Revision 14-1; Effective March 1, 2014

 

R-2100 Persons Discharged to Hospitals from Institutional Settings

Revision 09-4; Effective December 1, 2009

 

When a recipient in a long-term care facility is discharged to a Medicaid-certified hospital, the recipient continues to be eligible during his/her absence. Redetermine eligibility if the recipient does not re-enter the nursing facility after discharge from the hospital.

To monitor a recipient in a nursing facility who is discharged to a hospital, use a tracking system. This ensures prompt awareness of a change in the recipient's status, such as death or a return to the community after he/she is discharged to a hospital.

The following procedures are recommended for establishing a tracking system:

  • Immediately upon receipt of Form 3618, Resident Transaction Notice, showing discharge to a hospital, establish a control record for the recipient. Use Form 3618 as the control record or prepare a card file record. The control file may be maintained separately by each eligibility specialist or centrally for all eligibility specialists in an office.
  • At least every 15 calendar days, confirm the recipient's status and location. Contact the nursing facility first because the recipient may have been readmitted. If he/she has not returned to the facility, the facility may supply the name of the hospital or the authorized representative to determine if the recipient is still a patient. Follow up with the hospital or authorized representative every 15 days until the recipient returns to the nursing facility, is discharged to another living arrangement or dies.
  • If the recipient is no longer in the hospital, remove the control record from the file and take action to update the case, if required.

 

R-2200 Reserved for Future Use

Revision 12-2; Effective June 1, 2012

 

 

R-2300 Your Texas Benefits Medicaid ID Card

Revision 16-3; Effective September 1, 2016

 

When a person is certified for regular Medicaid benefits, HHSC promptly issues a Your Texas Benefits Medicaid ID card, which individuals will use to receive services.

  • Individuals only receive one Your Texas Benefits Medicaid ID card, which is intended to be the individual's permanent card.
    • If the individual's Medicaid coverage ends but they later regain coverage, the individual can use the same Your Texas Benefits Medicaid ID card.
    • If the individual loses the card, they can get a replacement card by calling 1-855-827-3748.
  • Individuals should carry and protect their Your Texas Benefits Medicaid ID card just as they do their driver's license or credit card.
  • The Your Texas Benefits Medicaid ID card is plastic like a credit card.
    • It will have a magnetic strip that holds the individual's Medicaid ID number.
    • Providers are able to use that number and the provider website (YourTexasBenefitsCard.com) to determine if the individual is covered by Medicaid.
  • The Your Texas Benefits Medicaid ID card will come printed with the following information on the front:
    • individual's name and Medicaid ID number;
    • managed care program name (if STAR Health);
    • date the card was issued; and
    • billing information for pharmacies.
  • The back of the card will come printed with a statewide toll-free phone number and a website (YourTexasBenefitsCard.com) where individuals can get more information on the Your Texas Benefits Medicaid ID card.
  • Individuals should use the card when they go to a Medicaid doctor or dentist visit or when they go to the pharmacy. The office staff can use the card to help determine if the individual is covered by Medicaid.
  • If the individual forgets the Your Texas Benefits Medicaid ID card, the doctor, dentist or pharmacy can verify that person's Medicaid coverage by calling the TMHP Contact Center at 1-800-925-9126 or visiting TMHP's TexMedConnect website and checking the individual's Medicaid ID number. Providers also can verify eligibility by using the secure website (YourTexasBenefitsCard.com) designed for use with the Your Texas Benefits Medicaid ID card, or by calling 1-855-827-3747 (7 am to 7 pm Monday - Friday, and 9 am to 5 pm Saturday).
  • If an individual loses the Your Texas Benefits Medicaid ID card and needs quick proof of eligibility, HHSC staff at a local benefits office can still generate a temporary Form H1027-A, Medicaid Eligibility Verification.
  • The Your Texas Benefits Medicaid ID card and the YourTexasBenefitsCard.com provider website are designed to give providers another way to verify the individual's Medicaid coverage. Providers are able to instantly access their Medicaid patient's Medicaid-related:
    • THSteps Alerts listing the last check-up dates for dental/medical services;
    • health Summary information;
    • prescription drug history and health events including diagnosis and treatment; and
    • vaccination history.
    Individuals can choose to not allow their Medicaid doctors and other providers to see their Medicaid-related health history through the provider website. Individuals can "opt out" by calling 1-855-827-3748 (toll-free) or through YourTexasBenefits.com MEHIS client portal.
  • The website will give providers a way to capture information showing when their Medicaid patient receives treatment.

HHSC does not issue Your Texas Benefits Medicaid ID cards for residents of a state supported living center because Medicaid state institutions are responsible for all medical care for Medicaid-eligible residents. HHSC sends each state institution a monthly listing of all Medicaid individuals currently shown on computer files as living in that facility.

Note: HHSC does not issue a Your Texas Benefits Medicaid ID card for Community Attendant Services (CAS) recipients unless they are eligible for Qualified Medicare Beneficiary Program (QMB).

 

R-2400 Issuance of Form H1027, Medicaid Eligibility Verification

Revision 16-3; Effective September 1, 2016

 

Occasionally, a recipient who needs medical services may lack current medical care identification.

HHSC may issue a Medicaid verification letter to an eligible Medicaid recipient who lacks a Your Texas Benefits Medicaid ID card if the:

  • recipient is newly certified and has not received the initial card; or
  • current card has been lost or destroyed.

Note: Do not issue Form H1027 to Community Attendant Services, SLMB or QDWI individuals (ME-Community Attendant with no QMB, MC-SLMB and MC-QDWI).

Form H1027 is issued in three versions. Issuance of the appropriate version of Form H1027 is dependent on the benefits the recipient is currently eligible for and receiving. Following is a brief description of each version of Form H1027.

Form H1027-A, Medicaid Eligibility Verification, is issued to recipients who are eligible for and receiving Medicaid benefits only.

Form H1027-B, Medicaid Eligibility Verification – MQMB, is issued to recipients who are eligible for and receiving both Medicaid and Qualified Medicare Beneficiary (QMB) benefits.

Form H1027-C, Medicaid Eligibility Verification – QMB, is issued to recipients who are eligible for and receiving QMB benefits only. Do not issue Form H1027-C to recipients who are receiving Medicaid benefits.

Reference: For additional information regarding client eligibility for QMB, see Chapter Q, Medicare Savings Programs.

Reminder: To ensure that the appropriate form is issued to an eligible person, only intake screeners and TANF, Medicaid, LTC (ME/CCAD), foster care or adoption assistance eligibility specialists and supervisors are authorized to complete the form.

Form H1027-A, Form H1027-B or Form H1027-C must be issued only to eligible persons who need verification of their current eligibility for benefits and who have no access to a current Your Texas Benefits Medicaid ID card. The forms are issued only for the current month and never for retroactive periods of eligibility.

Verify a recipient's current eligibility by:

  • contacting Data Integrity; or
  • checking inquiry in TIERS.

Note: If unable to verify the recipient's eligibility because of computer problems, follow regional procedures to verify eligibility.

After verifying eligibility, complete the appropriate Form H1027.

After completing the appropriate Form H1027, have the form approved, signed and dated by the unit supervisor. The supervisor may also approve the form by telephone. If obtaining the supervisor's approval by telephone, note "by telephone" on the approval line. If the unit supervisor is not available, the lead eligibility specialist in the locality may approve the form.

Reference: For additional information about issuing Form H1027, refer to the instructions. See Chapter B, Applications and Redeterminations, for emergency manual certification procedures.

 

R-2500 Explanation of Benefits

Revision 12-2; Effective June 1, 2012

 

Form H3086, Explanation of Benefits (EOB), is mailed each month to a random sample of Medicaid recipients. The EOB is a statement of all Medicaid services that were billed and paid on the recipient's behalf in the preceding month.

The EOB is mailed with a return envelope. If a recipient has a question about reported Medicaid services, the recipient circles the service in question, enters a contact telephone number and returns the EOB to state office. The recipient can call 1-800-252-8263 if questions arise about the EOB information.

If a recipient contacts HHSC about a questionable EOB, explain the purpose of the EOB. If a question still exists, instruct the recipient to mail the EOB to:

Office of Inspector General/Medicaid Provider Integrity
Mail Code 1361
P.O. Box 82500
Austin, TX 78708-9920

If the EOB is readily available, record on the EOB the recipient statement about the discrepancy. (Example: "Client states she has never seen a Dr. Jones.")

After an EOB is returned to state office, the EOB analyst checks the service in question for possible billing errors. If a billing error is found, appropriate action is taken to correct the files. The EOB analyst notifies the recipient that correction has been made. If no billing error can be found, the EOB is referred to the appropriate local office for a contact with the recipient.

When an EOB from state office is received, attempt to contact the recipient and discuss the reason for returning the EOB. The contact may be by telephone, office visit or home visit. Do not contact the provider of service under any circumstance.

If the recipient did not understand the purpose of the EOB, or if the problem can be resolved by talking to him/her, check the appropriate box on the EOB-Form Letter (FL) 1 and return the EOB-FL 1 and EOB to state office.

If the recipient alleges that the service in question was not received, reports an additional charge or reports other problems in relation to the service questions, check the appropriate box, record the recipient's statement in the space provided on the EOB-FL 1 and return the EOB-FL 1 and EOB to state office. (A cover memorandum is not necessary.) After the EOB is returned to state office, the EOB is referred to the Texas Medicaid and Healthcare Partnership (TMHP) for further investigation, and no further action on the part of the eligibility specialist is required.

If a provider of services has questions about an EOB, explain the purpose of the EOB. If additional information is requested, or a service listed is in question, ask the provider to telephone TMHP using the provider contact information below:

  • Automated Inquiry System (AIS) – 1-800-925-9126
  • TMHP Contact Center – 1-800-925-9126

Reminder: Only services billed and paid appear on the monthly EOB.

 

R-2600 Reserved for Future Use

Revision 14-1; Effective March 1, 2014

 

 

R-2700 Notification of Pre-Screening Result for Medicaid

Revision 12-2; Effective June 1, 2012

 

Occasionally, for purposes of receiving assistance from drug companies or other private entities, a person will request a pre-screening for Medicaid in conjunction with a request for a letter to substantiate the results of the pre-screening.

Form H1035, Pre-Screening Result for Medicaid, is used to notify an interested person of the pre-screening results for Medicaid if:

  • the notice is requested by the person;
  • the pre-screening is based on a verbal conversation;
  • an official determination of eligibility is not conducted; and
  • the person does not appear eligible for Medicaid.