Section 1000, Eligibility Begin Dates

Revision 15-4; Effective October 1, 2015

 

 

F—1010 General Policy

Revision 15-4; Effective October 1, 2015

 

The applicant is eligible for 12 months beginning the first day of the application month if all eligibility criteria are met. The applicants are eligible to receive benefits beginning the month after their 21st birthday through the end of the month of their 23rd birthday.

The medical effective date cannot precede the:

  • effective date of the program (October 1, 2009), or
  • the month after the individual's 21st birthday.

If an applicant applies in the month of the applicant’s 21st birthday, the individual cannot be eligible for the Former Foster Care in Higher Education (FFCHE) program until the following month.

Applicants who wish to have coverage during the month of their 21st birthday must apply for benefits under an appropriate Medicaid program.

Note: These individuals may be eligible for Medicaid for Transitioning Foster Care Youth (MTFCY) during the month of their 21st birthday. See Part M, Medicaid for Transitioning Foster Care Youth (MTFCY).

Examples:

  • An individual turns age 21 on May 5. She filed an FFCHE application on May 1. The individual is ineligible to receive FFCHE during May, the month of application, since she turns 21 during May. Her eligibility begin date will be June 1. If the applicant wishes to receive benefits for the application month, she must file an application for an appropriate Medicaid program.
  • The individual turns age 23 on May 5. She is no longer eligible to receive FFCHE benefits effective June 1.

Three months prior coverage is not available in the FFCHE program. An applicant may apply for three months prior coverage under a Medicaid program and receive assistance if eligible.

In the event an FFCHE recipient becomes pregnant and does not apply for or is not eligible for Medicaid, the newborn is not eligible for TP 45 – Medicaid for Newborn Children. If the mother wants coverage for the baby, she must apply for Medicaid; if eligible, the child will be certified for TP 43 – Medical Assistance for Children Under Age 1.

 

F—1011 Types of Coverage

Revision 15-4; Effective October 1, 2015

 

FFCHE recipients will have two types of coverage. The type of coverage determines how recipients access their health care services.

Fee-for-Service – Initial coverage for FFCHE recipients. Although FFCHE individuals are not Medicaid recipients, they will have access to any Medicaid provider and will be allowed to self-refer to specialists. The provider submits claims directly to the claims administrator for reimbursement of the FFCHE-covered services (the coverage mirrors services available to Medicaid recipients). The Texas Health and Human Services Commission (HHSC) will use state funds to pay these claims.

Managed Care – A service delivery program that provides medical care in a managed care setting. The state pays a monthly premium to the health maintenance organization (HMO) for each recipient enrolled in the plan. The plan processes all provider claims.

Enrollment into managed care is mandatory for FFCHE recipients; however, when a recipient is determined eligible for the FFCHE program, fee-for-service coverage is provided until the recipient is enrolled into managed care. Managed care coverage is determined using prospective enrollment following current cutoff rules. Managed care health benefits are provided through the STAR Program.

Example: An application is received on January 1 and processed on January 25 (after cutoff); the managed care effective date is March 1. The initial months (January and February) will be covered as fee-for-service.