Revision 19-2; Effective June 1, 2019

 

R-1100 Texas Administrative Code Rules

Revision 09-4; Effective December 1, 2009

 

§358.540. Medical Effective Date.

(a) If a person is eligible for a Medicaid-funded program for the elderly and people with disabilities (MEPD), the Texas Health and Human Services Commission (HHSC) includes in the notice of eligibility the date that the person's Medicaid benefits will begin, which is known as the medical effective date.

(b) HHSC determines the medical effective date:

(1) in accordance with 42 CFR §435.914, as the first day of the month in which a person meets all eligibility criteria, which may be up to three months before the date of application if:

(A) during the three months before the month of application, the person received MEPD services covered under the Texas State Plan for Medical Assistance; and

(B) would have been eligible for MEPD at the time the services were received if the person had applied (or someone had applied on behalf of the person), regardless of whether the person is alive when application for MEPD is made; or

(2) as approved by the Centers for Medicare and Medicaid Services for a §1915(c) waiver program.

§358.535. Notice of Eligibility Determination.

(a) After making an initial eligibility determination, the Texas Health and Human Services Commission (HHSC) sends the applicant, in accordance with 42 CFR §435.912:

(1) a written notice of eligibility, including notice of any co-payment the person must pay and the medical effective date described in §358.540 of this subchapter (relating to Medical Effective Date); or

(2) a written notice of ineligibility, explaining the reason for the decision and the specific provision supporting the decision.

(b) After making an eligibility redetermination, HHSC sends the recipient a written notice of any change in eligibility or co-payment.

(c) The written notice informs the applicant or recipient of the right to request a hearing to appeal the eligibility determination. The hearing is held in accordance with 42 CFR Part 431, Subpart E and HHSC's fair hearing rules in Chapter 357 of this title (relating to Hearings).

 

R-1200 Medical Effective Date

Revision 19-2; Effective June 1, 2019

 

The medical effective date (MED) is the first day of the month an applicant meets all eligibility criteria. The MED may be up to three months before the date of application, in which:

  • the applicant had unpaid or reimbursable medical expenses, regardless if the person is alive when the application is made; or
  • the applicant entered a nursing facility, intermediate care facility for persons with intellectual disabilities (ICF/IID), or state supported living center.

For persons transferring from Supplemental Security Income (SSI) to an MEPD program (excluding Medicare Savings Program recipients), the MED is the day after the effective date of the SSI denial (under ME – SSI).

The MED is used to initiate all medical benefits to the person and payments to providers.

The MED for Community Attendant Services (formerly 1929(b)) may be the first of the month in which:

  • the application was received; or
  • an eligibility decision was made.

MED for Home and Community-Based Waiver Services after a Denial of No Renewal Packet

Prior months' eligibility and ongoing eligibility for the financial Medicaid eligibility component is contingent upon verification of receipt of waiver services when re-establishing an MED for Home and Community-Based Services waiver services following a denial due for non-receipt of redetermination packet.

Coordinate financial case actions with a waiver case manager.

The following examples are for the financial Medicaid eligibility component for waivers and are not intended to address any situation with continuous Q benefits.

  • Example 1: A case is denied because of non-receipt of the redetermination packet effective June 30. In October, the redetermination packet is received. The redetermination is treated as an application. The person met all financial eligibility criteria for October and all months since the denial. Verification is received indicating that waiver services were provided continuously since June. The MED is July 1 and there is no break in coverage.
  • Example 2: A case is denied because of non-receipt of the redetermination packet effective March 31. In October, the redetermination packet is received. The redetermination is treated as an application. The person met all financial eligibility criteria for October and all months since denial.  Verification is received indicating that waiver services were provided continuously since March. The MED is July 1. This is a break in coverage because the MED is the first day of the month up to three months before the receipt of the application or redetermination.
  • Example 3: A case is denied because of non-receipt of the redetermination packet effective Jan 31. In June, the redetermination packet is received. The redetermination is treated as an application. The person met all financial eligibility criteria for February and all months since denial. Verification is received indicating that waiver services stopped effective Feb. 28. The MED is June 1 or the first day of the month waiver services begin. There is a break in coverage.

Related Policy
Administrative Denials, B-9100
Qualified Disabled and Working Individuals (QDWI), R-1230
Qualified Medicare Beneficiary ( QMB)-MC-QMB, Q-2000
QMB Medical Effective Date, Q-2700

 

R-1210 Medicare Skilled Nursing Facilities

Revision 12-2; Effective June 1, 2012

 

The medical effective date for a person in a Medicare skilled nursing facility (SNF) potentially can be as early as the first day of the month of entry to the nursing facility or the first day of a prior month. If eligible, this will ensure payment of any other medical expenses (including returns to the hospital during the initial 20 days of full Medicare coverage). At certification, the eligibility worker must verify and document in TIERS case comments section that the individual:

  • remains in the SNF section; or
  • has been discharged to a Medicaid-certified facility.

Medicare approval of the applicant for the SNF bed meets the medical necessity (MN) requirement. If the MED is prior to the applicant's move to the Medicaid-only bed, the MN requirement has been met.

Note: If the person remains in the SNF when the case is certified, it is recommended that a special review be scheduled to monitor for the completed MN determination when SNF does end.

See Chapter H, Co-Payment, for issues related to the 30 consecutive day stay requirement and the appropriate income limit.

Examples:

  • Marsha Ford is admitted to an SNF as full Medicare on 11-15-XX. The 21st SNF day is 12-05-XX. The application is received 12-14-XX. Application is ready to certify 01-03-XX. The eligibility worker verifies that Ms. Ford has unpaid/reimbursable hospital bills for 11-XX. Ms. Ford is still in the SNF bed and has met all eligibility criteria as of 12:01 a.m. 11-01-XX. MED = 11-01-XX. Co-payment begins 12-05-XX.
  • Fred McDaniel is admitted to an SNF as full Medicare on 03-24-XX. The 21st SNF day is 04-13-XX. The application is received 04-05-XX. He is discharged from the SNF to a Medicaid bed on 05-20-XX. Application is ready to certify 06-15-XX. Mr. McDaniel meets all eligibility criteria as of 12:01 a.m. 03-01-XX. MED = 03-01-XX. Co-payment begins 04-13-XX. MN is not necessary, as MED is prior to discharge to Medicaid-only bed.

 

R-1220 Out-of-State Transfers

Revision 12-2; Effective June 1, 2012

 

If a person from another state declares an intention to live in Texas and meets Texas eligibility requirements, contact the Medicaid agency of the former state of residence. Request that the agency notify HHSC about Medicaid eligibility and the denial, including its effective date. The denial effective date is the last day for which the person's former state of residence will pay Medicaid claims. This is not necessarily the denial effective date on the former state's computer system.

Texas residency is met the first day of the month of move to Texas with the intent to remain in Texas.

If the person did not receive any form of Medicaid in the former state of residence, the earliest MED is the first day of the month of move to Texas, regardless of the actual date of the move. Follow MED policy for month of application and three months prior.

Exception: For QMB, coverage begins the first of the month after eligibility is determined.

If the person did receive Medicaid in the former state of residence, the MED for the person in Texas is no earlier than the day following the date his/her former state of residence will pay Medicaid claims.

If an out-of-state person receives SSI and indicates that he/she intends to live in Texas, refer him/her to a Social Security office. That office makes the SSI (and Medicaid) residence determination.

Examples:

  1. A person was not receiving any form of Medicaid in another state, moved to Texas on July 7 and applied to have the Medicare premium paid. The application for Medicare Savings Programs was filed on July 28. The person met all eligibility criteria in July for Specified Low Income Medicare Beneficiaries (SLMB).

    The MED for SLMB is July 1. Prior months would not be applicable in this situation because the person did not reside in Texas before July.
  2. A person was not receiving any form of Medicaid in another state, moved to Texas on July 30 and entered a nursing facility (NF) that day. An application for MEPD was filed on Aug. 14. The individual met all eligibility criteria in July for Medicaid and QMB.

    In this situation, July is a prior month. Because coverage for a prior month must begin the first day of that month, the MED is July 1. The MED for QMB in Texas is the first day of the month following the month in which QMB eligibility is determined.
  3. A person was receiving Medicaid in another state, moved to Texas on Jan. 15 and entered an NF that day. The application for ME – Nursing Facility was filed on Feb. 10. Medicaid coverage in the other state ended on Jan. 15. The individual met all eligibility criteria in January.

    In this situation, January is a prior month. Because coverage for a prior month must begin the first day of that month, the MED would normally be Jan. 1. If the MED were reported as Jan. 1, there would be federal financial participation (FFP) for two states for the same time period (Jan. 1-15), which is prohibited by federal regulations. Because the correct MED in this case is Jan. 16, the file date must be adjusted to reflect the date following Medicaid closure in the other state, or Jan. 16. Case comments should explain the file date discrepancy.
  4. A person was an SSI recipient in another state and moved to Texas on July 7.

    Because the Social Security Administration (SSA) determines SSI entitlement, HHSC uses the effective date in Texas as communicated by the State Data Exchange (SDX) tape. This date should be the first day of the month following the month in which the SSI recipient moves to Texas.
  5. A person who was a QMB recipient in another state, moved to Texas on July 7 and applied to have the Medicare premium paid. The application for Medicare Savings Programs was filed on July 28.

    If QMB coverage in the other state ended during July, the effective date of QMB coverage in Texas should be no earlier than Aug. 1. The other state is payer of record for Medicare buy-in for July 1993 and receives FFP for that purpose. Any buy-in attempt by Texas for that month will be rejected by the federal system. Because of the prohibition against dual FFP, QMB eligibility cannot be divided between two states for a given month.
  6. The person received ME – Nursing Facility with Q benefits in a Texas NF, but moved out-of-state in April and began receiving Medicaid in the other state. The person returned to a Texas NF on Nov. 15 and applied for MEPD on Nov. 15. The person never received QMB benefits in the other state, although he/she appears to have been eligible since leaving Texas.

    The other state will pay no claims after Nov. 15; therefore, the MED for ME – Nursing Facility with may be no earlier than Nov. 16, because November is the month of application. In this situation, there is no continuous Q to ensure. The person did not have QMB coverage in the other state, and HHSC cannot grant QMB coverage for the period of time he/she lived out of state, as he/she was not a Texas resident. The effective date of QMB coverage in Texas is the first day of the month following the month in which QMB eligibility is determined.

 

R-1230 Qualified Disabled and Working Individuals (QDWI)

Revision 09-4; Effective December 1, 2009

 

The MED is influenced by whether a person enrolls for Medicare coverage during the initial enrollment period (IEP) but before his/her present Medicare entitlement ends, after the IEP begins but after his entitlement ends, or following the IEP. HHSC considers the date the person enrolled for continuation of his Medicare entitlement when determining the MED. The MED does not precede the earliest date the person is entitled to reinstatement of his/her Part A coverage. Otherwise, use the same procedures for determining the MED for all other MEPD non-institutional groups (including retroactive coverage).

The following chart may be used as a reference for the MED determination policies and examples.

Enrollment Period Month Activities
Initial Enrollment
Period (IEP)
April
May
Client notified his free Part A entitlement will end.
  June End of client's free entitlement.
  July
August
September
First month client meets QDWI criteria.
General Enrollment
Period (GEP)
January
February
QDWI coverage effective July 1.
  March End of GEP.

The following apply when determining the MED:

  • The IEP for a person who has been notified that his free entitlement to Medicare Part A coverage will end is a seven-month period. The enrollment period begins the month the person is notified.

    Example: A person is notified in April that his free entitlement to Part A coverage ends at the end of June. His initial enrollment period begins in the month of notification (April) and ends at the end of October. To reinstate his Part A coverage, he must enroll with SSA before the end of October. He then must apply with the department for QDWI benefits.
  • In the case of a person who enrolls in an IEP before meeting QDWI criteria and applies for QDWI benefits, the MED is the first day of the month he meets the QDWI criteria.

    Example: A client is notified in April that her free entitlement to Medicare Part A coverage ends at the end of June. She enrolls for reinstatement of her Part A coverage with SSA in April and applies for and is determined eligible for QDWI benefits with HHSC in May. The earliest MED she can have for QDWI benefits is July 1 because it is the first month she meets QDWI criteria and is allowed to purchase Part A coverage.
  • If a person enrolls in the first month that he meets all QDWI criteria except for reinstatement (fourth month of the initial enrollment period), and applies for QDWI benefits, the medical effective date is effective the first of the following month.

    Example: A person is notified in April that his free entitlement to Medicare Part A coverage ends at the end of June. He enrolls for reinstatement of his Part A coverage with SSA in July and applies for and is determined eligible for QDWI benefits in July. The earliest MED date he can have for QDWI benefits is August 1 because that is the first month he is entitled to reinstatement of his Part A coverage.
  • If a person enrolls in the second month that she meets all QDWI criteria except for reinstatement (fifth month of the IEP) and applies for QDWI benefits, the medical effective date is effective the second month after enrollment.

    Example: A person is notified in April that her free entitlement to Medicare Part A coverage ends at the end of June. She enrolls for reinstatement of her Part A coverage with SSA in August and applies for and is determined eligible for QDWI benefits in September. The earliest MED she can have for QDWI benefits is October 1 because that is the first month she is entitled to reinstatement of her Part A coverage.
  • If a person enrolls in the third or fourth month that he meets all QDWI criteria except for reinstatement (sixth or seventh month of the IEP) and applies for QDWI benefits, the MED is effective the first day of the third month following the month he enrolled.

    Example: A person is notified in April that his free entitlement to Medicare Part A coverage ends at the end of June. He enrolls for reinstatement of his Part A coverage with SSA in September and applies for and is determined eligible for QDWI benefits in October. The earliest MED he can have for QDWI benefits is December 1 because that is the first month he is entitled to reinstatement of his Part A coverage.
  • If a person enrolls during the general enrollment period (GEP), the MED is always effective July 1.

    Example: A person is notified in April that her free entitlement to Medicare Part A coverage ends at the end of June. She does not enroll during the IEP and decides to enroll during the GEP, from January through March 31, of the next year. The earliest MED she is allowed is the July 1 following her enrollment.

 

R-1300 Notices

Revision 15-2; Effective June 1, 2015

 

Note: See Appendix XI, Reference for Notification Forms, to find the right form to send to the applicant or recipient.

For Eligibility:

Send the applicant or recipient a written notice of eligibility for each program. On the eligibility notice, include the MED and any co-payment amount.

Note: For Mason Manor cases, see Appendix XXIII, Procedure for Designated Vendor Number to Withhold Vendor Payment, to find the appropriate forms and explanation to send to the applicant or recipient.

For Ineligibility:

Send the applicant or recipient a written notice of ineligibility for each program. On the ineligibility notice, explain the reason for the decision and the appropriate chapter of this handbook that supports the decision.

For redeterminations, tell a recipient about any change in eligibility or co-payment, if applicable. See Appendix XI.

Address the notice to the applicant or recipient or, if addressed to an authorized representative, say that the information is about the applicant or recipient. All information on notices must be accurate.

Make sure each written notice tells the applicant or recipient about the right to ask for a hearing to appeal the eligibility decision.

Mail the written notice to the applicant or recipient within two working days after the date of the eligibility decision.

Send each applicant or recipient a copy of the HIPAA — Notice of Privacy Practices or HIPAA — Notice of Privacy Practices (Spanish) upon certification.