Revision 15-4; Effective October 1, 2015



M—910 General Policy

Revision 15-4; Effective October 1, 2015


An applicant or recipient is not eligible to receive Medicaid for Transitioning Foster Care Youth (MTFCY) benefits if the individual currently has adequate health coverage. Adequate health coverage is also known as a third-party resource (TPR). Adequate health coverage is defined as receiving coverage under:

  • group health insurance,
  • health insurance coverage,
  • Medicare (Part A or Part B),
  • Medicaid (with the exception of the Texas Women's Health Program, Medicaid with Spend Down, and Community Attendant),
  • Armed Forces insurance, or
  • a state health risk pool.

Deny an application for an individual who has adequate health coverage.

Do not consider a plan with a limited scope of coverage such as dental, vision, long-term care, etc., or for only a specific illness/disease such as drug/substance abuse as adequate health coverage.

Consider an applicant/recipient as having adequate health coverage even if it has limits on benefits or high deductibles.

If staff receive a task with information that the individual has TPR and the "NHIC" box is greyed out, advisors deny rather than pend the EDG. This information has already been verified by the Office of Inspector General – Third Party Liability area. 

When an MTFCY applicant is denied due to adequate health care coverage, Form TF0001, Notice of Case Action, will read:

"We found that you already have private health insurance. To learn more about the insurance you already get, call toll-free 1-800-846-7307 (after you pick a language, press 2)."

In some instances, the parents of MTFCY recipients have TPR coverage for them without the individual knowing. If the individual states they are not aware of the TPR, staff should advise them to call the claims administrator's Third Party Liability Customer Service Line at 1-800-846-7307 and select option 2. This will allow the individual to obtain information regarding their TPR.

If the TPR information in the Texas Integrated Eligibility Redesign System (TIERS) has been verified by the claims administrator but needs to be updated, staff should fax the completed Form H1039, Medical Insurance Input, to the claims administrator at 512-514-4215.


M—920 Verification Requirements

Revision 10-2; Effective April 1, 2010


Accept self-declaration of adequate health coverage.

Exception: If an applicant is denied due to receiving adequate health coverage and the applicant calls to notify HHSC that the medical insurance is not adequate health coverage, staff would need to verify if the coverage is considered adequate health coverage.


M—930 Documentation Requirements

Revision 10-2; Effective April 1, 2010


Staff must document in case comments the existence of adequate health coverage.