are met for both the:

  • waiver eligibility component; and
  • financial eligibility component.

See Section R-1200, Medical Effective Date. For waiver eligibility, the medical effective date is one of the following:

  • The first day of the month of entry to a nursing facility, ICF/IID or state supported living center if the applicant filed a Medicaid application during that month, then requested a program transfer before being certified, and met all eligibility criteria.
  • The first day of the month if the applicant met all waiver eligibility component and financial Medicaid eligibility component criteria. See Section O-1100, Application for Waiver Programs.
  • The day after the effective date of SSI denial for persons transferred from SSI assistance to a MEPD program (excluding any Medicare Savings Program).

 

Notes:

  • Remember to consider eligibility for QMB and SLMB, including prior coverage for SLMB, and prior coverage if the person was in a nursing facility, ICF/IID or state supported living center before the waiver.
  • A person can also be eligible under Category 2 for HCS through Texas Works Medicaid or through the foster care program. Assist in verifying Medicaid eligibility coverage and take no further action on these cases.
  • A Medicaid recipient is still eligible for Texas Health Steps until age 21.
  • Restitution and reconciliation policy does not apply.

 

O-1700 Medically Dependent Children Program (MDCP)

Revision 18-1; Effective March 1, 2018

 

MDCP provides services to support families caring for children who are medically dependent and to encourage de-institutionalization of children in nursing facilities.

See Section O-1100, Application for Waiver Programs.

 

Waiver Eligibility Component

HHSC is responsible for determining if the person meets the criteria specific to MDCP for the waiver eligibility component and will communicate that the person has:

  • a medical necessity (MN) determination;
  • an approved plan of care or service plan; and
  • a service begin date no later than 30 days from certification.

HHSC will determine that the person:

  • is or will be residing in the community; and
  • is under age 21.

If HHSC determines that the person is not residing in the community or is not under age 21, HHSC will take appropriate action.

Since Supplemental Security Income (SSI) parental deeming ends at age 18, when a person reaches age 18, refer to the Social Security Administration (SSA) for an SSI determination. If certified for SSI, deny ME – Waivers. Notify the recipient of the change. Notify HHSC of the change.

 

Financial Medicaid Eligibility Component

HHSC is responsible for determining if the person meets the criteria specific to MDCP for the financial Medicaid eligibility component and will communicate that the person has met all eligibility factors. If the person is already eligible for Medicaid through another program under the Texas State Medicaid Plan, the financial Medicaid eligibility component for this waiver has already been met.

When determining financial Medicaid eligibility for MDCP, give special consideration to the following:

  • Receipt of a signed and dated application. Section O-1100, Application for Waiver Programs, and Section B-4000, Date of Application.
  • Age of the person. If the person's age is less than 65 and the person does not receive an SSA, SSI or Railroad Retirement (RR) disability benefit, a disability determination by HHSC is required even if the person has received a level of care (LOC) determination under the waiver eligibility component criteria.
  • Post-DRA transfer of assets. The person is ineligible until the transfer does not appear during the look-back period. See Chapter I, Transfer of Assets, for calculation of penalty period.
  • Post-DRA substantial home equity. A person with a home whose equity interest in the home exceeds the established limit is not eligible for waiver services unless the person's spouse, child or disabled adult child is also living in the home.
  • Support and maintenance and deeming. Even if the person receives support and maintenance, do not develop this as income. If the person is living with parents or spouse, do not deem.
  • Income limit. Use the special income limit – 300% cap limit. See Appendix XXXI, Budget Reference Chart.
  • Co-payment calculation. Always determine the co-payment calculation for MDCP at initial application. Reference the appropriate worksheet from Appendix XXII, Home and Community-Based Services Waiver Program Co-Payment Worksheets, to check the calculations made in TIERS.
  • Spousal impoverishment resources. If married, consider spousal impoverishment for a waiver. See Chapter J, Spousal Impoverishment.
  • Spousal co-payment. See the appropriate worksheet from Appendix XXII to determine the spousal diversion or the dependent allowance.

 

Multiple Program Processing

If there is a delay in certifying the waiver services because the waiver eligibility component criteria has not been met or there is no available waiver slot, certify the person for other benefits for which the person may be entitled, such as QMB or SLMB, as soon as eligibility can be determined. If the application is due, delay of certification procedures should be used for the ME – Waiver EDG.

This allows the application to remain open for an additional 90 days.

HHSC notifies MEPD by completing and sending Form H1746-A, MEPD Referral Cover Sheet, to the Midland Data Processing Center. MEPD continues to notify HHSC of eligibility status using the MEPD communication tool (http://dadsview.dads.state.tx.us/me-to-dads/).

When all pending waiver eligibility component criteria have been met and there is an available slot, complete a disposition of the ME – Waiver EDG.

If the delay of certification period is expiring, and the waiver eligibility component criteria have not been met or there is still no available slot, proceed with denial of the ME – Waiver EDG. The MEPD specialist informs HHSC of the denial using the MEPD communication tool.

 

Instructions for Processing the Program Transfer

  • After reviewing the case, if the person is eligible for a waiver and is already an institutional (ME – Non-State Group Home, ME – State Hospital or ME – Nursing Facility) or CAS (ME – Community Attendant) MEPD Medicaid recipient, process a program transfer directly to ME – Waivers. The QMB or SLMB coverage must be continued if the person continues to meet the QMB/SLMB eligibility criteria.
  • When a program transfer for a noninstitutional MEPD Medicaid recipient is processed to ME – Waivers and waiver services have been authorized/received before the program transfer effective date, request a force change to ensure retroactive coverage of the waiver services.
  • See Appendix XLV, Program Transfer with Form H1200 Guide, to determine if a Form H1200 is needed. Verify resources and income including transfer of resources and substantial home equity. If there is a community spouse, verify all income and resources and treat according to spousal policy.

 

Notices

When the Financial Medicaid Eligibility Component is determined, follow established procedures from the HHSC Office of Eligibility Services (OES) on notifications.

If the applicant does not meet the financial Medicaid eligibility component criteria for MDCP Medicaid, send the appropriate denial notice to the person with a copy to the designee. Continue to send notices regarding QMB, SLMB, MQMB and MSLMB eligibility to the person with a copy to the designee.

The financial Medicaid eligibility component redeterminations follow an annual schedule. If a recipient fails to return the review form, HHSC will communicate to the designee that the recipient may be denied.

 

Co-Payment

To comply with the federally approved waiver, co-payment must be calculated for any person in a waiver whose eligibility is determined under the special income limit. See Appendix XXII, Home and Community-Based Services Waiver Program Co-Payment Worksheets, for the sequence in which deductions are allowed. Allow deductions indicated on the appropriate co-payment worksheet. For MDCP, the co-payment usually will be $0 unless a QIT is involved. Notify the designee of the co-payment amount using the MEPD communication tool, even if the co-payment is $0 at initial application. For redeterminations and reported changes, notify HHSC only if the co-payment amount changes.

 

Medical Effective Date (MED)

An MED can be established when all the criteria are met for both the:

  • waiver eligibility component;
  • and financial eligibility component.

See Section R-1200, Medical Effective Date. For waiver eligibility, the medical effective date is one of the following:

  • The first day of the month of entry to a nursing facility, ICF/IID or state supported living center if the applicant filed a Medicaid application during that month, then requested a program transfer before being certified, and met all eligibility criteria.
  • The first day of the month if the applicant met all waiver eligibility component and financial Medicaid eligibility component criteria. See Section O-1100, Application for Waiver Programs.
  • The day after the effective date of SSI denial for persons transferred from SSI assistance to a MEPD program (excluding any Medicare Savings Program).

 

Notes:

  • Remember to consider eligibility for QMB and SLMB, including prior coverage for SLMB, and prior coverage if the person was in a nursing facility, ICF/IID or state supported living center before the waiver.
  • A person can also be eligible under Category 2 for MDCP through Texas Works Medicaid or through the foster care program. Assist in verifying Medicaid eligibility coverage and take no further action on these cases.
  • A Medicaid recipient is still eligible for Texas Health Steps until age 21. Refer the person to SSI at age 18. If the recipient becomes SSI-eligible, HHSC notifies MDCP staff via the MEPD communication tool that the recipient's coverage is being transferred to SSI. HHSC must then terminate ME – Waivers coverage to allow SSI eligibility to process.
  • Restitution and reconciliation policy does not apply.

 

O-1800 Texas Home Living (TxHmL)

Revision 18-1; Effective March 1, 2018

 

This program provides selected essential services and supports to people with intellectual disabilities who live with their families or in their own homes in the community. TxHmL services are intended to supplement, rather than replace, the services and supports a person may receive from other programs, such as the Texas Health Steps Program, or from family, neighbors or community organizations.

See Section O-1100, Application for Waiver Programs.

 

Waiver Eligibility Component

HHSC is responsible for determining if the person meets the criteria specific to TxHmL for the waiver eligibility component and that the person:

  • has an ICF/IID level of care;
  • has an approved plan of care or service plan;
  • has a service begin date no later than 30 days from certification;
  • is residing in the community; and
  • is a Medicaid recipient or would be eligible under either ME – SSI, ME – Pickle, ME – Disabled Widow(er), ME – Early Aged Widow(er) or ME – Disabled Adult Child. Persons cannot be determined eligible for this waiver under the special income limit program.

 

Financial Medicaid Eligibility Component

The TxHmL Program requires that the person be eligible for Medicaid or would be eligible under either ME – SSI, ME – Pickle, ME – Disabled Widow(er), ME – Early Aged Widow(er) or ME – Disabled Adult Child. Persons cannot be determined eligible for this waiver under the special income limit program.

 

Notes:

  • Individuals who are Medicaid eligible under Texas Works do not need to be redetermined eligible under an MEPD program. Assist the provider in verifying Medicaid eligibility coverage and take no further action on these cases.
  • Restitution and reconciliation policy does not apply.