Revision 17-2; Effective April 1, 2017

 

 

W—910 General Policy

Revision 17-2; Effective April 1, 2017

 

A woman is continuously eligible for 12 months beginning the first day of the month all eligibility criteria are met. There is no three months prior eligibility for the Healthy Texas Women (HTW) program.

Note: This does not include three months prior only Medicaid or Medical Assistance - Medically Needy with Spend Down programs. An applicant can apply for and receive three months prior benefits under a Medicaid program.

The medical effective date (MED) cannot precede the month of the women's 15th birthday.

This is a fee-for-service program. Fee-for-service allows access to any health care provider and self-referral to specialists. The provider submits claims directly to the claims administrator for reimbursement of covered services.

If a household failed to report required information at the time of the application that causes the woman to be ineligible for HTW, advisors must deny the case.

Eligibility Determination Groups (EDGs) with end dates do not require an action to close when the individual does not return Form H1867-R/H1867-RS, Healthy Texas Women Renewal, or Form H1831, Adjunctive Eligibility Letter. These EDGs will close the last day in the 12th month of the certification period.

Note: Women are eligible to receive HTW during their Pay for Performance forfeit month(s).

Related Policy
Pay for Performance, A-2150
Eligibility Begin Dates, W-1920

 

W—911 Current Medicaid, Medicare (Part A or B) and Children's Health Insurance Program (CHIP) Recipients

Revision 17-2; Effective April 1, 2017

 

A woman is not eligible to receive Healthy Texas Women (HTW) benefits if currently receiving Medicaid, Medicare (Part A or B) or CHIP. If an application is received for a woman who is actively receiving Medicaid, Medicare (Part A or B) or CHIP, deny the application using the following disposition denial reason:

  • English — You are ineligible to receive Healthy Texas Women services as you are currently receiving assistance under Medicare, Medicaid or CHIP.
  • Spanish — Usted no llena los requisitos para recibir los servicios del Healthy Texas Women ya que actualmente recibe ayuda de Medicare, Medicaid o CHIP.

Staff must verify via State Online Query (SOLQ) that an applicant is not currently enrolled in Medicare (Part A or B). The Texas Integrated Eligibility Redesign System (TIERS) verifies if the applicant is receiving Medicaid or CHIP benefits at application, renewal and during the HTW 12-month continuous eligibility period.

If applications are received for … and the … the advisors must … TIERS will … Note:
both HTW and Medicaid before either are processed, HTW application is certified first, continue working on the Medicaid application. If the Medicaid EDG is certified, automatically deny the HTW EDG. If the individual is eligible, the MED for the Medicaid application will follow current MED policy. If the applicant is not certified for Medicaid, she will continue to receive ongoing HTW benefits.
both HTW and Medicaid before either are processed, Medicaid application is certified first, deny the HTW application. Use the appropriate denial code and provide the individual with Form TF001W, Notice of Case Action. issue an error if the worker attempts to certify a HTW EDG and the individual is actively receiving Medicaid benefits.  

Note: This does not include three months prior only Medicaid or Medical Assistance - Medically Needy with Spend Down programs. An applicant can apply for and receive three months prior benefits under Medicaid. The three months prior check boxes will be disabled when Health Care-HTW is selected.

Related Policy
Eligibility Begin Dates, W-1920

 

W—912 Pregnant Women

Revision 17-2; Effective April 1, 2017

 

Women who are pregnant are ineligible to receive HTW benefits. If the question, "Are you pregnant?" is marked Yes on Form H1867/H1867-S, Healthy Texas Women Application; Form H1867-R/H1867-RS, Healthy Texas Women Renewal; or Form H1831, Adjunctive Eligibility Letter, deny the application/renewal using the following denial reason code and add the statement below to the comment section of Form TF001W, Notice of Case Action.

  • English — On your application, you told us you are pregnant. Women who are pregnant cannot receive Healthy Texas Women benefits. To find out if you can receive Medicaid for pregnant women, please complete, sign and return the attached application.
  • Spanish — En la solicitud, usted nos dijo que está embarazada. Las mujeres embarazadas no pueden recibir beneficios del programa Healthy Texas Women. Para saber si puede recibir Medicaid para mujeres embarazadas, por favor, llene, firme y envíe la solicitud adjunta.

Include Form H1010, Texas Works Application for Assistance — Your Texas Benefits, along with Form TF001W, Notice of Case Action, and a self-addressed stamped envelope addressed to the Document Processing Center when denying an application due to pregnancy.

If the question is not answered, pend the EDG. Allow the applicant normal processing time frames to provide an answer. Advisors must manually pend for verification. Verification is self-declared. Deny the application for failure to provide verification if the applicant/recipient does not provide verification.

Do not deny the recipient if a report of pregnancy is received during the 12-month continuous coverage period. Record the change and take action on the information at the next renewal.

Note: For HTW recipients who apply for Medicaid for Pregnant Women (TP 40), TIERS will deny the HTW EDG once the recipient is certified to receive benefits for her pregnancy.

 

W—913 Third-Party Resource (TPR)

Revision 17-2; Effective April 1, 2017

 

A woman is ineligible to receive HTW benefits if she has creditable health coverage (TPR). The applicant/recipient has creditable health coverage if her private health insurance covers family planning services.

An applicant/recipient's private health insurance is considered to cover family planning services if it provides both:

  • family planning-related physician office visits and procedures, and
  • contraceptive drugs and devices.

In making this determination, only consider whether the private health insurance provides coverage and do not give consideration to other issues such as high deductibles or dollar limits on drug coverage.

Form H1867/H1867-S, Healthy Texas Women Application, and Form H1867-R/H1867-RS, Healthy Texas Women Renewal, ask the applicant the following questions:

  1. Do you have health insurance that covers family planning services? Yes No
  2. If yes, will filing a claim on your health insurance cause physical, emotional or other harm to you from your spouse, parents or other person? Yes No
  3. If yes, you must provide an explanation below of your situation.

A HTW applicant with creditable health coverage is eligible to receive benefits only if identifying and providing information to assist in pursuing third parties is against her best interest.

Staff must pend the applicant if she does not answer questions 1 and/or 2. Allow the applicant normal processing time frames to provide an answer. Verification is self-declared by the applicant. If the applicant does not self-declare the answer to question 1 and/or 2 by the deadline, deny the application for failure to provide.

If the applicant states Yes to question 1 and question 2 but leaves question 3 blank, do not pend the applicant for an answer; continue determining eligibility.

If the applicant states Yes to question 1 and No to question 2, deny the application using the following denial reason code and add the statement below to the comment section of Form TF001W, Notice of Case Action.

  • English — On your application you told us you are covered by other health insurance. Women who are covered by other health insurance cannot receive Healthy Texas Women benefits.
  • Spanish — En la solicitud, usted nos dijo que tiene cobertura de otro seguro médico. Las mujeres con cobertura de otro seguro médico no pueden recibir beneficios del programa Healthy Texas Women.

If during the recipient's 12-month continuous coverage period she reports having creditable health insurance, record the change and take action on the TPR information at the next renewal.

 

W—914 Auto Enrollment into HTW

Revision17-2; Effective April 1, 2017

 

Individuals receiving Medicaid for Pregnant Women (TP40) will be auto-enrolled in HTW at the end of their TP40 certification (with or without a birth outcome), if the woman is not eligible for Medicaid or CHIP.

The individual must meet the following eligibility requirements to be auto-enrolled to HTW:

  • must be age 18 through 44; and
  • must not have open/active TPR.

TIERS triggers Alert 824, Pregnancy Ending Test MAGI, on first day of the TP40 last benefit month to create a Task List Manager. Advisors will run the full modified adjusted gross income (MAGI) cascade. If the worker process results in a denial of Medicaid and CHIP because the individual:

  • does not meet eligibility requirements, the TP40 individual is referred to the Marketplace and auto-enrolled into HTW; or
  • failed to provide the verification needed to make a Medicaid/CHIP eligibility determination, the individual is not referred to the Marketplace; however, is auto-enrolled into HTW.

No other financial or non-financial rules will be applied for individuals who are auto-enrolled to HTW.

The effective date of the HTW EDG will be the first day of the month following the TP40 end of certification month.

When a woman is auto enrolled into HTW, TIERS will generate:

  • a TF0001W– Notice of Case Action; and
  • Form H1872, HTW Opting Out and Reporting Confidential Address.

The Form H1872 will provide the HTW individual with an opportunity to voluntarily withdrawal (opt out) and/or report a confidential address. The Form TF0001-W and H1872 will be mailed to the individual's current case address, since a confidential address for the HTW individual may not be available at the time of auto-enrollment.

Related Policy
Confidentiality, W-2400

 

W—920 Verification Requirements

Revision 17-2; Effective April 1, 2017

 

Accept self-declaration of pregnancy and TPR.

 

W—930 Documentation Requirements

Revision 07-0; Effective July 1, 2007

 

For TPR, staff must document in case comments:

  • the availability of TPR for family planning services;
  • if filing a claim would cause physical, emotional or other harm to the individual; and
  • why, if provided.