Revision 19-3; Effective July 1, 2019

 

 

C—1110 Medical Information

Revision 05-1; Effective January 1, 2005

 

 

C—1111 State Medicaid Agencies

Revision 13-3; Effective July 1, 2013

 

Medical Programs

For links to all State Medicaid Agencies, go to https://www.medicaid.gov/medicaid/by-state/by-state.html.

 

C—1112 Services Under the Texas Medical Assistance Program

Revision 19-3; Effective July 1, 2019

 

Medical Programs

Benefits provided through health insuring agent:

  • In-patient hospital services*
  • Out-patient hospital services*
  • Laboratory and x-ray services
  • Physician's services
  • Podiatrist's services
  • Optometric services*
  • Ambulance services*
  • Family planning services*
  • Home health services limited to nurse and home health aide visits*
  • Medicare Part A deductible and coinsurance when benefits would otherwise be payable under Medical Assistance and Medicare Part B deductible and coinsurance for assigned claims only
  • Chiropractic treatment — limited to Medicare Part B deductible and coinsurance for assigned claims only
  • Eyeglasses*
  • Rural health clinics*

Services provided through contract or by direct vendor payments from the Health and Human Services Commission (HHSC):

  • Nursing care skilled and intermediate care. Skilled care is limited to recipients age 21 and over. Medicare SNF coinsurance.*
  • Active treatment for recipients or patients of any age in licensed and approved section of institutions for persons with intellectual disabilities.*
  • In-patient hospital care for recipients or patients age 65 and older in contracted mental hospitals and state (tuberculosis) hospitals.*
  • Texas Health Steps screening program and limited dental treatment for eligible persons under age 21.
  • Prescriptions limited to no more than three covered per month if over 18. Unlimited if 18 and under.
  • Prior authorized hearing aid services.*
  • Primary home care for recipients age 18 and over.*
  • Other medical transportation.

*With limitations — see appropriate provider manuals for details.

The benefits of this program do not extend to:

  • Inmates in a public institution. (Recipients in approved medical units in certain contracted institutions are eligible for vendor payments made by HHSC.)
  • Special shoes or other supportive devices for the feet or walking aids.
  • Services in military medical facilities, Veteran's Administration (VA) facilities, or United States Public Health Service Hospitals.
  • Care and treatment related to any condition for which benefits are provided or are available under Workman's Compensation laws.
  • Dental care and services except certain oral surgery or that provided under Texas Health Steps.
  • Any services or supplies provided in connection with a routine physical examination except family planning services.
  • Any care or services payable under Title XVIII (Medicare).
  • Any service provided by an immediate relative of the recipient or member of the recipient's household.
  • Any services or supplies not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of the malformed body member.
  • Custodial care.
  • Any services provided to the recipient after a utilization review or medical review finding that such services are not medically necessary.
  • Any services or supplies that are payable through a third party.
  • Any service or supplies not specifically provided by the Texas Medical Assistance Program.

Disclaimer: This list is for convenient reference and does not have the effect of law, regulation or policy. If there is a conflict between this list and law, regulations, and policy, the latter will prevail. If there is a question, use the appropriate provider manuals or filed releases for clarification.

 

C—1113 Qualified Hospital/Qualified Entity Policy and Procedures for Presumptive Eligibility Determinations

Revision 15-3; Effective July 1, 2015

 

TA 66, TA 74, TA 75, TA 76, TA 83, TA 86 and TP 42

Presumptive eligibility (PE)provides short-term medical coverage to pregnant women, Medicaid for Breast and Cervical Cancer (MBCC) applicants, children under age 19, parents and caretaker relatives of dependent children under age 19, and former foster care children. PE provides full fee-for-service Medicaid with the exception of pregnant women. Pregnant women receive ambulatory prenatal care only.

Qualified hospitals (QHs)determine PE for all groups except MBCC.

Qualified entities (QEs)determine PE for pregnant women and MBCC applicants. For MBCC applicants, only QEs that are also Texas Department of State Health Services (DSHS) Breast and Cervical Cancer Services contractors can make MBCC PE determinations, following the process outlined inX-100, Application Processing.

 

C—1113.1 Eligible Groups

Revision 15-3; Effective July 1, 2015

 

The following groups can receive presumptive eligibility coverage:

  • Children:
    1. MA-Children Under 1 Presumptive — TA 74
    2. MA-Children 1–5 Presumptive — TA 75
    3. MA-Children 6–18 Presumptive — TA 76
  • Former Foster Care Children (MA-FFCC Presumptive —TA 83)
  • Pregnant Women (MA-Pregnant Women Presumptive — TP 42)
  • Parents and Other Caretaker Relatives (MA-Parents and Caretaker Relatives Presumptive — TA 86)

 

C—1113.2 Household Composition

Revision 15-3; Effective July 1, 2015

 

The QH/QE uses the non-taxpayer/non-tax dependent rules to determine the household composition.

 

C—1113.3 Modified Adjusted Gross Income (MAGI) Methodology

Revision 15-4; Effective October 1, 2015

 

The QH/QE uses a simplified MAGI methodology to determine if an individual meets the income requirements for PE. The income limits for each PE type of assistance are the same as the income limits for the associated regular Medicaid type of assistance. For example, MA-Children Under 1 Presumptive has the same income limit as MA-Children Under 1.

 

C—1113.4 Verifications

Revision 15-3; Effective July 1, 2015

 

The individual must attest to being:

  • a Texas resident, and
  • a United States citizen or an eligible immigrant.

For all other PE criteria, the individual's statement is acceptable verification. Additional forms of verification beyond an individual's statement are not required.

 

C—1113.5 Medical Effective Dates

Revision 15-4; Effective October 1, 2015

 

The medical effective date (MED) is the date the QH or QE determines the individual is presumptively eligible for Medicaid. If the individual is presumptively eligible, QH/QE staff give the individual Form H1266, Short-term Medicaid Notice: Approved. It informs the individual when the PE coverage begins and when the PE coverage ends, based on whether the individual applies for regular Medicaid.

Note: An individual is not eligible for PE if they are currently receiving Medicaid, Children's Health Insurance Program (CHIP) or CHIP perinatal.

If the individual does not apply for regular Medicaid, the PE coverage ends the last day of the month after the month of the PE determination (see scenario 1 below).

If the individual submits Form H1205, Texas Streamlined Application, or Form H1010, Texas Works Application for Assistance — Your Texas Benefits, HHSC staff determine whether the individual is eligible for regular Medicaid. If the individual is not eligible for regular Medicaid, the individual’s PE coverage ends the date that HHSC determines the individual is ineligible (see scenario 2 below). If the individual is eligible for regular Medicaid, the individual’s PE coverage ends when HHSC makes the Medicaid eligibility determination, following cutoff rules.

If an individual is Medicaid-eligible during the application month, the individual receives Medicaid from the first of that month through the PE MED. Regular Medicaid coverage for the ongoing period begins once the PE period ends (see scenarios 3 and 4 below). Exception: Since PE for pregnant women provides only limited prenatal services, ongoing Medicaid coverage overlays the PE coverage (see scenario 5 below).

Examples:

PE Scenarios
  1. Individual does not apply for regular Medicaid
A child is determined eligible for MA-Children 6–18 Presumptive on February 2. Her mother does not submit an application for regular Medicaid. The child’s PE coverage ends on March 31.
  1. Individual is ineligible for regular Medicaid
A child is determined eligible for MA-Children Under 1 Presumptive on April 4. Her father submits an application for regular Medicaid on the same date. HHSC determines on April 20 that the child is not eligible for regular Medicaid. Her PE coverage ends on April 20.
  1. Individual is eligible for regular Medicaid (HHSC makes eligibility determination before cutoff)
A child is determined eligible for MA-Children 1–5 Presumptive on March 6. His mother submits an application for regular Medicaid on the same date. HHSC determines on March 15 (before cutoff) that the child is eligible for regular Medicaid. His PE coverage ends March 31. He is certified for regular Medicaid effective March 1 to March 5 and April 1 through ongoing.
  1. Individual is eligible for regular Medicaid (HHSC makes eligibility determination after cutoff)
A former foster care child is determined eligible for MA-FFCC Presumptive on May 9. He submits an application for regular Medicaid on the same date. HHSC determines on May 22 (after cutoff) that the individual is eligible for regular Medicaid. His PE coverage ends June 30. He is certified for regular Medicaid effective May 1 to May 8 and July 1 through ongoing.
  1. Pregnant woman is eligible for regular Medicaid
A woman is determined eligible for MA-Pregnant Women Presumptive on June 4. She submits an application for regular Medicaid on the same date. HHSC determines on June 10 that the woman is eligible for regular Medicaid. Her PE coverage ends on June 30. Regular Medicaid overlays her PE coverage with an effective date of June 1.

 

C—1113.6 Periods of Presumptive Eligibility

Revision 15-3; Effective July 1, 2015

 

Pregnant women are allowed one PE period per pregnancy.

For all other PE groups, an individual is allowed no more than one period of PE per two calendar years.Example:An individual receives MA-Children 6–18 Presumptive in June 2015. He cannot receive another period of PE until January 2017.

 

C—1113.7 Three Months Prior Coverage

Revision 15-3; Effective July 1, 2015

 

Three months prior coverage does not apply to presumptive eligibility. Eligibility for three months prior Medicaid coverage is determined when HHSC eligibility staff make a regular Medicaid determination, if requested.

 

C—1113.8 Application Processing

Revision 15-4; Effective October 1, 2015

 

QH/QE staff first must perform a PE portal inquiry to find out if an individual is currently receiving Medicaid, CHIP or CHIP perinatal or if the applicant has received a period of PE within the PE period limit.

QH/QE staff make the PE determination based on information the individual provides about citizenship/immigration status, Texas residency, income and household composition. To determine whether the individual is presumptively eligible, QH/QE staff fill out Form H1265, Presumptive Eligibility (PE) Worksheet, using the information the individual provides.

If the individual is presumptively eligible, QH/QE staff do the following:

  • Enter the individual’s demographic information and the PE type of assistance for which the individual is eligible into the PE portal. QH/QE staff use the PE portal to conduct limited inquiries and submit PE determinations.
  • Give the individualForm H1266, Short-term Medicaid Notice: Approved. QH/QE staff also help the individual complete and submit the regular Medicaid application viaYourTexasBenefits.comif the individual wants to apply.Note:An individual is not required to submit a regular Medicaid application to receive PE Medicaid.

If the individual is not eligible for PE, QH/QE staff issueForm H1267, Short-term Medicaid Notice: Not Approved, to the individual and tell the individual about the right to apply for regular Medicaid.

 

C—1113.9 Due Dates and Processing Time Frames

Revision 15-3; Effective July 1, 2015

 

Within one business day of the PE determination, the QH/QE must submit the PE determination to HHSC through the PE portal.

 

C—1113.10 How to Become a Qualified Hospital or Qualified Entity

Revision 15-3; Effective July 1, 2015

 

Hospitals or entities that want to become qualified to make PE determinations must (1) submit to HHSC a notice of intent, (2) sign a Memorandum of Understanding, and (3) complete online training at the PE website at www.TexasPresumptiveEligibility.com.

 

C—1113.11 Presumptive Eligibility Forms

Revision 15-3; Effective July 1, 2015

 

Qualified hospital/qualified entity staff use the following forms in the presumptive eligibility process:

  • Form H1265, Presumptive Eligibility (PE) Worksheet—Completed by the QH/QE and used to determine if an applicant is presumptively eligible.
  • Form H1266, Short-term Medicaid Notice: Approved-Completed by the QH/QE and given to an individual determined presumptively eligible. This form notifies the individual about PE coverage and lists the eligibility start date and end date, which is based on whether the individual submits an application for regular Medicaid. If an individual needs proof of Medicaid coverage before receiving their Medicaid identification card, the individual can present this form in an HHSC local eligibility determination office, and HHSC staff will provide the individual withForm H1027-A, Medicaid Eligibility Determination.
  • Form H1267, Short-term Medicaid Notice: Not Approved— Completed by the QH/QE and given to an individual determined ineligible for PE coverage. This form explains the reason for ineligibility and how to apply for regular Medicaid.

Related Policy
Processing Presumptive Eligibility Applications, A-124

 

C—1114 Guidelines for Providing Retroactive Coverage for Children and Medical Programs

Revision 19-2; Effective April 1, 2019

 

Medical Programs

When determining retroactive eligibility for children and pregnant women, use the applicable income, standard MAGI income disregard, and IRS monthly income thresholds charts.

March 2017 through February 2018

Federal Poverty Income Limits (FPIL)
Family Size 133% FPIL
(3-1-17)
TP 44, 34, TA 76
144% FPIL
(3-1-17)
TP 48, 33, TA 75
198% FPIL
(3-1-17)
TP 40, 42, 43, 36, 35, TA 74
1 $1,337 $1,448 $1,990
2 $1,800 $1,949 $2,680
3 $2,264 $2,451 $3,370
4 $2,727 $2,952 $4,059
5 $3,190 $3,454 $4,749
6 $3,654 $3,956 $5,439
7 $4,117 $4,457 $6,129
8 $4,580 $4,959 $6,818
9 $5,043 $5,460 $7,508
10 $5,507 $5,962 $8,198
11 $5,970 $6,464 $8,887
12 $6,433 $6,965 $9,577
13 $6,897 $7,467 $10,267
14 $7,360 $7,968 $10,956
15 $7,823 $8,470 $11,646
For each additional member $464 $502 $690

 

Family Size 200% FPIL
(3-1-17)
TA 41
201% FPIL
(3-1-17)
TA 84
202% FPIL
(3-1-17)
TA 85
400% FPIL
(3-1-17)
TA 77
413% FPIL
(3-1-17)
TP 70
1 $2,010 $2,021 $2,031 $4,020 $4,151
2 $2,707 $2,721 $2,734 $5,414 $5,590
3 $3,404 $3,421 $3,438 $6,807 $7,028
4 $4,100 $4,121 $4,141 $8,200 $8,467
5 $4,797 $4,821 $4,845 $9,594 $9,906
6 $5,494 $5,521 $5,549 $10,987 $11,344
7 $6,190 $6,221 $6,252 $12,380 $12,783
8 $6,887 $6,922 $6,956 $13,774 $14,221
9 $7,584 $7,622 $7,660 $15,167 $15,660
10 $8,280 $8,322 $8,363 $16,560 $17,099
11 $8,977 $9,022 $9,067 $17,954 $18,537
12 $9,674 $9,722 $9,771 $19,347 $19,976
13 $10,370 $10,422 $10,474 $20,740 $21,415
14 $11,067 $11,122 $11,178 $22,134 $22,853
15 $11,764 $11,823 $11,881 $23,527 $24,292
For each additional member $697 $701 $704 $1,394 $1,439

 

Five Percentage Points of FPIL
Family Size 2017 Monthly
Disregard Amount
1 $50.25
2 $67.70
3 $85.10
4 $102.50
5 $119.95
6 $137.35
7 $154.75
8 $172.20
9 $189.60
10 $207.00
11 $224.45
12 $241.85
13 $259.25
14 $276.70
15 $294.10
Per each additional person $17.45

 

IRS Monthly Income Thresholds
Type of
Income
2017
Threshold
Apply Threshold Value in Form H1042,
Modified Adjusted Gross Income (MAGI)
Worksheet: Medicaid and CHIP
Unearned Income $87.50
  • Pages 5-7, Step 3, Line 7
  • Pages 5-7, Step 3, Line 9
Earned Income $525.00
  • Pages 5-7, Step 3, Line 8

 

March 2018 through February 2019

Federal Poverty Income Limits (FPIL)
Family Size 133% FPIL
(3-1-18)
TP 44, 34, TA 76
144% FPIL
(3-1-18)
TP 48, 33, TA 75
198% FPIL
(3-1-18)
TP 40, 42, 43, 36, 35, TA 74
1 $1,346 $1,457 $2,004
2 $1,825 $1,976 $2,716
3 $2,304 $2,494 $3,429
4 $2,782 $3,012 $4,142
5 $3,261 $3,531 $4,855
6 $3,740 $4,049 $5,568
7 $4,219 $4,568 $6,280
8 $4,698 $5,086 $6,993
9 $5,176 $5,604 $7,706
10 $5,655 $6,123 $8,419
11 $6,134 $6,641 $9,132
12 $6,613 $7,160 $9,844
13 $7,092 $7,678 $10,557
14 $7,570 $8,196 $11,270
15 $8,049 $8,715 $11,983
For each additional member $479 $519 $713

 

Family Size 200% FPIL
(3-1-18)
TA 41
201% FPIL
(3-1-18)
TA 84
202% FPIL
(3-1-18)
TA 85
400% FPIL
(3-1-18)
TA 77
413% FPIL
(3-1-18)
TP 70
1 $2,024 $2,034 $2,044 $4,047 $4,179
2 $2,744 $2,758 $2,771 $5,487 $5,665
3 $3,464 $3,481 $3,498 $6,927 $7,152
4 $4,184 $4,205 $4,226 $8,367 $8,639
5 $4,904 $4,928 $4,953 $9,807 $10,126
6 $5,624 $5,652 $5,680 $11,247 $11,613
7 $6,344 $6,376 $6,407 $12,687 $13,099
8 $7,064 $7,099 $7,134 $14,127 $14,586
9 $7,784 $7,823 $7,862 $15,567 $16,073
10 $8,504 $8,546 $8,589 $17,007 $17,560
11 $9,224 $9,270 $9,316 $18,447 $19,047
12 $9,944 $9,994 $10,043 $19,887 $20,533
13 $10,664 $10,717 $10,770 $21,327 $22,020
14 $11,384 $11,441 $11,498 $22,767 $23,507
15 $12,104 $12,164 $12,225 $24,207 $24,994
For each additional member $720 $724 $728 $1,440 $1,487

 

Five Percentage Points of FPIL
Family Size 2018 Monthly
Disregard Amount
1 $50.60
2 $68.60
3 $86.60
4 $104.60
5 $122.60
6 $140.60
7 $158.60
8 $176.60
9 $194.60
10 $212.60
11 $230.60
12 $248.60
13 $266.60
14 $284.60
15 $302.60
Per each additional person $18.00

 

IRS Monthly Income Thresholds
Type of
Income
2018
Threshold
Apply Threshold Value in Form H1042,
Modified Adjusted Gross Income (MAGI)
Worksheet: Medicaid and CHIP
Unearned Income $87.50
  • Pages 5-7, Step 3, Line 7
  • Pages 5-7, Step 3, Line 9
Earned Income $529.17
  • Pages 5-7, Step 3, Line 8

C—1115 Immunization Terms

Revision 13-3; Effective July 1, 2013

 

TANF and Medical Programs

Immunization by inoculation or vaccination protects against childhood diseases. Except for tetanus, these diseases are contagious. Encourage individuals to follow the Texas Department of Health's recommended schedule found on Form H1012, Immunization Record. If a child is on an alternate schedule refer to A-2125, Immunizations.

The following are descriptions of the diseases and symptoms associated with immunizations.

  • Diphtheria — An acute, bacterial illness that causes a sore throat and a fever and sometimes causes more serious or even fatal complications.
  • Haemophilus Influenza Type b (HIB) — A bacterium that can cause meningitis and pneumonia and infect other body systems such as blood, joints, bones and soft tissue under the skin, throat, and the covering of the heart.
  • Hepatitis A — An infection of the liver caused by the Hepatitis A virus.
  • Hepatitis B — An infection of the liver caused by the Hepatitis B virus.
  • Measles — An acute, highly contagious viral disease involving the respiratory tract that causes a characteristic rash, fever, runny nose, sore eyes, and cough.
  • Mumps — An acute viral disease mainly of childhood. It is characterized by a swelling of the parotid (salivary) glands on one or both sides and may cause fever, headache, and difficulty swallowing may develop.
  • Pertussis (Whooping Cough) — An acute highly contagious respiratory disease characterized by a severe attack of coughing that ends in a characteristic "whoop" as breath is drawn in.
  • Poliomyelitis (Polio – once known as "infantile paralysis") — An infectious disease that may lead to extensive paralysis of the muscles.
  • Rubella (German Measles) — A viral infection characterized by a mild fever, swollen glands in the neck and a rash that lasts up to three days.
  • Tetanus (Lockjaw) — A very serious disease of the central nervous system caused by an infection of a wound that makes an individual unable to open his/her mouth or swallow and causes muscle spasms in the jaw, neck, leg or other muscles.
  • Varicella (Chickenpox) — A highly contagious viral infection which presents as a generalized, itchy, vesicular rash. The rash begins as smooth, red spots which develop into blisters that last three to four days before forming crusty scabs.

 

C—1116 Managed Care Plans

Revision 19-1; Effective January 1, 2019

 

Information concerning the medical and dental managed care plans with contact information for each plan is located at hhs.texas.gov/services/health/medicaid-chip/programs/medical-dental-plans.

Related Policy
Managed Care,A-821.2
Releasable Information for Medicaid Providers and Their Contractors, B-1230
Office of the Ombudsman,B-1420

 

C—1118 Health Care Orientation Quick Reference Guide

Revision 19-3; Effective July 1, 2019

 

TP 43, TP 44 and TP 48

Effective 7/1/19

STEPS TO VERIFICATION

Use the following items to verify the person’s identity. See the Expanded Health Care Orientation and Enrollment Script below for verification instructions.

  • Medicaid ID Number or SSN
  • Name
  • Address
  • Phone Number
  • DOB
  • Third-Party Resources (Private Insurance)
  • Primary Language Spoken in Home

ESSENTIAL STEPS to EDUCATION

  1. Introduction (your name, your position, etc.)
  2. Explain managed care including how to enroll and what a primary care provider (PCP) is.
  3. Explain about Primary Care Providers and emergency rooms.
  4. Explain about specialists and referrals.
  5. Explain about preventive medical and dental checkups.
  6. Explain STAR or STAR Kids enrollment will be effective in 15-45 days and traditional Medicaid is in effect until then.
  7. Explain they will receive an ID card from the health plan.
  8. Other education is provided as necessary (i.e., TP40 education script, newborn education).
  9. Managed Care changes – How to change plans or a primary care provider and how often it is allowed. Provide the contact information necessary to call to make changes.
  • Medicaid Program Knowledge – don't pay bills, what Medicaid covers, etc.
  • Your Texas Benefits Medicaid ID card, primary care provider, restrictions.
  • Maintaining Eligibility – reading mail, sending back information, receiving checkups
  • Texas Health Steps Program Knowledge, including checkup schedules, for children through age 20 - Refer to the Texas Health Steps Desk Reference for the information that should be covered (a link to the desk reference may be found below).
  • Medical and Dental Providers – Give choices and handout or give the person the number to call to have a list mailed or, for immediate assistance finding a doctor or dentist, 877-847-8377.
  • How to Schedule an Appointment – offer to help or give the toll-free number, 877-847-8377; keeping and canceling appointments.
  • Case Management for Children and Pregnant Women – health risk or health condition, trouble finding services.
  • Medical Transportation – available benefit, call for transportation assistance, provide contact information.
  • CHIP – any uninsured children in the household?
  • WIC – pregnant women or child in the family who is under 5
  • Summary – Inquire whether the person has any questions or if they would like you to repeat any information, especially any of the contact information given.

Expanded Health Care Orientation Script

(Effective July 1, 2019)

Introduction

Standard greeting to include your name, program and purpose for calling. For example: Hello, may I speak with [case name]: Hello, Mr./Mrs._______________________. My name is _________________. Since your child/children are new to Medicaid, a state law requires that you receive what is known as a Health Care Orientation. This will only take a few minutes and I will give you some valuable information about how to use your child's/children's Medicaid benefits.

Use the following to verify the caller's identity.

Steps to Caller VERIFICATION

  • Medicaid ID Number or SSN-Do you have Your Texas Benefits Medicaid ID card handy? Will you read the number that appears on the card below your child's name?
  • Name-Is this the name of your child?
  • Address-Are you still living at this address?
  • Primary Language Spoken in Home-Ask and document the language
  • Phone Number-Is this the correct phone number?
  • DOB-Is this your child's date of birth?
  • Third Party Resources (Private Insurance)-Does your child have any private health insurance?

Steps to EDUCATION

Essential Information About Medicaid Health Plans (Managed Care)

  1. Explain Managed Care and Primary Care Provider.  "Let me tell you a little about the STAR and STAR Kids program. The STAR and STAR Kids program are Texas Medicaid Managed Care programs. Managed care means that you will receive your Medicaid services through a health plan. You only have 30 days from the date you are certified to select a health plan and a primary care provider. The primary care provider can be a doctor, specially trained nurse, clinic or health center. If you don't choose, the STAR or STAR Kids program will pick a health plan and primary care provider for you. The primary care provider is available 24 hours a day, 7 days a week to coordinate care for you and your child/children. Have you received an enrollment packet? This is a large white envelope with the different health plan booklets, enrollment form and instructions. Have you already enrolled? If not, I can tell you how to enroll (or change plan if they have been defaulted).” If the person has not yet enrolled, refer the person to the enrollment hotline 800-964-2777.   
  2. Explain about primary care providers and emergency rooms. “Your child's primary care provider is the one you contact first when your child/children needs/need any kind of medical health care. Unless it is an emergency, you should contact your primary care provider before you take your child to the emergency room. An emergency would be a problem or condition, including severe pain that is so serious that waiting for routine care might result in serious harm. In an emergency, you may not have time to contact the primary care provider, in that case, call 9-1-1 or take your child to the nearest emergency room.”
  3. Explain referrals: “Referrals to specialists for STAR and STAR Kids recipients must be obtained through the primary care provider. However, families do not need a referral for the following services: family planning, eye exams and glasses, behavioral health and Texas Health Steps medical/dental checkups. The primary care provider will refer your child/children to specialists or hospitals when needed.”
  4. Texas Health Steps Preventive checkups: “Recipients through age 20 are eligible for preventive medical and dental checks-ups through Texas Health Steps.”
  5. Explain the recipients will receive a Your Texas Benefits Medicaid ID card.  “After the recipient is enrolled in the STAR or STAR Kids program, a Your Texas Benefits Medicaid ID card will be mailed. The recipient will also receive a member ID card from the plan.”
  6. STAR and STAR KIDS “Recipients can change their primary care provider up to four times a year. They can have unlimited changes in their health plan (however, there are time restrictions – each health plan change can take 15-45 days). Call the STAR helpline to change the health plan and call the health plan directly to request a primary care provider change.”
  7. Pregnant Women: If applicable, expand education to include TP40 (pregnant women) information. Ask, "Are you currently seeing a provider for your prenatal care?" Pregnant women must choose a plan and primary care provider within 15 days from their Medicaid certification. The enrollment will take effect as soon as the recipient is found eligible for Medicaid. All efforts will be made to expedite the enrollment. If that is not possible, the enrollment will be effective within 15-45 days. Remind the recipient the importance of selecting a plan for herself and the baby since the recipient will not be able to change the baby's plan until the baby is three months old. After the baby is born, the recipient should call the plan to pick a primary care provider for the baby. Explain when the STAR program is effective for pregnant women. If the pregnant woman's managed care enrollment is certified before the 10th of the month, the enrollment is effective the first day of the certification month. If the pregnant woman's managed care enrollment is certified after the 10th of the month, the enrollment is effective the first day of the month following the certification date.

    Note for Pregnant Women: If a pregnant woman has 12 weeks or less remaining in her pregnancy (third trimester), she may choose to remain with her current OB/GYN for the remainder of her pregnancy, delivery, and postpartum checkup, even if the OB/GYN does not participate with the chosen health plan.
  8. Medicaid Program Knowledge
  • “Medicaid pays for you or your child's care when they go to the doctor, if they are in the hospital, if they go to the dentist and if they go to a specialist. It will also pay for prescriptions, vaccines, transportation to any Medicaid covered service, and for behavioral health services. It also pays for Texas Health Steps preventive medical and dental checkups for children through age 20.”
  • “Medicaid pays only providers like doctors, dentists, specialists and hospitals. You should not receive any bills. However, if you receive a bill don't pay it. First call the provider and find out why they did not send the bill to Medicaid. Make sure your provider has the Medicaid ID number needed for billing.” If the recipient is on STAR or STAR Kids direct them to call their health plan. If they are on fee for service direct them to call the number on the back of the Your Texas Benefits Medicaid ID card for billing questions 800-252-8263.


Your Texas Benefits Medicaid ID Card-Process

  • Ask the family if they have received their new Your Texas Benefits Medicaid Id card. If not, explain the new card they will receive is good for as long as they are on Medicaid. Describe the Your Texas Benefits Medicaid ID card.
  • Inform the family that their STAR or STAR Kids health plan should be listed on the Your Texas Benefits Medicaid ID card. 
  • Remind the family to take the Your Texas Benefits Medicaid ID card to the doctor, dentist, pharmacy or every time they obtain a Medicaid service.
  • Explain to the family if they do not receive their Your Texas Benefits Medicaid ID card in the next couple of weeks, they should contact their local HHSC office to confirm eligibility. Once eligibility is confirmed, they can contact the Your Texas Benefits Medicaid ID card Help Desk at 855-827-3748 to check the status of the card order. Inform them they can also print a copy of their card from the YourTexasBenefits.com website while they wait on their permanent card.

Maintaining Eligibility

  • “Follow up with any paper work you receive from the Texas Health and Human Services Commission (also called HHSC). HHSC reviews your case from time to time, usually every 12 months, and so it is very important to complete the paperwork to keep your child/children on Medicaid.”
  • “It is a requirement to receive your health care orientation (we are providing that right now) and for your children to receive their Texas Health Steps preventive checkups to avoid having to go to the office for a face-to-face interview or to be required to return follow-up information at your redetermination.”

Texas Health Steps Program Knowledge

If the parent or caretaker is being interviewed and it is for an initial certification including a reapplication after a break in benefits of 60 days or more, the advisor is responsible for initial Texas Health Steps informing, even if the household does not require a Health Care Orientation.

Refer to the Texas Health Steps Desk Reference for the information that must be covered during the Health Care Orientation or when the parent or caretaker must receive just the initial Texas Health Steps informing.

Refer to the Texas Health Steps Program Desk Reference to educate parents and caretakers about when a child's Texas Health Steps medical and dental* checkups are due and issues a health care provider may address during a Texas Health Steps medical or dental checkup. The health care provider will address specific issues for each age and each child.

* Emergency dental services are available at any age and do not require a check on ID.

Texas Health Steps Desk Reference

  • If the information is being provided in person, give the family a:
    • “Checkups Help Children Stay Healthy!” wallet card
    • “Don't Miss a Beat” brochure
    • "Keep Your Child's Checkups in Check” brochure
  • Advise the family to contact the Texas Health Steps helpline if they would like a medical or dental provider list mailed to them or if they would like immediate assistance: 877-847-8377, available 8 a.m. – 6 p.m. Central Time, Monday – Friday.

Case Management for Children and Pregnant Women

  • Case Management for Children and Pregnant Women is a Medicaid benefit. Case managers help families get medical services, school services, medical equipment and supplies, and other services that are medically necessary.
  • Case managers can help children and young adults age 20 and younger who have a health condition or health risk who are covered by Medicaid. They also can help women of any age with a high risk pregnancy.  The person or family must need help getting services or they must be having trouble finding or connecting with the services that they need related to their health condition or health risk.  The family must want the case management services.
  • Case managers are either licensed social workers or registered nurses and are trained to help get families the services that they have trouble finding on their own.
  • The case manager will meet with the person approved for Medicaid, the person’s parent or guardian.  They will do a full assessment to find out all of the needs a family might have related to the health condition. Then the case manager and family will make a service plan that addresses all the needs. 
  • Anyone can refer someone for case management services by calling the Texas Health Steps helpline toll-free at 877-847-8377, 8 a.m. – 6 p.m. Central Time, Monday - Friday.

Medical Transportation Program (MTP)

  • The Medical Transportation Program provides non-emergency medical transportation (NEMT) services.
  • Explain the Medical Transportation Program is available for all Medicaid-covered health care services to those with full Medicaid (not Qualified Medicare Beneficiary [QMB] or Specified Low-Income Medicare Beneficiary [SLMB]), Children with Special Health Care Needs (CSHCN), and Transportation for Indigent Cancer Patients (TICP), who do not have any other means of transportation.
  • “Call at least two business days before the appointment in the same county or adjacent county and five business days before an appointment outside the county adjacent to your residence and be prepared to provide your:
    • name;
    • Medicaid ID number;
    • address;
    • phone number;
    • doctor's name and address;
    • doctor's phone number;
    • date; and
    • time of appointment.”

Ways to Travel:

  • If you don't have a car and you don't have anyone else to drive you, the Medical Transportation Program will help. This may be by bus tickets or by van.
  • If you have a car, or know someone who can drive you to the appointment, the Medical Transportation Program can pay you or your driver gas reimbursement by the mile.

 

Call to schedule a ride.

Houston/Beaumont area: 855-687-4786

Dallas area: 855-687-3255

Everyone else: 877-633-8747 (877-MED-TRIP)

If you have a complaint or concern, call 877-633-8747 (877-MED-TRIP), Option 2.

 

Children's Health Insurance Program (CHIP)

  • If anyone in the household is under age19 does not have health insurance, explain they may be eligible for some type of state-funded health insurance. They may call 2-1-1 Option 2 to apply for CHIP and Children's Medicaid.

WIC (Women, Infant, and Children's Program)

  • Explain WIC is a supplemental nutrition and education program to provide nutritious foods to help women, infants and children improve on their nutrition. “If you are receiving Medicaid, you are income-eligible for the program, but you will have to complete a nutritional screening to receive benefits.”
  • If pregnant or a postpartum woman or a child under age 5 lives in the household, give the parent the 800-942-3678 number to locate their nearest WIC office.

Summary

  • “Any questions regarding Texas Health Steps or Medicaid?”
  • Inform the person that they have received a "Health Care Orientation."
  • Verify the person’s information, phone number, migrant status, any other children in the household.
  • If enrolled, recap enrollment information including the names of the primary care provider and main dentist, if known, and the name of the health plan.
  • Provide toll free number for future assistance (see below). Thank the person for their time.
  • If in person, provide literature and any numbers needed from the Resource Directory (see below).
Resource Directory
Resource List Toll Free Numbers TTY  LINE
2-1-1-Information and Referral for other types of community resources 2-1-1, Option 1 2-1-1, Option 1
Billing Questions Hotline for Traditional Medicaid, also known as fee-for-service 800-335-8957 800-735-2988
HHSC  512-424-6500 512-424-6597
Medicaid Hotline Number 800-252-8263 800-735-2988
Medical Transportation Program (MTP) Houston/Beaumont area: 855-687-4786
Dallas area: 855-687-3255
Everyone else: 877-633-8747 (877-MED-TRIP)
800-735-2988
Social Security Administration (for Medicare and SSI Medicaid) 800-772-1213 800-325-0778
STAR/STAR+PLUS/STAR Kids/STAR Health Help Line 800-964-2777 800-735-2988
HHS Ombudsman Managed Care Assistance Team 866-566-8989 7-1-1
Texas Health Steps   877-847-8377 800-735-2988
HHSC Case Management for Children and Pregnant Women information and referral assistance 877-847-8377 800-735-2988
Children's Health Insurance Program (CHIP) 877-543-7669 800-735-2988
WIC 800-942-3678 800-735-2988

 

C—1120 IRS Tax Code

Revision 15-4; Effective October 1, 2015

Unauthorized disclosure or unauthorized inspection of an applicant or client’s federal tax information by HHSC staff is punishable by law, including but not limited to:

  • felony charges,
  • imprisonment,
  • fines,
  • employment dismissal, or
  • civil charges.

See United States Code (U.S.C.), Title 26, §7213; 26 U.S.C. §7213A; and 26 U.S.C. §7431 for a complete list of penalties for the unauthorized disclosure or inspection of this information.

 

C—1130 Electronic Benefit Transfer (EBT) Charts and Guides

Revision 15-4; Effective October 1, 2015

 

 

 

C—1131 Advisor Guide for Explaining EBT

Revision 18-1; Effective January 1, 2018

 

TANF and SNAP

Instruct the cardholder to read Form H1185, Important Information About Your Lone Star Card, and to ask questions about any EBT issuance procedures the cardholder does not understand. Advisors must also explain:

  • Procedures for Lone Star Card issuance and PIN issuance/self-selection to access benefits including:
    • primary cardholder and secondary cardholder (including how to establish a secondary cardholder);
    • how access is limited to a person with both the card and the PIN;
    • that there is no charge for using the Lone Star Card for food account purchases; and
    • that to obtain benefits they need to have a card, PIN and available benefits.
  • When applicants will be able to use their initial benefits, if certified, and explain the availability of monthly benefits as specified in Form H1184, Here Is Your Lone Star Card.
  • How and where to use the Lone Star Card including:
    • how to make a purchase (and/or cash withdrawal for TANF), availability of receipts and the need to save EBT receipts to keep track of account balance(s);
    • how to identify stores accepting SNAP/Lone Star Cards and how to ask store personnel if the store provides TANF cash-back services; and
    • the TANF cash-back policy. See B-239.1, Advisor Interview Requirements for Client Training.
  • Card/PIN security including:
    • how to keep their benefits secure;
    • what to do if a card is lost or stolen or the PIN is compromised; and
    • that HHSC will not replace benefits used before a card is reported lost or stolen to the Lone Star Help Desk.
  • The dormant account policy. If the cardholder does not access the EBT account for a limited number of consecutive months, their benefits become dormant. They may still access benefits in their EBT account. See B-361, Dormant Account Policy.
  • Procedures when moving out of Texas including the:
    • use of the Lone Star Card to access:
      • TANF at retailers in other states; or
      • SNAP benefits at retailers; and
    • recommendation to withdraw all available cash benefits from the cash account before leaving the state.

      Note: HHSC may mail a benefit conversion warrant (full month's TANF benefit only) to the household's new address if the:

      • cardholder cannot find a retailer that accepts the Lone Star Card; and
      • household moved out of state on or after the first of the month but before accessing that month's TANF benefits. See B-331, Cancelling Benefits in EBT Accounts.

 

C—1132 Issuance Staff Guide for EBT Issuance and Client Training

Revision 18-1; Effective January 1, 2018

 

TANF and SNAP

After receiving Form H1172, EBT Card, PIN and Data Entry Request, authorizing an initial Lone Star Card and PIN to the primary cardholder, take the following actions:

  • Issue and briefly explain the:
    • Lone Star Card;
    • card sleeve;
    • PIN packet, if applicable;
    • Form H1184, Here Is Your Lone Star Card; and
    • second cardholder form.
  • If giving the Lone Star Card to someone other than the primary cardholder, then:
    • explain the use of each item to the person receiving the card;
    • place a registration sticker on the card; and
    • if applicable, request that the vendor mail a PIN packet to the primary cardholder.
  • If mailing the Lone Star Card to the primary cardholder, then select vendor mail out.
  • Explain:
    • the importance of saving the last receipt for the current account balance(s);
    • card registration, if required;
    • the requirement for the primary cardholder to sign the back of the card;
    • how to protect the card and what to do if it is lost or stolen; and
    • how to protect the PIN and what to do if it is compromised.
  • Advise the individual to call the toll-free Lone Star Help Desk (800-777-7EBT or 800-777-7328) if they have problems accessing benefits or additional questions.

 

C—1140 TANF and SNAP Overpayment Determination Chart

Revision 01-7; Effective October 1, 2001

 

 

 

C—1141 Timely Reported

Revision 13-3; Effective July 1, 2013

 

TANF and SNAP

When the individual reports a change timely (i.e., individual reported within 10 days of knowing of the change), use B-600, Changes, B-752.1.2, Errors After Certification, and the following chart to determine the first month of overpayment.

If the household reported the change... then the first month of potential overpayment is...
January 1-8
January 9-31
February
March
February 1-5
February 6-28 (or 29th)
March
April
March 1-8
March 9-31
April
May
April 1-7
April 8-30
May
June
May 1-8
May 9-31
June
July
June 1-7
June 8-30
July
August
July 1-8
July 9-31
August
September
August 1-8
August 9-31
September
October
September 1-7
September 8-30
October
November
October 1-8
October 9-31
November
December
November 1-7
November 8-30
December
January
December 1-8
December 9-31
January
February

 

Note: The first month of overpayment can be no later than two months from the month the change occurred.

 

C—1142 Untimely Reported

Revision 13-3; Effective July 1, 2013

 

TANF and SNAP

When the individual fails to report a change timely (i.e., does not report a change later discovered by HHSC or untimely reports a change), use B-600, Changes, B-752.1.2, Errors After Certification, and the following chart to determine the first month of overpayment.

If the change occurred... then the first month of potential overpayment is...
January 1-31 March
February 1-28 (29) April
March 1-31 May
April 1-30 June
May 1-31 July
June 1-30 August
July 1-31 September
August 1-31 October
September 1-30 November
October 1-31 December
November 1-30 January
December 1-31 February

 

Note: The first month of overpayment can be no later than two months from the month the change occurred.

 

C—1150 Type Programs (TP) and Type Assistance (TA)

Revision 19-1; Effective January 1, 2019

 

SNAP, TANF and Medical Programs/Assistance

 

SNAP

Code Description Long Description
TA 51 SNAP-CAP/FS-CAP Supplemental Nutrition Assistance Program Combined Application Project
TA 52 SNAP-SSI/FS-SSI Supplemental Nutrition Assistance Program Supplemental Security Income
TP 06 SNAP (PA)/FS-PA Supplemental Nutrition Assistance Program Public Assistance
TP 09 SNAP/FS-NPA Supplemental Nutrition Assistance Program

 

TANF

Code Description Long Description
TP 01 TANF Basic Cash assistance for caretakers and deprived children with income below TANF recognizable needs
TP 60 TANF Grandparent Payment One-time payment for grandparent who is caretaker of their TANF-certified grandchild
TP 61 TANF State Program Cash assistance for two-parent household with income below TANF recognizable needs
TP 71 OTTANF – 1 Adult One-Time TANF (OTTANF) payment for households with one parent
TP 72 OTTANF – 2 Parents OTTANF payment for households with two parents

 

Medical Programs/Assistance — Texas Works

Code Description Long Description
TA 31 MA – Parents and Caretaker Relatives – Emergency Medicaid for an emergency condition for parents and caretaker relatives who do not meet alien status requirements and are caring for a dependent child who receives Medicaid
TA 41 Health Care – Healthy Texas Women Healthy Texas Women (HTW) for women age 15–44 with income at or below the applicable income limit
TA 66 MA – MBCC – Presumptive Medicaid for Breast and Cervical Cancer – Presumptive
TA 67 MA – MBCC Medicaid for Breast and Cervical Cancer
TA 74 MA – Children Under 1 Presumptive Short-term Medicaid for children under age 1 with income at or below the applicable income limit
TA 75 MA – Children 1–5 Presumptive Short-term Medicaid for children ages 1–5 with income at or below the applicable income limit
TA 76 MA – Children 6–18 Presumptive Short-term Medicaid for children ages 6–18 with income at or below the applicable income limit
TA 77 Health Care – FFCHE Health Care for Former Foster Care in Higher Education with income at or below the applicable income limit
TA 82 MA – Former Foster Care Children Medicaid for former foster care children ages 18–25
TA 83 MA – FFCC Presumptive Short-term Medicaid for former foster care children ages 18–25
TA 84 CI – CHIP The Children’s Health Insurance Program (CHIP) is health care coverage for children under age 19 who are ineligible for Medicaid due to income and who have income at or below the applicable income limit
TA 85 CI – CHIP perinatal CHIP perinatal is health care coverage for unborn children whose mother is ineligible for Medicaid or CHIP due to income and/or immigration status and whose income is at or below the applicable income limit
TA 86 MA – Parents and Caretaker Relatives Presumptive Short-term Medicaid for parents and caretaker relatives caring for a dependent child
TP 07 MA – Earnings Transitional Twelve months of transitional Medicaid resulting from an increase in earnings
TP 08 MA – Parents and Caretaker Relatives Medicaid for parents and caretaker relatives caring for a dependent child with income at or below the applicable income limit
TP 20 MA Alimony/Spousal Support Transitional Up to four months of post Medicaid resulting from an increase in alimony/spousal support
TP 32 MA – MN w/Spend Down – Emergency Medicaid for an emergency condition for children or pregnant women who do not meet alien status requirements and who are ineligible for any other type of Medicaid, but who have medical expenses that spend down their income to below the Medically Needy Income Limit (MNIL)
TP 33 MA – Children 1–5 – Emergency Medicaid for an emergency condition for children age 1–5 who do not meet alien status requirements and who have income at or below the applicable income limit
TP 34 MA – Children 6–18 – Emergency Medicaid for an emergency condition for children age 6–18 who do not meet alien status requirements and who have income at or below the applicable income limit
TP 35 MA – Children Under 1 – Emergency Medicaid for an emergency condition for children under age 1 who do not meet alien status requirements and who have income at or below the applicable income limit
TP 36 MA – Pregnant Women – Emergency Medicaid for an emergency condition for pregnant women who do not meet alien status requirements and who have income at or below the applicable income limit
TP 40 MA – Pregnant Women Medicaid for pregnant woman with income at or below the applicable income limit
TP 42 MA – Pregnant Women Presumptive Short-term Medicaid for pregnant women with income at or below the applicable income limit
TP 43 MA – Children Under 1 Medicaid for children under age 1 with income at or below the applicable income limit
TP 44 MA – Children 6–18 Medicaid for children age 6–18 with income at or below the applicable income limit
TP 45 MA – Newborn Children Medicaid for children through age 1 who are born to a Medicaid-eligible mother
TP 48 MA – Children 1–5 Medicaid for children age 1–5 with income at or below the applicable income limit
TP 56 MA – MN w/Spend Down Medicaid for children or pregnant women who are ineligible for any other type of Medicaid, but who have medical expenses that spend down their income to below the MNIL
TP 70 Medicaid for the Transitioning Foster Care Youth Medicaid for Transitioning Foster Care Youth people with income at or below the applicable income limit
TPAL MA – Historical FMA – Emergency N/A
TPDE MA – Deceased Prior Medical Medicaid for a deceased person
TPPM MA/ME – Historical Prior Medical Three months of prior Medicaid – not currently eligible

 

Medical Programs/Assistance — Texas Department of Family and Protective Services

Code Description Long Description
TP 52 MA – State Foster Care – A Medicaid
TP 53 MA – State Foster Care – B Medicaid
TP 54 MA – State Foster Care – 32 Medicaid
TP 57 MA – State Foster Care – D Medicaid
TP 58 MA – State Foster Care – JPC Medicaid
TA 78 PCA Medicaid – Federal Match – No Cash Permanency Care Assistance (PCA) Medicaid – Federal Match – No Cash
TA 79 PCA Medicaid – No Federal Match – No Cash PCA Medicaid – No Federal Match – No Cash
TA 80 PCA Medicaid – Federal Match – With Cash PCA Medicaid – Federal Match – With Cash
TA 81 PCA Medicaid – No Federal Match – With Cash PCA Medicaid – No Federal Match – With Cash
TP 88 MA – Non-AFDC Foster Care – JPC Medicaid
TP 90 MA – State Foster Care Medicaid
TP 91 Adoption Assistance – Federal Match – No Cash Adoption Assistance – Federal Match – No Cash
TP 92 Adoption Assistance – Federal Match – With Cash Adoption Assistance – Federal Match – With Cash
TP 93 Foster Care – Federal Match – No Cash Foster Care – Federal Match – No Cash
TP 94 Foster Care – Federal Match – With Cash Foster Care – Federal Match – With Cash
TP 95 Adoption Assistance – No Federal Match – No Cash Adoption Assistance – No Federal Match – No Cash
TP 96 Adoption Assistance – No Federal Match – With Cash Adoption Assistance – No Federal Match – With Cash
TP 97 Foster Care – No Federal Match – No Cash Foster Care – No Federal Match – No Cash
TP 98 Foster Care – No Federal Match – With Cash Foster Care – No Federal Match – With Cash
TP 99 MA – Non-AFDC Foster Care Medicaid
TPAS MA – Historical Adoption Subsidy Medicaid

 

Medical Programs/Assistance — Medicaid for the Elderly and People with Disabilities

Code Description Long Description
TA 01 ME – Interim SSI Denied Child Medicaid (processed by SSA)
TA 02 ME – SSI Waivers SSI Recipient Waivers
TA 03 ME – Manual SSI Waivers Manual SSI Waivers
TA 04 ME – Manual SSI State Group Home Manual SSI Recipient State Community-based Group Homes
TA 05 ME – Manual SSI Non-State Group Home Manual SSI Recipient Non-State Community-based Group Homes
TA 06 ME – Manual SSI Nursing Facility Medicaid for Nursing Facility Resident
TA 07 ME – Manual SSI State Hospital Medicaid for State Hospital Resident
TA 08 ME – SSI State Group Home SSI Recipient State Community Based Group Home
TA 09 ME – Manual SSI State Supported Living Center Medicaid for State Supported Living Center Resident
TA 10 ME – Waivers Medicaid
TA 12 ME – State Group Home Medicaid for ICF/IID Resident
TA 15 ME – Rider 51 – Non-State Group Home  
TA 16 ME – Rider 51 – State Supported Living Center Medicaid for State Supported Living Center Resident
TA 17 ME – Rider 51 – Nursing Facility Medicaid for Nursing Facility Resident
TA 18 ME – Grandfathered LTC N/A
TA 21 ME – SSI Chest Hospital Medicaid for Chest Hospital Patient
TA 22 ME – Manual SSI Manually certified SSI — processed by SSA
TA 24 ME – Rider 51 – State Group Home  
TA 25 ME – Rider 51 – State Hospital  
TA 26 ME – SSI Non-State Group Home SSI Non-State Community-based Group Homes
TA 27 ME – Prior Medicaid Institutional/Waiver Prior Medicaid for person applying for Institutional or Waiver Medicaid
TA 88 ME – Medicaid Buy-In for Children Medicaid benefits to eligible children with disabilities who are not eligible for Supplemental Security Income (SSI) for reasons other than disability. Individuals must pay a share of the Medicaid premium
TP 03 ME – Pickle RSDI COLA Disregard Programs — considered eligible based on the 1977 Pickle Amendment
TP 10 ME – State Supported Living Center Medicaid for State Support Living Center Resident
TP 11 ME – SSI Prior SSI, two or three months prior, as appropriate
TP 12 ME – Temp Manual SSI Manually certified SSI (processed by SSA)
TP 13 ME – SSI SSI (processed by SSA)
TP 14 ME – Community Attendant Community Attendant Services
TP 15 ME – Non-State Group Home Medicaid for ICF/IID Resident
TP 16 ME – State Hospital Medicaid for State Hospital Resident
TP 17 ME – Nursing Facility Medicaid for Nursing Facility Resident
TP 18 ME – Disabled Adult Child Adult children (at least age 18) who have a disability and who were denied SSI due to an entitlement to or an increase in their RSDI Disabled Adult Child (DAC) benefits and who are eligible for Medicaid to ensure continued coverage
TP 21 ME – Disabled Widow(er) Widows, widowers or surviving divorced spouses age 50 and less than 60 who have a disability and who are ineligible for Medicare and were denied SSI due to an increase in their RSDI widow/widower benefits. They are eligible for Medicaid under TP 21 until they reach age 60 or become eligible for Medicare, whichever occurs first
TP 22 ME – Early Aged Widow(er) Early age widows, widowers or surviving divorced spouses age 50–65 who are ineligible for Medicare and who were denied SSI due to an increase in their RSDI widow/widower benefits. They are eligible for Medicaid under TP 22 until they reach age 65 or become eligible for Medicare, whichever occurs first
TP 23 MC – SLMB Medicare Savings Program — Specified Low-Income Medicare Benefits
TP 24 MC – QMB Medicare Savings Program — Qualified Medicare Beneficiary
TP 25 MC – QDWI Qualified Disabled and Working Individuals — A special Medicare savings program that pays Part A Medicare premiums for certain working people under age 65 who have a disability and are no longer eligible for free Medicare Part A because of earnings
TP 26 MC – QI 1 Medicare savings program — Qualified people
TP 27 MC – QI 2 Medicare savings program — Qualified people (not an active program)
TP 30 ME – A and D Emergency Emergency Medicaid for a nonqualified alien
TP 38 ME – SSI Nursing Facility Medicaid for Nursing Facility Resident
TP 39 ME – SSI State Hospital Medicaid for State Hospital Resident
TP 41 ME – Skilled Nursing Care Skilled Nursing Facility Co-payments
TP 46 ME – SSI State Supported Living Center Medicaid for State Supported Living Center Residents
TP 50 ME – Rider 51J Medicaid for Nursing Facility Resident
TP 51 ME – Rider 51J Waivers Medicaid
TP 87 ME – Medicaid Buy In Working people with disabilities who pay a share of the Medicaid premium to be eligible for Medicaid