us-tx/manual/hhsc/medicaid

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us-tx/manual/hhsc/medicaid · Axiom

(mepd-a-2300)Medicaid for the Elderly and People with Disabilities Handbook: A-2300, RSDI Cost of Living Adjustment Increase#

(mepd-a-2300)(block-1)A-2300, RSDI Cost of Living Adjustment Increase#

Revision 09-4; Effective December 1, 2009

Medicaid eligibility for the aged, blind and disabled is directly related to receipt of SSI in most states. Loss of SSI payments can result in loss of Medicaid coverage. To preserve Medicaid coverage for certain groups of persons who lose SSI payments, Congress enacted special Medicaid continuation provisions. Persons denied SSI due to certain increases in Social Security benefits may continue to be eligible for Medicaid coverage. SSA informs HHSC through automated files to help locate potential eligible persons who may apply for continued Medicaid.

(mepd-a-2300)(block-2)A-2310 Disabled Adult Children (DAC)#

Revision 11-4; Effective December 1, 2011

This applies to persons denied SSI after July 1, 1987, and who meet SSI eligibility criteria when qualifying RSDI disabled adult children's benefits are excluded from countable income ( OBRA 1986). These persons were denied SSI benefits because of an increase in or receipt of RSDI disabled children's benefits. These persons may continue to be eligible for Medicaid if they:

are at least 18;

become disabled before they are 22;

are denied SSI benefits because of entitlement to or an increase in RSDI disabled children's benefits received on or after July 1, 1987, and any subsequent increase; and

meet current SSI criteria, excluding the children's benefit specified above.

Automated System Program Identifier

TIERS – ME-Disabled Adult Child

Note: Based on SSA information, adult disabled child benefits generally end if the person gets married. There are exceptions such as marriage to another adult disabled child. This is an SSA requirement and not part of MEPD policy.

(mepd-a-2300)(block-3)A-2320 Historical 1972 Income Disregard#

Revision 11-4; Effective December 1, 2011

This applies to persons who were receiving both public assistance and Social Security benefits in August 1972. These persons must meet current SSI or MEPD eligibility criteria, with the exclusion from income of the amount of the October 1972, 20% Social Security cost of living adjustment (COLA) increase.

Automated System Program Identifier

TIERS – ME-Pickle

(mepd-a-2300)(block-4)A-2330 Pickle#

Revision 11-4; Effective December 1, 2011

This applies to persons denied SSI cash benefits for any reason since April 1977. They must meet all current SSI eligibility criteria, with the exclusion of any Social Security COLA increases received since they were eligible for and entitled to both SSI and Social Security benefits in the same month. The earliest COLA increase that can be excluded is the increase received in July 1977. There are two files received from SSA for Title II COLA denials. The 503 file identifies "Pickle" potentials and is received late November of each year. The Lynch vs. Rank file is usually received mid-December.

Automated System Program Identifier

TIERS – ME-Pickle

(mepd-a-2300)(block-5)A-2340 Widow(er)s#

Revision 11-4; Effective December 1, 2011

This applies to persons age 60 to 65 who are ineligible for Medicare and who are denied SSI due to excess widow/widower's RSDI benefits. They must meet SSI eligibility criteria, with the exclusion of their RSDI benefit and any subsequent COLA increases from countable income ( OBRA 1987).

Automated System Program Identifier

TIERS – ME-Early Age Widow(er)

This applies to persons age 50 to 60 who are ineligible for Medicare and who are denied SSI due to excess disabled widow/widower's and surviving divorced spouse's RSDI benefits. They must meet SSI eligibility criteria, with the exclusion of their RSDI benefit and any subsequent COLA increases from countable income (OBRA 1990).

Historically this also applies to persons denied SSI due to a recomputation of their Social Security disabled widows/widowers benefits for January 1984. They must meet SSI eligibility criteria, with the exclusion of the recomputation increase and any subsequent Social Security COLA increases from countable income. Persons had to have filed an application before July 1, 1998, to be eligible under this program. Enrollment for this program ended June 30, 1998 ( OBRA 1985).

Automated System Program Identifier

TIERS – ME-Disabled Widow(er)

(mepd-a-2300)(block-6)A-2350 Reserved for Future Use#

Revision 19-4; Effective December 1, 2019

(mepd-a-3300)Medicaid for the Elderly and People with Disabilities Handbook: A-3300, Home and Community-Based Services Waiver Programs#

(mepd-a-3300)(block-1)A-3300, Home and Community-Based Services Waiver Programs#

Revision 16-1; Effective March 1, 2016

Home and Community-Based Services (HCBS) waiver programs may have limited enrollment and are an alternative to institutionalization. A person can enroll in only one HCBS waiver at a time, but may be on the interest list for multiple HCBS waivers. Persons applying for certain HCBS waiver programs who are not already Medicaid eligible under another coverage group covered by the waiver and who meet the waiver eligibility criteria may be Medicaid eligible using the special income limit.

For additional information about HCBS waiver programs, including interest lists, see Intellectual or Developmental Disabilities (IDD) – Long-term Care .

Descriptions for some of the Home and Community-Based Services waiver programs follow in this section.

(mepd-a-3300)(block-2)A-3310 Community Living Assistance and Support Services (CLASS)#

Revision 16-1; Effective March 1, 2016

A person may be eligible for services through CLASS if the person:

is residing in the community;

is age 65 or older or, if less than 65, receives a Social Security Administration (SSA), Supplemental Security Income (SSI), or Railroad Retirement (RR) disability benefit or has a disability determination by HHSC, which is required;

has an ICF/IID Level of Care (LOC) VIII;

has an approved plan of care or service plan;

has a service begin date no later than 30 days from certification; and

is eligible for Medicaid using the special income limit.

(mepd-a-3300)(block-3)Automated System Program Identifier#

TIERS – ME-Waivers

(mepd-a-3300)(block-4)A-3320 Deaf Blind with Multiple Disabilities (DBMD)#

Revision 16-1; Effective March 1, 2016

A person may be eligible for services through DBMD if the person:

is residing in the community;

is 65 or older or, if less than 65, receives a Social Security Administration (SSA), Supplemental Security Income (SSI), or Railroad Retirement (RR) disability benefit or has a disability determination by HHSC, which is required;

has an ICF/IID Level of Care (LOC) VIII;

has an approved plan of care or service plan;

has a service begin date no later than 30 days from certification; and

is eligible for Medicaid using the special income limit.

(mepd-a-3300)(block-5)Automated System Program Identifier#

TIERS – ME-Waivers

(mepd-a-3300)(block-6)A-3330 Home and Community-based Services (HCS)#

Revision 16-1; Effective March 1, 2016

A person may be eligible for services through HCS if the person:

is residing in the community;

has an ICF/IID Level of Care ( LOC ) VIII;

has an approved plan of care or service plan;

has a service begin date no later than 30 days from certification; and

is eligible for Medicaid using the special income limit.

(mepd-a-3300)(block-7)Automated System Program Identifier#

TIERS – ME-Waivers

(mepd-a-3300)(block-8)A-3340 Youth Empowerment Services (YES)#

Revision 16-1; Effective March 1, 2016

A person may be eligible for services through YES if the person:

is residing in the community;

is at least age 3, but less than age 19;

receives a Social Security Administration (SSA), Supplemental Security Income (SSI), or Railroad Retirement (RR) disability benefit or has a disability determination by HHSC, which is required;

meets clinical level of care criteria;

has an approved individual plan of care (IPC);

has a service begin date no later than 30 days from certification; and

is eligible for Medicaid using the special income limit.

Note : This program is administered by the Department of State Health Services. For additional information, go to www.dshs.state.tx.us .

(mepd-a-3300)(block-9)Automated System Program Identifier#

TIERS – ME-Waivers

(mepd-a-3300)(block-10)A-3350 Medically Dependent Children Program (MDCP)#

Revision 16-1; Effective March 1, 2016

A person may be eligible for services through MDCP if the person:

is residing in the community;

is less than age 21;

receives a Social Security Administration (SSA), Supplemental Security Income (SSI), or Railroad Retirement (RR) disability benefit or has a disability determination by HHSC, which is required;

has an MN ;

has an approved plan of care or service plan;

has a service begin date no later than 30 days from certification; and

is eligible for Medicaid using the special income limit.

(mepd-a-3300)(block-11)Automated System Program Identifier#

TIERS – ME-Waivers

(mepd-a-3300)(block-12)A-3360 Reserved for Future Use#

Revision 16-1; Effective March 1, 2016

(mepd-a-3300)(block-13)A-3370 Texas Home Living (TxHmL)#

Revision 18-1; Effective March 1, 2018

A person may be eligible for services through TxHmL if the person:

is residing in the community;

has an ICF/IID Level of Care ( LOC ) VIII;

has an approved plan of care or service plan; and

is currently a Medicaid recipient.

Eligibility is not determined using the special income limit.

(mepd-a-3300)(block-14)Automated System Program Identifier#

TIERS shows this as ME-Pickle, ME-Disabled Adult Child, etc. HHSC puts the person on TxHmL.

(mepd-a-3300)(block-15)A-3380 STAR+PLUS Waiver (SPW)#

Revision 16-1; Effective March 1, 2016

The SPW provides for the managed care delivery of home and community-based Medicaid services in addition to all other services provided through STAR+PLUS.

(mepd-a-4300)Medicaid for the Elderly and People with Disabilities Handbook: A-4300, Retroactive Coverage#

(mepd-a-4300)(block-1)A-4310 General#

Revision 12-4; Effective December 1, 2012

In addition to the creation of the SSI program, Public Law 92-603 extended Medicaid benefits to cover the three-month time period before the month an application is filed with the Social Security Administration for SSI, if unpaid or reimbursable medical bills are incurred during the prior months.

Medicaid coverage also is extended to cover the three-month time period before the month an application is filed with MEPD for an ongoing MEPD program. For example, if an individual applies for ME – Nursing Facility, the eligibility specialist explores three months prior coverage.

People are potentially eligible for coverage in the prior months, regardless of their eligibility for the month of application and ongoing is approved or denied.

Note: This provision does not provide prior coverage for an application for which no MEPD program is available.

For specific program coverage, see Section G-7100 , Prior Coverage for SSI Applicants, Section G-7200 , Prior Coverage for Medical Assistance Only (MAO) Applicants, Section G-7210 , Prior Coverage for Deceased Applicants, and Section G-7300 , Prior Coverage for Aliens.

(mepd-a-4300)(block-2)A-4320 Two Months Prior#

Revision 11-4; Effective December 1, 2011

Public Law 104-193, Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA), Section 3502.4, changed policy for retroactive Medicaid coverage for persons found eligible for SSI . Effective July 1997, HHSC automatically adds Medicaid coverage for the month prior to the first month of SSI cash payment due (20 CFR §416.501). The person may apply with HHSC for coverage for the two preceding months if there are unpaid or reimbursable medical bills and the person meets all Medicaid eligibility requirements in those months.

Automated System Program Identifier

TIERS – ME-SSI Prior

(mepd-a-4300)(block-3)A-4330 Deceased Individuals#

Revision 12-4; Effective December 1, 2012

Medicaid coverage is extended to a deceased person, if a bona fide agent files an application with MEPD on behalf of a deceased person. The three-month time period is the three months prior to the month the application is received by MEPD.

(mepd-a-5200)Medicaid for the Elderly and People with Disabilities Handbook: A-5200, Hospice in a Long-Term Care Facility#

(mepd-a-5200)(block-1)A-5200, Hospice in a Long-Term Care Facility#

Revision 18-1; Effective March 1, 2018

A Medicaid recipient may elect to receive hospice services in a Medicaid-certified nursing facility (NF) or intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID). In order to receive Medicaid hospice services, the person must meet all eligibility criteria for MEPD in a long-term care facility, including confinement in one or more Medicaid-certified long-term care facilities for 30 consecutive days. Form 3071 , Individual Election/Cancellation/Update, substitutes for the medical necessity determination when hospice is elected.

The hospice provider informs the eligibility specialist of the possibility of hospice election by a recipient. When the recipient (or authorized representative) signs and dates Form 3071, the hospice provider contacts the eligibility specialist, providing the effective date that the recipient is starting/electing hospice services. The hospice provider follows up this contact by sending Form 3071 to the contractor for Medicaid claims, with a copy to the eligibility specialist.

For Medicaid hospice residents in long-term care facilities, the hospice provider is responsible for collecting the applied income, and the nursing facility manages the patient trust fund. The hospice provider is responsible for completing Form 3071 in the event of any change in the hospice provider, cancellation of the hospice election, and death. There is normally no need for the eligibility specialist to take any action in response to any of these changes. The automated system receives this information through interfacing with the Service Authorization System Online (SASO) and communication with HHSC . If the eligibility worker becomes aware of the death of the recipient, manual denial of the case should be taken.

(mepd-a-9100)Medicaid for the Elderly and People with Disabilities Handbook: A-9100, Medicare Benefits#

(mepd-a-9100)(block-1)A-9100, Medicare Benefits#

Revision 18-1; Effective March 1, 2018

Medicare is a federal program under Title XVIII of the Social Security Act and is administered by the Social Security Administration (SSA). Medicare provides health care benefits for individuals age 65 or older, under age 65 with certain disabilities, and any age with permanent kidney failure (called end-stage renal disease).

Those younger than 65 will receive Medicare after getting Social Security disability benefits for at least two years.

There are exceptions to the two-year waiting period, including:

a chronic renal disease that requires a kidney transplant or maintenance dialysis (SSA determines if an individual with a chronic renal disease diagnosis meets the requirements for the exception to the waiting period); or

Lou Gehrig's disease (amyotrophic lateral sclerosis).

Medicare is available to an individual who has paid into the Medicare trust account through payroll taxes sometimes called the Federal Income Contributions Act (FICA). Most employers are required to withhold FICA taxes, but there are some exceptions. Federal government employees have been eligible to participate in Social Security only since 1984. As a result, some older employees have opted to remain with the former Civil Service Retirement System. Some state and local government employee retirement plans also are not covered by Social Security.

If an individual receives Medicare, they are either:

65 years old or older; or

determined disabled by SSA.

Medicare is divided into four parts:

Medicare Part A (Hospital Insurance) – Helps pay for inpatient care in a hospital, skilled nursing facility or hospice, and for home health care if certain conditions are met. Most people do not have to pay a monthly premium for Medicare Part A because they or a spouse paid Medicare taxes while working in the U.S. If the Part A premium is not automatically free, an individual still may be able to enroll and pay a premium.

Medicare Part B (Medical Insurance) – Helps pay for medically necessary doctors’ services and other outpatient care. It also pays for some preventive services (like flu shots), and some services that keep certain illnesses from getting worse. Most individuals pay the standard monthly Medicare Part B premium.

Medicare Part C (Medicare Advantage Plans) – Individuals must be enrolled in both Part A and Part B. These plans are available through Medicare-approved private insurance companies. The plans cover all of the Part A and Part B services and, in most cases, include Part D Prescription Drug Coverage as well. Some plans offer additional services, such as vision, hearing, dental, and health and wellness programs. Individuals pay a monthly premium and co-payments that are usually lower than the coinsurance and deductibles under the original Medicare. Actual costs and benefits vary by plan.

Medicare Part D (Medicare Prescription Drug Coverage) provides prescription drug coverage. Individuals can add Part D by joining a Medicare Prescription Drug Plan (PDP). Individuals must pay a deductible and usually pay coinsurance each time services are received. The PDPs are available through private insurance companies approved by Medicare. Costs and benefits vary by plan.

(mepd-a-9100)(block-2)Premiums#

In most cases, the Part B and Part D premiums are deducted from the Social Security or Railroad Retirement check. The recipient is responsible for calendar-year deductibles and co-pay liabilities for both Parts A and B.

The Part C premium is handled by the private company that offers the benefit as a Medicare Advantage Plan. The Medicare Advantage Plan has its own benefits and coverage that differs from the traditional Medicare benefits. Medicare pays a fixed amount every month to the companies offering Medicare Advantage Plans. These companies must follow rules set by Medicare. However, each Medicare Advantage Plan can charge different out-of-pocket costs and have different rules for how one gets services.

Extra help for Part D (Medicare Prescription Drug Coverage) is available for people with Medicare who have limited income and resources. If eligible for extra help, Medicare will pay for almost all prescription drug costs. Extra help provides a subsidy based on the amount of income and resources an individual has.

Full Subsidy Benefits from Extra Help:

Full premium assistance up to the premium subsidy amount

Nominal cost sharing up to out-of-pocket threshold

No coverage gap

Other Low Income Subsidy Benefits from Extra Help:

Sliding scale premium assistance

Reduced deductible

Reduced coinsurance

No coverage gap

Individuals who have Medicare and Medicaid or who are eligible for the Medicare Savings Program (MSP) do not need to apply for extra help through the SSA.

Individuals can apply for extra help or get more information about extra help subsidy by calling Social Security at 800-772-1213 (TTY 800-325-0778) or visiting www.socialsecurity.gov .

(mepd-a-9200)Medicaid for the Elderly and People with Disabilities Handbook: A-9200, Medicare Buy-In#

(mepd-a-9200)(block-1)A-9200, Medicare Buy-In#

Revision 11-4; Effective December 1, 2011

To ensure that Medicaid recipients who are entitled to Medicare receive maximum health care protection, the state pays for certain recipients' Medicare Part B premiums. This process is called buy-in. For those persons who have dual entitlement, Medicare becomes the payer of first resort, with Medicaid paying deductibles and co-insurance for Medicaid-covered services.

If recipients in ME-Nursing Facility, ME-State School, ME-Waivers and ME-Community Attendant are not eligible for QMB or SLMB , they are not eligible for buy-in.

(mepd-a-9200)(block-2)A-9210 Eligibility Requirements for Medicare Buy-In#

Revision 11-4; Effective December 1, 2011

Recipients are eligible for buy-in if they are:

65 or older and U.S. citizens;

65 or older and lawfully admitted aliens who have lived in the U.S. five consecutive years;

under 65 and have received or been eligible to receive Social Security or Railroad Retirement disability benefits for 24 consecutive months; or

under 65 and qualify for Medicare Part A because of chronic renal disease.

If recipients in ME-Nursing Facility, ME-State School, ME-Waivers and ME-Community Attendant are not eligible for QMB or SLMB , they are not eligible for buy-in.

(mepd-a-9200)(block-3)A-9220 Time Frames for Medicare Buy-In Enrollment#

Revision 13-4; Effective December 1, 2013

Persons who have Medicare Part B coverage at the time they are certified for Medicaid are enrolled as follows:

SSI and Temporary Assistance for Needy Families (TANF) recipients are enrolled for buy-in effective the first month they receive a cash payment.

ME-Pickle recipients who are RSDI pass-on recipients are enrolled in continuous buy-in. Example: The recipient was denied SSI on Dec. 31 due to a cost of living increase. The recipient applied for ME-Pickle in February and was certified eligible on March 5. Medical effective date is Jan. 1. Medicare Part B buy-in is effective Jan. 1. The recipient will be reimbursed by SSA for any premiums withheld from the recipient's RSDI check.

ME-Disabled Adult Child (DAC) recipients who are RSDI pass-on recipients are enrolled in continuous buy-in. Example: The recipient was denied SSI on Dec. 31 due to a cost of living increase. The recipient applied for ME-DAC in March and was certified eligible on April 10. Medical effective date is Jan. 1. Medicare Part B buy-in is effective Jan. 1. The recipient will be reimbursed by SSA for any premiums withheld from the recipient’s RSDI check.

ME-Nursing Facility, ME-State School, ME-Waivers, ME-Non-State Group Home and ME-State Group Home recipients who are QMB -eligible, whose certification was accomplished as a program transfer, and whose certification has no break in Medicaid coverage are eligible for continuous buy-in. Example: The MQMB recipient has SSI and RSDI income and enters a nursing facility in January. SSI is denied effective Feb. 28. The recipient qualifies for QMB and Medicaid. The medical effective date for MQMB is March 1. The recipient is entitled to continued Medicare buy-in and is reimbursed for any premium withheld from the RSDI check.

Recipients who are denied in error and are recertified have continuous enrollment for buy-in. This is true except for those recipients in ME-Nursing Facility who are not eligible for QMB benefits. Example: The MQMB recipient is enrolled in Medicaid, ME-Nursing Facility. During the first year's review process, the recipient was denied due to excess resources effective Jan. 31. During a subsequent application in March, the eligibility specialist discovers the recipient should not have been denied in January and grants a medical effective date of Feb. 1, reopening the case. The recipient is entitled to continued Medicare buy-in and is reimbursed for any premium withheld from the RSDI check.

ME-Nursing Facility recipients who are also QMB-eligible are enrolled for buy-in effective the month of their eligibility for QMB benefits. Example: The recipient is certified for ME-Nursing Facility and is also eligible for MQMB. Certification is Jan. 15, and the MQMB effective date is Feb. 1. Medicare buy-in is effective Feb. 1. The recipient will be reimbursed by SSA for any premiums withheld after the effective date of buy-in.

Recipients eligible for QMB who do not have Medicare Part B coverage at the time of Medicaid certification are enrolled in buy-in when they meet Medicare criteria. These recipients remain on the buy-in rolls while they are eligible for Medicare, Medicaid and QMB benefits.

When a recipient is enrolled in buy-in, SSA stops charging for Part B premiums. Usually this occurs the month after SSA has acknowledged receiving the recipient's name as an addition to the buy-in rolls. If premiums have been withheld from the monthly benefit, the recipient's check should reflect an upward adjustment by the third month after the month of certification.

Address questions about the buy-in status of a recipient who has been certified for at least three months to:

CCC_Data_Integrity_Program@hhsc.state.tx.us

(mepd-appendix-i)Medicaid for the Elderly and People with Disabilities Handbook: Appendix I, MAO Action Codes#

(mepd-appendix-i)(block-1)Appendix I, MAO Action Codes#

Revision 07-1; Effective January 1, 2007

(mepd-appendix-i)(block-2)1. Reasons for Opening Aged, Blind, or Disabled MAO Cases#

The code selected should represent the occurrence, during the six months preceding the date of approval for assistance, which had the greatest effect in producing the need for assistance.

When two or more reasons apply in a case, use the code for the reason primarily responsible for the need for assistance. If a reduction in income or resources and an increase in need are of equal importance, the code reflecting the reduction in income or resources should be used. If the increase in need is considerably greater than the reduction in income, the increased need becomes the primary reason.

Computer-printed reasons to the applicant will be initiated by use of the appropriate opening code. The statements that are to be computer-printed to the applicant are listed after each opening code for informational purposes.

The appropriate opening code should be taken from the following list and entered on the Form H1000-A.

(mepd-appendix-i)(block-3)Reasons Relating to Material Change in Income or Resources During Six Months Preceding Approval for Assistance#

A change in income or resources should be regarded as material only if the amount of the reduction or loss of income is substantial in relation to the need for assistance. A loss of income that is based on need, such as assistance from a public or private agency, is not regarded as a material change in income. (Cases transferred from another assistance program will be coded 047.)

(mepd-appendix-i)(block-4)Earnings Lost or Reduced#

Code 028 (TP03, 14) — Use this code if the applicant lost employment or had a reduction in earnings during the six months preceding application. Computer-printed reason to applicant: "Your earnings are less due to loss of or decrease in employment."

(mepd-appendix-i)(block-5)Support From Other Person#

Code 038 (TP03, 14) — Use this code if the needs of the applicant have been met wholly or in part through contributions from a person and such contributions have been discontinued or reduced during the six months preceding application. Computer-printed reason to applicant: "Income available to you from another person is less."

(mepd-appendix-i)(block-6)Other Income#

Code 041 (TP03, 14) — Use this code if the applicant suffered a loss of or reduction in income during the six months preceding application from some source other than those specified in Codes 028 or 038. Examples of such income are RSDI; an allowance, pension, or other payment connected with military service; unemployment benefits; workmen's compensation; and rental income. Do not include the loss of any income that was based on need. Computer-printed reason to applicant: "Income available to you is less."

(mepd-appendix-i)(block-7)Assets Depleted or Reduced#

Code 044 (TP03, 14) — Use this code if the assets of the applicant have been depleted or reduced during the six months preceding application to an amount permitted under Department policy. Computer-printed reason to applicant: "Your financial resources have been reduced."

(mepd-appendix-i)(block-8)No Material Change in Income or Resources During Six Months Preceding Approval for Assistance#

If the need for assistance is caused primarily by some change other than a loss of or reduction in income or assets of the applicant, use one of codes 045 through 055.

Such a change may result, for example, if the allowance for a standard budget item is raised; if an eligibility requirement such as residence is liberalized; or if an applicant's needs increased without a material change in income or assets.

(mepd-appendix-i)(block-9)Increased Medical Needs#

Code 045 (TP 03, 14) — Use this code if the requirements of the applicant increased during the six months preceding application as a result of need for medical care without a corresponding increase in income or resources. The term medical care is used in the generic sense, that is, it embraces all items usually considered medical or remedial care, including care in a nursing facility.

Computer-printed reason to applicant: "You have increased medical expense." "Sins cuentas médicas han aumentado."

(mepd-appendix-i)(block-10)Miscellaneous#

Code 047 (TP 03, 14) – Program Transfer — Use this code if the recipient receiving assistance is being transferred from a non-DHS assistance program to a DHS assistance program. Computer-printed reason to applicant: "You have changed from one type of assistance program to another." "Su caso ha sido traspasado de inn programa de asistencia a otro."

Codes 048-052 (TP 03, 14) – Attained Technical Eligibility — If the applicant has been living below Department standards and the only change during the last six months is that the applicant has now fulfilled some technical eligibility requirement, enter the appropriate code for the particular requirement from the following codes (048-052). Do not use these codes if the applicant was eligible during the six months period but postponed applying. In such circumstances, code 053 should be used.

Code 048 — Age Computer-printed reason to applicant: "You now meet the age requirement." "Ahora usted cumple con el requisito de edad."

Code 049 — Residence Computer-printed reason to applicant: "You now meet residence requirement." "Ahora usted cumple con el requisito de residencia."

Code 050 — Citizenship or Legal Entry Computer-printed reason to applicant: "You now meet the citizenship requirement." "Ahora usted cumple con el requisito de ciudadanía."

Code 051 — Blindness or Disability Computer-printed reason to applicant: Blind – "You now meet the agency's definition of economic blindness." Ciego – "Ahora esta agencia considera que la condición de usted es ceguedad económica." Disabled – "You now meet the agency's definition of disability." Incapacitado – "Ahora esta agencia le considera a usted incapacitado(a)."

Code 052 — Other Technical Eligibility Requirement Computer-printed reason to applicant: "You now meet eligibility requirements." "Ahora cumple usted con los requisitos de elegibilidad."

Code 053 (TP 03, 14) – Needy and Eligible — Use this code if the applicant has been needy and eligible over an extended period of time (more than six months prior to application) but postponed applying and during this period lived at a level below the Department standards. Computer-printed reason to applicant: "You meet all eligibility requirements." "Usted cumple con todos los requisitos de elegibilidad."

Code 055 (TP 03, 14, 18, 19, 22, 23, 24, 51) – Denied in Error — Use this code if a case is reopened after having been closed by mistake, either as a result of an erroneous report of death or an erroneous denial, including a denial made on presumptive ineligibility. Reassign the previous case number. Make the medical effective date as the date after the denial.

Use this code to open MQMB and QMB coverage in order to prevent a gap in QMB coverage. Code 055 will allow QMB eligibility to begin prior to the application file date. Computer-printed reason to applicant: "Your case was closed by mistake." "Su caso fue cerrado por error."

(mepd-appendix-i)(block-11)2. Reasons for Denial of Aged, Blind, and Disabled MAO Applications and Cases#

Reasons for denying applications or closing cases are classified into four major groups: (1) death of applicant or recipient; (2) ineligible with respect to need; (3) ineligible with respect to requirements other than need; and (4) miscellaneous reasons.

Select the code reflecting the primary reason for denial. If a reason producing ineligibility with respect to need and reason producing ineligibility with respect to some requirement other than need occur at the same time, use the code for need. If several events occur simultaneously, none of which, alone, would produce ineligibility with respect to need, but collectively they do make the recipient ineligible, use the code for the reason having the greatest effect.

Although the applicant or recipient will receive a card explaining action taken on his/her case, the worker should make an adequate interpretation of the decision to the applicant or recipient.

Computer-printed reasons to the applicant or recipient will be initiated by use of the appropriate closing code and the computer will automatically print out the appropriate reason to the recipient corresponding to the code used.

The statements that are to be computer-printed to the applicant or recipient are listed after each closing code. The Spanish translations are to assist workers in completing FL-4 (MAO) and Form h1801. The Spanish translation will not be included on the Form H1029 mailed by the State Office.

The appropriate denial code should be taken from the following list and entered on the Forms H1000-A/B. These codes may be used on both Forms H1000-A and H1000-B with any type program unless otherwise specified.

(mepd-appendix-i)(block-12)Death#

Code 059 – Death — Use this code if an application is denied because of death of applicant, or active case is closed because of death or the recipient. Do not use this code for deceased applications that are simultaneously opened and closed. Computer-printed reason to applicant or recipient: No reason necessary — no notice will be sent to applicant or recipient.

(mepd-appendix-i)(block-13)Ineligible with Respect to Need: Material Change in Income or Resources During Last Six Months#

A change in income or resources should be regarded as material only if the additional income is substantial in relation to the need for assistance. A material change in income or resources may result from the conversion of nonliquid assets into cash or other non-income producing assets into income producing assets, as well as from earnings or other direct income. A material change in income or resources does not necessarily mean a change with respect to cash income. For example, a recipient who has been keeping house may go to live with another person who provides food, clothing, and shelter.

(mepd-appendix-i)(block-14)Earnings#

Code 060 – Earnings of Applicant or Recipient — Use this code if an application is denied because of applicant's earnings from employment, or active case is denied because of a material change in income as a result of recipient's employment or increased earnings. The change in earnings must have occurred during the preceding six months. Earnings may be from self-employment, seasonal employment, increased employment, or higher wages. Computer-printed reason to applicant or recipient: "Your employment earnings meet needs that can be recognized by this agency." "Su salario es suficiente para cubrir las necesidades que esta agencia puede reconocer."

Code 061 – Earnings of Spouse — Use this code if an applicant is denied because of earnings of his or her spouse, or active case is denied because of a material change in income as a result of employment or increased earnings of spouse. The change in earnings must have occurred during the preceding six months. Earnings may be from self-employment, seasonal employment, increased employment, or higher wages. Computer-printed reason to applicant or recipient: "Employment earnings of your husband or wife meet needs that can be recognized by this agency." "El salario de su esposo o esposa es suficiente para cubrir las necesidades que esta agencia puede reconocer."

(mepd-appendix-i)(block-15)Support From Other Person#

Code 066 — Use this code if an application is denied because of support from another person, or active case is denied because of the receipt of or increase in support from another person. The change must have occurred during the preceding six months. Computer-printed reason to applicant or recipient: "Income available to you from another person meets needs that can he recognized by this agency." "El dinero que recibe de otra persona es suficiente para cubrir las necesidades que esta agencia puede reconocer."

(mepd-appendix-i)(block-16)Benefits – Pensions#

Code 067 – RSD I — Use this code for applicants or recipients denied if the material change in income resulted, or will result from the receipt of or increase in benefits under the Federal RSDI program during the preceding six months. Computer-printed reason to applicant or recipient: "Income available to you from Social Security Benefit meets needs that can be recognized by this agency." "La entrada que tiene a su disposición de los Beneficios del Seguro Social es suficiente para cubrir las necesidades que esta agencia puede reconocer."

Code 068 – Other Federal — Use this code if an application is denied because of receipt of a Federal benefit or pension other than RSDI, or active case is denied because of receipt of or increase in a Federal benefit or pension other than RSDI, during the preceding six months. Examples of such income include Veterans' Administration, Federal Civil Service Retirement, or SSI. Computer-printed reason to applicant or recipient: "Income available to you from other Federal benefit or pension meets needs that can be recognized by this agency." "La entrada que tiene a su disposición de otros beneficios o pensiones federales es suficiente para cubrir las necesidades que esta agencia puede reconocer."

Code 069 – State or Local — Use this code if an application is denied because of receipt of a benefit or pension administered by a state or local government, or active case is denied because of receipt of or increase in a benefit or pension administered by a state or local government during the preceding six months. Examples include workmen's compensation benefits, State employees', teachers' or policemen's retirement. Computer-printed reason to applicant or recipient: "Income available to you from state or local benefit or pension meets needs that can be recognized by this agency." "La entrada que tiene a su disposición de beneficios o pensiones locales o del estado es suficiente para cubrir las necesidades que esta agencia puede reconocer."

Code 070 – Non-Governmental — Use this code if an application is denied because of receipt of a non-governmental pension or benefit, or active case is denied because of receipt of or increase in a non-governmental benefit or pension during the preceding six months. Examples are pensions from United Auto Workers Union and other pensions financed by private industry. Computer-printed reason to applicant or recipient: "Income available to you from pension or benefit meets needs that can be recognized by this agency." "La entrada que tiene a su disposiciòn de beneficios o pensiones es suficiente para cubrir las necesidades que esta agencia puede reconocer."

Code 071 – Other Income — Use this code if an application is denied because of receipt of, or active case is denied because of receipt of or increase in income during the preceding six months other than that covered by codes 060-070. Examples are income from investments or real property. Computer-printed reason to applicant or recipient: "Income available to you meets needs that can be recognized by this agency." "La entrada que tiene a su disposición es suficiente para cubrir las necesidades que esta agencia puede reconocer."

(mepd-appendix-i)(block-17)Excess Assets#

Code 072 — Use this code if an application is denied because of excess resources, or active case is denied because of receipt of or increase in resources during the preceding six months. Examples are cash, savings bonds, inheritance of money or property, and increase in income from investments or real property. Computer-printed reason to applicant or recipient: "Resources available to you from other property meets needs that can be recognized by this agency." "Los recursos de otra propiedad que tiene a su disposición son suficientes para las necesidades que esta agencia puede reconocer."

(mepd-appendix-i)(block-18)Decreased Medical Needs#

Code 073 — Use this code if an applicant or recipient is ineligible because the need for medical or remedial care (available under the department's program) decreased during the preceding six months. Computer-printed reason to applicant or recipient: "Your need for medical care expenses that can be recognized by this agency is less." "Se ha reducido la necesidad que esta agencia puede reconocer de gastos médicos."

(mepd-appendix-i)(block-19)Ineligible With Respect to Requirement(s) Other Than Need#

If two or more reasons apply, code the one occurring first. If the occurrences were simultaneous, code the reason appearing first on the list.

(mepd-appendix-i)(block-20)Refusal To#

Code 076 – Furnish Information — Use this code if an application or active case is denied because of refusal to comply with department policy or to furnish information necessary to determine eligibility. This code does not apply to applicants or recipients who fail to return their client-completed form. Code 091, Failure To Furnish Information, should be used in this circumstance. Computer-printed reason to applicant or recipient: "You did not wish to furnish enough information for this agency to establish eligibility for assistance." "Usted no quiso darnos suficiente información para que esta agencia pudiera establecer su calificación para asistencia."

Code 077 (Form H1000-B Only) – Follow Agreed Plan — Use this code for those situations in which a recipient was granted assistance with the understanding that he would take certain steps to utilize resources that were not actually available at time of application but could be made available through recipient's efforts. Computer-printed reason to applicant or recipient: "You did not wish to follow agreed plan so that eligibility for assistance could be continued." "Usted no quiso cumplir con el plan convenido para continuar su calificación para asistencia."

(mepd-appendix-i)(block-21)Other Requirements#

Code 080 – Blind (Not Blind) Disabled (Not Disabled) — Use this code if a blind applicant does not meet the definition of economic blindness or a blind recipient is denied because his vision has been restored. Also, enter if a disabled applicant does not meet the definition of total and permanent disability or a disabled recipient is no longer totally disabled. If recovery from the incapacity is accompanied by employment or increased earnings, use codes 060 or 061. Computer-printed reason to applicant or recipient: Blind – "You do not meet the agency's definition of economic blindness." Disabled – "You do not meet the agency's definition of total and permanent disability." Blind – "Usted no cumple con la definición de ceguedad económica de la agencia." Disabled – "Usted no cumple con la definición de incapacidad total y permanente de la agencia."

Code 081 – Not Enrolled in Medicare Part A — Use this code if the applicant is not enrolled for Medicare Part A benefits and therefore cannot qualify for Qualified Medicare Beneficiary (QMB) or the Qualified Disabled Working Individuals (QDWI) programs. Use the code to deny a QMB or QDWI case if the client becomes unenrolled in Medicare Part A. Computer-printed reason to applicant or recipient: "You do not have Medicare Part A benefits." "Usted no tiene los beneficios de la Parte A de Medicare."

Code 083 (Form H1000-A Only) – 30 Consecutive Days Requirement — Use this code if an applicant has been denied because he does not meet the 30 consecutive day requirement. Computer-printed reason to applicant: "You have not lived in a Medicaid-certified long-term care facility for 30 consecutive days." "Usted no tiene 30 días consecutivos de vivir en un establecimiento certificado por Medicaid para proveer atención de largo plazo."

Code 086 – Admitted to Institution — Use this code if an applicant or recipient has been denied because he is an inmate of or has been admitted to an institution. Computer-printed reason to applicant or recipient: "You have been admitted to an institution." "Usted fue admitido en una institución."

Code 087 – Age — Use this code if an application or active case is denied because evidence proves ineligibility on the basis of age. This code does not apply to disabled recipients transferred to aged assistance on becoming 65 years old. In these cases use code 122, Category Change. Computer-printed reason to applicant or recipient: "You do not meet the age requirement." "Usted no cumple con el requisito de edad."

Code 088 – Residence — Use this code if evidence proves applicant is ineligible on the basis of residence, or if a recipient is known to have moved out of the state or remained out of the state longer than the minimum time allowed. If a recipient has moved out of the state to obtain employment, support from relatives, or for other known reason, use the code for that reason, rather than code 088. If an applicant or recipient cannot be located, use code 095. Computer-printed reason to applicant or recipient: "You do not meet residence requirements for assistance." "Usted no cumple con los requisitos de residencia para asistencia."

Code 089 – Citizenship or Legal Entry — Use this code if an applicant or recipient is ineligible because he is not a citizen nor a noncitizen lawfully admitted for permanent residence in the United States nor residing in the United States under color of law. Computer-printed reason to applicant or recipient: "You do not meet legal United States entry or citizenship requirement for assistance." "Usted no cumple con el requisito para asistencia de entrada legal en los E.U., ni de naturalización."

Code 090 (Form H1000-A Only) – Prior Eligibility (Used for Simultaneous Open and Close Only) — Use this code if an applicant is either deceased or currently ineligible for assistance but was eligible for Medicaid coverage during a prior period. Computer-printed reason to applicant: "Medical assistance was granted during a prior period, but you are not eligible now for medical or financial assistance." "Consiguió asistencia médica durante un periodo anterior, pero ahora no califica para asistencia médica ni financiera."

Code 091 – Failure to Furnish Information — Use this code only when an applicant or recipient fails to execute and return the completed eligibility form. Computer-printed reason to applicant or recipient: "You failed to complete and return the necessary eligibility form." "No devolvió usted debidamente completada la forma necesaria para calificar."

Code 092 – Other Eligibility Requirement — Use this code if an application or active case is denied because applicant or recipient does not meet an eligibility requirement other than need not covered by codes 076-089. Computer-printed reason to applicant or recipient: "You do not meet eligibility requirements for assistance." "Usted no cumple con los requisitos para calificar para asistencia."

Code 136 – Failure to Provide Proof of U.S. Citizenship — Use this code if an application or active case is denied because applicant or recipient is a U.S citizen or national and fails to provide proof of U.S. citizenship. Computer-printed reason to applicant or recipient: “(Last, First) is not eligible for Medicaid because proof of U.S. citizenship was not provided. As soon as this information is provided, this person may be eligible for Medicaid.” “(Last name, first name) no llena los requisitos de Medicaid porque no presentó prueba de ciudadanía estadounidense. Una vez que esta persona presente la información, es posible que llene los requisitos de Medicaid.”

(mepd-appendix-i)(block-22)Miscellaneous Reasons#

Code 094 – Appointment Not Kept — Use this code when an applicant or recipient is denied because: (1) he/she has failed to keep an appointment, and (2) he/she has made no response within 10 days to a follow-up inquiry. Computer-printed reason to applicant or recipient: "You failed to keep your appointment." "Usted no vino a la cita qine tenía."

Code 095 – Unable to Locate — Use this code if an applicant or recipient is denied because he/she cannot be located. Computer-printed reason to applicant or recipient: "You cannot be located." "No lo podemos localizar a usted."

Code 096 (Form H1000-A Only) – Application Filed in Error — Use this code if an application is to be denied because of being filed or pending in error or to deny a duplicate application, that is, more than one application filed for an individual in the same category. Computer-printed reason to applicant: No reason necessary - no notice will be sent to applicant.

Code 097 – Transfer of Property — Use this code if an application or active case is denied because of transfer of property, either real or personal, for purpose of qualifying for or increasing the need for assistance. Computer-printed reason to applicant or recipient: "You transferred property that has an effect on your eligibility for assistance." "Usted transfirió propiedad que afecta su calificació; para asistencia."

Code 098 – Voluntary Withdrawal — Use this code only if an applicant does not wish to pursue his/her application further, or if a recipient requests that his/her grant be discontinued and the underlying cause for the withdrawal request cannot be determined. If a specific reason for the withdrawal can be determined, always use the applicable code. Do not use for applicant/recipients who have moved out-of-state. Code 088 will be used for this reason. Computer-printed reason to applicant or recipient: "You have requested that your application for or your grant of assistance be withdrawn." "Usted ha pedido que su aplicación para, o su concesión de asistencia sea retirada."

Code 099 – Other Miscellaneous — Use this code only if an application or active case is denied for a reason which cannot be related in some respect to one of the preceding codes. Include under this code cases closed because the applicant or recipient is incarcerated, or was originally ineligible. Computer-printed reason to applicant or recipient: "You do not presently meet eligibility requirements." "Al presente usted no cumple con los requisitos para calificar."

(mepd-appendix-i)(block-23)3. Reasons for Sustaining Aged, Blind, and Disabled MAO Cases#

Notices to recipients for all redeterminations are computer-printed on special forms. These notices are "triggered" by the action code entered on the Form H1000-B. Since the reason is general, an adequate interpretation should be made to the recipient for any action taken to sustain the case.

(mepd-appendix-i)(block-24)Code#

110 – "You remain eligible for medical coverage."

121 – Type Program Transfer — "You have been transferred to another type of medical assistance."

122 – Category Change — "You continue to be eligible for medical assistance."

( Note: Use Code 122 if both type program and category change.)

(mepd-appendix-ix)Medicaid for the Elderly and People with Disabilities Handbook: Appendix IX, Medicare Savings Program Information#

(mepd-appendix-ix)(block-1)Appendix IX, Medicare Savings Program Information#

Revision 26-2; Effective June 1, 2026

Note: The following information is effective March 1, 2026.

(mepd-appendix-ix)(block-2)Eligibility as a Qualified Medicare Beneficiary (QMB)#

Medicare Entitlement

Must be entitled to Medicare Part A or enrolled in Medicare Part B immunosuppressive drug (Medicare Part B-ID).

Income — Maximum gross monthly income

$1,330 Individual

$1,804 Couple

Income can equal the maximum gross monthly income or be less than this limit. Use the couple income limit when both spouses are applying for the same program. If both are not eligible, use the individual income limit to test eligibility for each spouse separately. A portion of the spouse's income can be considered as part of the applicant's income.

Income limit amounts do not include the $20 general income disregard.

What counts as income?

Social Security benefits

Railroad retirement benefits

State or local retirement benefits

Interest or dividends

Gifts or contributions

Civil service annuities

Veterans benefits

Private pension benefits

Royalty and rental payments

Earnings or wages

Value of shelter paid by someone else

Resources — Maximum countable resources

$9,950 Individual

$14,910 Couple

What is a resource?

Bank accounts and certificates of deposit (CDs)

Real property

Life insurance policies

Burial funds

Individual retirement accounts (IRAs)

Stocks and bonds

Oil, gas or mineral rights

Jewelry and antiques

Cars and other vehicles

Boats and recreational vehicles

What can be excluded?

A Texas homestead where a person lives that they consider their principal place of residence

Life insurance if the face value is $1,500 or less

Separately identifiable burial funds of $1,500, less any excluded life insurance or irrevocable arrangement for burial, for the applicant and the applicant's spouse

A car

Burial spaces

Benefits

QMB covers Medicare premiums for Parts A, B, and B-ID, deductibles, and coinsurance fees for Medicare services. A QMB-eligible person does not get regular Medicaid benefits. The state sends a special identification card to people who are eligible for QMB to show their medical service providers.

Eligibility as Specified Low-Income Medicare Beneficiaries (SLMB)

Medicare Entitlement

Must be entitled to Medicare Part A or enrolled in Medicare Part B-ID.

Income

The income range for a person is equal to a minimum monthly amount of $1,330.01 to a maximum monthly amount of less than $1,596.

The income range for a couple is equal to a minimum monthly amount of $1,804.01 to a maximum monthly amount of less than $2,164.

Use the couple income range when both spouses are applying for the same program. Use the individual income range to test eligibility for each spouse separately if both are not eligible. A portion of the spouse's income can be considered as part of the applicant's income.

Income limit amounts do not include the $20 general income disregard.

What counts as income?

Social Security benefits

Railroad retirement benefits

State or local retirement benefits

Interest or dividends

Gifts or contributions

Civil service annuities

Veterans benefits

Private pension benefits

Royalty and rental payments

Earnings or wages

The value of shelter paid by someone else

Resources — Maximum countable resources

$9,950 Individual

$14,910 Couple

What is a resource?

Bank accounts and CDs

Real property

Life insurance policies

Burial funds

IRAs

Stocks and bonds

Oil, gas or mineral rights

Jewelry and antiques

Cars and other vehicles

Boats and recreational vehicles

What can be excluded?

A Texas homestead where a person lives that they consider their principal place of residence

Life insurance if the face value is $1,500 or less

Separately identifiable burial funds of $1,500, less any excluded life insurance or irrevocable arrangement for burial, for the applicant and the applicant's spouse

A car

Burial spaces

Benefits

SLMB covers only the payment of Medicare Part B or Part B-ID premiums. An SLMB-eligible person does not get regular Medicaid benefits or a monthly medical identification card.

Eligibility for the Qualifying Individuals Program (QI-1)

Medicare Entitlement

Must be entitled to Medicare Part A or enrolled in Medicare Part B-ID.

Must not otherwise be receiving Medicaid.

Income

The income range for a person is equal to a minimum monthly amount of $1,596 to a maximum monthly amount of less than $1,796.

The income range for a couple is equal to a minimum monthly amount of $2,164 to a maximum monthly amount of less than $2,435.

Use the couple income range when both spouses are applying for the same program. Use the individual income range to test eligibility for each spouse separately if both are not eligible. A portion of the spouse's income may also be considered as part of the applicant's income.

Income limit amounts do not include the $20 general income disregard.

What counts as income?

Social Security benefits

Railroad retirement benefits

State or local retirement benefits

Interest or dividends

Gifts or contributions

Civil service annuities

Veterans benefits

Private pension benefits

Royalty and rental payments

Earnings or wages

The value of shelter paid by someone else

Resources — Maximum countable resources

$9,950 Individual

$14,910 Couple

What is a resource?

Bank accounts and CDs

Real property

Life insurance policies

Burial funds

IRAs

Stocks and bonds

Oil, gas or mineral rights

Jewelry and antiques

Cars and other vehicles

Boats and recreational vehicles

What can be excluded?

A Texas homestead where a person lives that they consider their principal place of residence

Life insurance if the face value is $1,500 or less

Separately identifiable burial funds of $1,500, less any excluded life insurance or irrevocable arrangement for burial, for the applicant and the applicant's spouse

A car

Burial spaces

Benefits

QI-1 covers only the payment of Medicare Part B or Part B-ID premiums. A QI-1-eligible person does not get regular Medicaid benefits or a medical identification card. A person cannot receive QI-1 benefits if receiving benefits under any other Medicaid-funded program.

MSP and Medicare Part B-ID

A person diagnosed with end-stage renal disease (ESRD) who receives a kidney transplant remains eligible for Medicare coverage for 36 months after the month of the transplant. Medicare coverage ends after the 36th month unless the person is otherwise entitled to Medicare based on age or disability.

ESRD Medicare beneficiaries who lose Medicare entitlement after a successful kidney transplant may be eligible for Medicare Part B-ID, a limited Part B benefit that only covers immunosuppressive drugs. Part B-ID does not cover any other items or services, including hospital stays, physician services, supplies or medications. Part B-ID beneficiaries are not entitled to Medicare Part A.

Part B-ID beneficiaries cannot be eligible for Medicare on another basis or eligible for any other type of comprehensive health care coverage that covers immunosuppressive drugs, including Medicaid and the Children’s Health Insurance Program (CHIP). A person enrolled in Medicare Part B-ID may be eligible for Community Attendant Services (CAS) or the Healthy Texas Women (HTW) program because these types of assistance do not cover immunosuppressive drugs.

Eligible Part B-ID beneficiaries receive a new Medicare card that shows Medicare coverage for immunosuppressive drugs only.

Part B-ID beneficiaries with limited income and resources may be eligible for help with all or some of the Medicare Part B-ID premiums, coinsurance and cost sharing under QMB, SLMB or QI-1. They must meet all other MSP eligibility criteria, excluding entitlement to Medicare Part A.

If approved for QMB Part B-ID, Medicare Part B-ID beneficiaries receive help with the Medicare Part B-ID premiums, deductibles and co-insurance costs associated to immunosuppressive drugs only . For QMB Part B-ID recipients, the Medicaid card will show Part B-ID only in the upper right-hand corner. SLMB or QI-1 Part B-ID recipients receive help with Medicare Part B-ID premiums only .

Qualified Disabled and Working Individuals Program (QDWI)

Entitlement

Must be entitled to enroll in Medicare Part A.

Must be under 65 and not receiving Medicaid.

Income — Maximum gross monthly income

$2,660 Individual

$3,607 Couple

Income can be less than or equal to the maximum limit. Use the couple income limit when both spouses are applying for the same program. Use the individual income limit to test eligibility for each spouse separately if both are not eligible. A portion of the spouse's income may also be considered as part of the applicant's income.

Income limit amounts do not include the $20 general income disregard.

What counts as income?

Social Security benefits

Railroad retirement benefits

State or local retirement benefits

Interest or dividends

Gifts or contributions

Civil service annuities

Veterans benefits

Private pension benefits

Royalty and rental payments

Earnings or wages

Value of shelter paid by someone else

Resources — Maximum countable resources

$4,000 Individual

$6,000 Couple

What is a resource?

Bank accounts and CDs

Real property

Life insurance policies

Burial funds

IRAs

Stocks and bonds

Oil, gas or mineral rights

Jewelry and antiques

Cars and other vehicles

Boats and recreational vehicles

What can be excluded?

A Texas homestead where a person lives that they consider their principal place of residence

Life insurance if the face value is $1,500 or less

Separately identifiable burial funds of $1,500, less any excluded life insurance or irrevocable arrangement for burial, for the applicant and the applicant's spouse

A car

Burial spaces

(mepd-appendix-ix)(block-3)Benefits#

QDWI covers only Medicare Part A premiums. A QDWI-eligible person does not get regular Medicaid benefits or a medical identification card.

(mepd-appendix-li)Medicaid for the Elderly and People with Disabilities Handbook: Appendix LI, Self-Service Portal (SSP) Information#

(mepd-appendix-li)(block-1)Appendix LI, Self-Service Portal (SSP) Information#

Revision 12-3; Effective September 1, 2012

(mepd-appendix-li)(block-2)Basics of the SSP#

The SSP located at www.yourtexasbenefits.com is available to individuals 24 hours a day, seven days a week. They can use this website to:

Request or print a blank: Form H1200, Medicaid for the Elderly and People with Disabilities Application for Assistance – Your Texas Benefits; Form H1010, Texas Works Application for Assistance – Your Texas Benefits; and Form H1014, Application for Children's Health Insurance Program (CHIP), Children's Medicaid, and CHIP Perinatal Coverage.

Apply for the following benefits: SNAP food benefits, Medicaid, TANF and TANF-Level Medicaid, Medicare savings programs, Long-term care.

View Past and future interview date and times.

View and print submitted applications.

View case status (approve, denied. and/or terminated).

View benefit amounts.

View effective and review date.

View pending information.

Report changes: address, phone number, household members, employment income, self-employment income, unearned income, liquid resources, shelter expenses including utility, dependent care expense.

View Medicaid services and health history.

Submit redeterminations.

(mepd-appendix-li)(block-3)Account Management#

SSP provides the user with an option of Application Visibility or Case Visibility . Users with application visibility will be given the option to update to case visibility by going through advanced authentication .

Individuals must set up an SSP Case Visibility account in order to view case information and report changes by going through advanced authentication. If an individual loses their SSP password or is unable to set up a case visibility account because they cannot correctly respond to the authentication security questions via the SSP, they may request assistance from HHSC or the vendor.

If the individual is in the office requesting assistance with alternate account set-up/password reset, staff must verify the individual's identity and use the State Portal SSP account Management tab to grant case visibility access or password reset. See C-2220 , In-Person Contact.

If the individual is on the phone, then staff should refer the individual to 2-1-1 for assistance.

For additional information see https://oss.txhhsc.txnet.state.tx.us/sites/tw/SitePages/State%20Processes.aspx , Group: Support Tools. Select Support Tool-SSP Application Registration.

(mepd-appendix-v)Medicaid for the Elderly and People with Disabilities Handbook: Appendix V, Levels of Evidence of Citizenship and Acceptable Evidence of Identity Reference Guide#

(mepd-appendix-v)(block-1)Appendix V, Levels of Evidence of Citizenship and Acceptable Evidence of Identity Reference Guide#

Revision 07-4; Effective October 1, 2007

Important: Current SSI recipients and individuals entitled to or enrolled in Medicare are exempt from the citizenship documentation requirement for Medicaid. This includes individuals determined disabled for Social Security benefits and in the 24-month period before receiving Medicare.

Primary Evidence of Citizenship and Identity U.S. passport Certificate of naturalization Certificate of U.S. citizenship SDX for denied SSI recipients when the denial is for any reason other than citizenship (N13) SOLQ/WTPY and documentation of reason for Medicare denial

If primary evidence of citizenship is not available, the individual must provide two documents – one to establish U.S. citizenship and one to establish identity. Acceptable evidence of identity documents is outlined last at the end of this reference guide.

When primary evidence of citizenship is not available, begin with the second level of evidence of citizenship and continue through the levels to locate the best available documentation.

Second Level of Evidence of Citizenship (Use only when primary evidence is not available.) A U.S. public birth certificate showing birth in one of the 50 states, the District of Columbia, Puerto Rico (if born on or after Jan. 13, 1941), Guam (on or after April 10, 1899), the Virgin Islands of the U.S. (on or after Jan. 17, 1917), American Samoa, Swain’s Island or the Northern Mariana Islands (after Nov. 4, 1986). Conduct Bureau of Vital Statistics (BVS) inquiry for an individual born in Texas. If an individual’s date of birth is earlier than 1903 or if the birth was out of state, accept a legible/non-questionable copy. For a birth out of state, individuals may obtain a birth certificate through the following: BirthCertificate.com; vitalchek.com; or usbirthcertificate.net. Individuals may also contact usbirthcertificate.net toll-free at:1-888-736-2692. Report of Birth Abroad of a U.S. Citizen (FS-240) Certification of Birth Abroad (FS 545 or DS-1350) U.S. Citizen Identification card (Form I-179 or I-197) Northern Mariana Identification card (I-873) American Indian card (I-872) issued by Department of Homeland Security with classification code “KIC” Final adoption decree showing the child’s name and U.S. place of birth Evidence of U.S. Civil Service employment before June 1, 1976 U.S. Military record showing a U.S. place of birth ( Example: DD-214)

Third Level of Evidence of Citizenship (Use only when primary and second level evidence is not available.) Hospital record of birth showing a U.S. place of birth Life, health or other insurance record showing a U.S. place of birth Religious record of birth recorded in the U.S. or its territories within three months of birth that indicates a U.S. place of birth showing either the date of birth or the individual’s age at the time the record was made Early school record showing a U.S. place of birth, name of the child, date of admission to the school, date of birth, and name(s) and place(s) of birth of the applicant’s/recipient’s parents

Fourth Level of Evidence of Citizenship (Use only when primary, second level and third level evidence is not available.) Any listed documents used must include biographical information, including U.S. place of birth. Federal or state census record showing U.S. citizenship or a U.S. place of birth and the individual’s age (generally for individuals born 1900-1950) Seneca Indian Tribal census record showing a U.S. place of birth Bureau of Indian Affairs Tribal census records of the Navajo Indians showing a U.S. place of birth Bureau of Indian Affairs Roll of Alaska Natives U.S. State Vital Statistics official notification of birth registration showing a U.S. place of birth Statement showing a U.S. place of birth signed by the physician or midwife who was in attendance at the time of birth Institutional admission papers from a nursing facility, skilled care facility or other institution showing a U.S. place of birth Medical (clinic, doctor or hospital) record, excluding an immunization record, showing a U.S. place of birth Affidavits from two adults regardless of blood relationship to the individual; use only as a last resort when no other evidence is available

Evidence of Identity Driver's license issued by a state either with a photograph or other identifying information such as name, age, sex, race, height, weight or eye color School identification card with a photograph U.S. Military card or draft record Identification card issued by the federal, state or local government with the same information included on driver’s license Department of Public Safety identification card with a photograph or other identifying information such as name, age, sex, race, height, weight or eye color Birth certificate Hospital record of birth Military dependent’s identification card Native American Tribal document U.S. Coast Guard Merchant Mariner card Certificate of Degree of Indian Blood or other U.S. American Indian/Alaskan Native and Tribal document with a photograph or other personal identifying information Data matches with other state or federal government agencies ( Example: Employee Retirement System and Teacher Retirement System) Three or more corroborating documents, such as marriage license, divorce decrees, high school diplomas and employer ID cards. Use only with second and third levels of evidence of citizenship. Adoption papers or records Work identification card with photograph Signed application for Medicaid (accept signature of an authorized representative or a responsible person acting on the individual’s behalf) Health care admission statement For children under 16, school records may include nursery or day care records For children under 16, clinic, doctor or hospital records For children under 16, an affidavit signed by a parent or guardian stating the date and place of birth of the child; use as a last resort when no other evidence is available and if an affidavit is not used to establish citizenship For disabled individuals in residential care facilities, an affidavit signed by the facility director or administrator attesting the identity of the individual when the individual does not have or cannot get any document on this list. Use as a last resort when no other evidence is available and if an affidavit is not used to establish citizenship.

(mepd-appendix-vi)Medicaid for the Elderly and People with Disabilities Handbook: Appendix VI, SSA Claim Number Suffixes#

(mepd-appendix-vi)(block-1)Appendix VI, SSA Claim Number Suffixes#

Revision 21-1; Effective March 1, 2021

BIC Code Type of Beneficiary A Primary Claimant B Wife, 62 or older (1st claimant) B1 Husband, 62 or older (1st claimant) B2 Young wife with a child in her care (1st claimant) B3 Wife, 62 or older (2nd claimant) B4 Husband, 62 or older (2nd claimant) B5 Young wife with a child in her care (2nd claimant) B6 Divorced wife, 62 or older (1st claimant) B7 Young wife with a child in her care (3rd claimant) B8 Wife, 62 or older (3rd claimant) B9 Divorced wife, 62 or older (2nd claimant) BA Wife, 62 or older (4th claimant) BD Wife, 62 or older (5th claimant) BG Husband, 62 or older (3rd claimant) BH Husband, 62 or older (4th claimant) BJ Husband, 62 or older (5th claimant) BK Young wife with a child in her care (4th claimant) BL Young wife with a child in her care (5th claimant) BN Divorced wife, 62 or older (3rd claimant) BP Divorced wife, 62 or older (4th claimant) BQ Divorced wife, 62 or older (5th claimant) BR Divorced husband, 62 or older (1st claimant) BT Divorced husband, 62 or older (2nd claimant) BW Young husband with a child in his care (2nd claimant) BY Young husband with a child in his care (1st claimant) C1-C9 Child (minor, disabled or student) CA-CK Child (minor, disabled or student) CA = C11, CB = C12, etc. See Note 1. D Widow, 60 or older (1st claimant) D1 Widower, 60 or older (1st claimant) D2 Widow, 60 or older (2nd claimant) D3 Widower, 60 or older (2nd claimant) D4 Widow (remarried after turning 60) (1st claimant) D5 Widower (remarried after turning 60) (1st claimant) D6 Surviving divorced wife, 60 or older (1st claimant) D7 Surviving divorced wife, 60 or older (2nd claimant) D8 Widow, 60 or older (3rd claimant) D9 Widow (remarried after turning 60) (2nd claimant) DA Widow (remarried after turning 60) (3rd claimant) DC Surviving divorced husband, 60 or older (1st claimant) DD Widow, 60 or older (4th claimant) DG Widow, 60 or older (5th claimant) DH Widower, 60 or older (3rd claimant) DJ Widower, 60 or older (4th claimant) DK Widower, 60 or older (5th claimant) DL Widow (remarried after turning 60) (4th claimant) DM Surviving divorced husband, 60 or older (2nd claimant) DN Widow (remarried after turning 60) (5th claimant) DP Widower (remarried after turning 60) (2nd claimant) DQ Widower (remarried after turning 60) (3rd claimant) DR Widower (remarried after turning 60) (4th claimant) DS Surviving divorced husband, 60 or older (3rd claimant) DT Widower (remarried after turning 60) (5th claimant) DV Surviving divorced wife, 60 or older (3rd claimant) DW Surviving divorced wife, 60 or older (4th claimant) DX Surviving divorced husband, 60 or older (4th claimant) DY Surviving divorced wife, 60 or older (5th claimant) DZ Surviving divorced husband, 60 or older (5th claimant) E Mother (widow) (1st claimant) E1 Surviving divorced mother (1st claimant) E2 Mother (widow) (2nd claimant) E3 Surviving divorced mother (2nd claimant) E4 Father (widower) (1st claimant) E5 Surviving divorced father (1st claimant) E6 Father (widower) (2nd claimant) E7 Mother (widow) (3rd claimant) E8 Mother (widow) (4th claimant) E9 Surviving divorced father (2nd claimant) EA Mother (widow) (5th claimant) EB Surviving divorced mother (3rd claimant) EC Surviving divorced mother (4th claimant) ED Surviving divorced mother (5th claimant) EF Father (widower) (3rd claimant) EG Father (widower) (4th claimant) EH Father (widower) (5th claimant) EJ Surviving divorced father (3rd claimant) EK Surviving divorced father (4th claimant) EM Surviving divorced father (5th claimant) F1 Father F2 Mother F3 Stepfather F4 Stepmother F5 Adopting father F6 Adopting mother F7 Second alleged father F8 Second alleged mother G1-G9 Claimants of lump-sum death payments J1 Primary PROUTY entitled to HIB (less than 3 Q.C.) (General Fund) See Note 2 J2 Primary PROUTY entitled to HIB (over 2 Q.C.) (RSI Trust Fund) J3 Primary PROUTY not entitled to HIB (less than 3 Q.C.) (General Fund) J4 Primary PROUTY not entitled to HIB (over 2 Q.C.) (RSI Trust Fund) K1 PROUTY wife entitled to HIB (less than 3 Q.C.) (General Fund) K2 PROUTY wife entitled to HIB (over 2 Q.C.) (RSI Trust Fund) K3 PROUTY wife not entitled to HIB (less than 3 Q.C.) (General Fund) K4 PROUTY wife not entitled to HIB (over 2 Q.C.) (RSI Trust Fund) K5 PROUTY wife entitled to HIB (less than 3 Q.C.) (2nd claimant) (General Fund) K6 PROUTY wife entitled to HIB (over 2 Q.C.) (2nd claimant) (RSI Trust Fund) K7 PROUTY wife not entitled to HIB (less than 3 Q.C.) (2nd claimant) (General Fund) K8 PROUTY wife not entitled to HIB (over 2 Q.C.) (2nd claimant) (RSI Trust Fund) K9 PROUTY wife entitled to HIB (less than 3 Q.C.) (3rd claimant) (General Fund) KA PROUTY wife entitled to HIB (over 2 Q.C.) (3rd claimant) (RSI Trust Fund) KB PROUTY wife not entitled to HIB (less than 3 Q.C.) (3rd claimant) (General Fund) KC PROUTY wife not entitled to HIB (over 2 Q.C.) (3rd claimant) (RSI Trust Fund) KD PROUTY wife entitled to HIB (less than 3 Q.C.) (4th claimant) (General Fund) KE PROUTY wife entitled to HIB (over 2 Q.C.) (4th claimant) (RSI Trust Fund) KF PROUTY wife not entitled to HIB (less than 3 Q.C.) (4th claimant) (General Fund) KG PROUTY wife not entitled to HIB (over 2 Q.C.) (4th claimant) (RSI Trust Fund) KH PROUTY wife entitled to HIB (less than 3 Q.C.) (5th claimant) (General Fund) KJ PROUTY wife entitled to HIB (over 2 Q.C.) (5th claimant) (RSI Trust Fund) KL PROUTY wife not entitled to HIB (less than 3 Q.C.) (5th claimant) (General Fund) KM PROUTY wife not entitled to HIB (over 2 Q.C.) (5th claimant) (RSI Trust Fund) LM Black lung miner (1st claimant) LW Black lung miner's widow (1st claimant) M Beneficiary not entitled to Title II or monthly benefits (Not qualified for automatic free Part A – HIB) M1 Similar to M, but qualified for automatic free Part A – HIB, but elects to file for Part B – SMIB only T Fully insured beneficiaries who have elected entitlement only to HIB (usually but not always along with SMIB) End Stage Renal Disease (ESRD) filing for Medicare only Deemed insured (hospital insurance only) T2-T9 Multiple eligible children (Medicare Qualified Government Employment (MQGE) childhood disability benefits) (2nd – 9th claimant) TA MQGE primary beneficiary TB MQGE aged spouse (1st claimant) TC MQGE childhood disability benefits (1st claimant) TD MQGE aged widow or widower (1st claimant) TF MQGE father TG, TH, TJ, TK Multiple eligible MQGE aged spouses TL, TM, TN, TP Multiple eligible MQGE aged widow(er)s TQ MQGE mother TE, TR, TS, TT , TU Multiple eligible MQGE young widow(er)s TV, TW, TX, TY, TZ Multiple eligible MQGE disabled widow(er)s W Disabled widow, 50 or older (1st claimant) W1 Disabled widower, 50 or older (1st claimant) W2 Disabled widow, 50 or older (2nd claimant) W3 Disabled widower, 50 or older (2nd claimant) W4 Disabled widow, 50 or older 3rd claimant) W5 Disabled widower, 50 or older 3rd claimant) W6 Disabled surviving divorced wife (1st claimant) W7 Disabled surviving divorced wife (2nd claimant) W8 Disabled surviving divorced wife (3rd claimant) W9 Disabled widow, 50 or older (4th claimant) WB Disabled widower, 50 or older (4th claimant) WC Disabled surviving divorced wife (4th claimant) WF Disabled widow, 50 or older (5th claimant) WG Disabled widower, 50 or older (5th claimant) WJ Disabled surviving divorced wife (5th claimant) WR Disabled surviving divorced husband (1st claimant) WT Disabled surviving divorced husband (2nd claimant)

Note 1 : Youngest child is assigned suffix "1." If there are more than nine children in an Eligibility Determination Group (EDG), the 10th child is coded with an A rather than 10, the 11th child is coded with a B, etc.

Note 2 : Quarters of covered employment.

(mepd-appendix-vii)Medicaid for the Elderly and People with Disabilities Handbook: Appendix VII, County Names, Codes and Regions#

(mepd-appendix-vii)(block-1)Appendix VII, County Names, Codes and Regions#

Revision 12-1; Effective March 1, 2012

(mepd-appendix-vii)(block-2)A#

County Code Region Anderson 001 04 Andrews 002 09 Angelina 003 05 Aransas 004 11 Archer 005 02 Armstrong 006 01 Atascosa 007 08 Austin 008 06

(mepd-appendix-vii)(block-3)B#

County Code Region Bailey 009 01 Bandera 010 08 Bastrop 011 07 Baylor 012 02 Bee 013 11 Bell 014 07 Bexar 015 08 Blanco 016 07 Borden 017 09 Bosque 018 07 Bowie 019 04 Brazoria 020 06 Brazos 021 07 Brewster 022 10 Briscoe 023 01 Brooks 024 11 Brown 025 02 Burleson 026 07 Burnet 027 07

(mepd-appendix-vii)(block-4)C#

County Code Region Caldwell 028 07 Calhoun 029 08 Callahan 030 02 Cameron 031 11 Camp 032 04 Carson 033 01 Cass 034 04 Castro 035 01 Chambers 036 06 Cherokee 037 04 Childress 038 01 Clay 039 02 Cochran 040 01 Coke 041 09 Coleman 042 02 Collin 043 03 Collingsworth 044 01 Colorado 045 06 Comal 046 08 Comanche 047 02 Concho 048 09 Cooke 049 03 Coryell 050 07 Cottle 051 02 Crane 052 09 Crockett 053 09 Crosby 054 01 Culberson 055 10

(mepd-appendix-vii)(block-5)D#

County Code Region Dallam 056 01 Dallas 057 03 Dawson 058 09 Deaf Smith 059 01 Delta 060 04 Denton 061 03 DeWitt 062 08 Dickens 063 01 Dimmit 064 08 Donley 065 01 Duval 066 11

(mepd-appendix-vii)(block-6)E#

County Code Region Eastland 067 02 Ector 068 09 Edwards 069 08 Ellis 070 03 El Paso 071 10 Erath 072 03

(mepd-appendix-vii)(block-7)F#

County Code Region Falls 073 07 Fannin 074 03 Fayette 075 07 Fisher 076 02 Floyd 077 01 Foard 078 02 Fort Bend 079 06 Franklin 080 04 Freestone 081 07 Frio 082 08

(mepd-appendix-vii)(block-8)G#

County Code Region Gaines 083 09 Galveston 084 06 Garza 085 01 Gillespie 086 08 Glasscock 087 09 Goliad 088 08 Gonzales 089 08 Gray 090 01 Grayson 091 03 Gregg 092 04 Grimes 093 07 Guadalupe 094 08

(mepd-appendix-vii)(block-9)H#

County Code Region Hale 095 01 Hall 096 01 Hamilton 097 07 Hansford 098 01 Hardeman 099 02 Hardin 100 05 Harris 101 06 Harrison 102 04 Hartley 103 01 Haskell 104 02 Hays 105 Hemphill 106 01 Henderson 107 04 Hidalgo 108 11 Hill 109 07 Hockley 110 01 Hood 111 03 Hopkins 112 04 Houston 113 05 Howard 114 09 Hudspeth 115 10 Hunt 116 03 Hutchinson 117 01

(mepd-appendix-vii)(block-10)I#

County Code Region Irion 118 09

(mepd-appendix-vii)(block-11)J#

County Code Region Jack 119 02 Jackson 120 08 Jasper 121 05 Jeff Davis 122 10 Jefferson 123 05 Jim Hogg 124 11 Jim Wells 125 11 Johnson 126 03 Jones 127 02

(mepd-appendix-vii)(block-12)K#

County Code Region Karnes 128 08 Kaufman 129 03 Kendall 130 08 Kenedy 131 11 Kent 132 02 Kerr 133 08 Kimble 134 09 King 135 01 Kinney 136 08 Kleberg 137 11 Knox 138 02

(mepd-appendix-vii)(block-13)L#

County Code Region Lamar 139 04 Lamb 140 01 Lampasas 141 07 LaSalle 142 08 Lavaca 143 08 Lee 144 07 Leon 145 07 Liberty 146 06 Limestone 147 07 Lipscomb 148 01 Live Oak 149 11 Llano 150 07 Loving 151 09 Lubbock 152 01 Lynn 153 01

(mepd-appendix-vii)(block-14)M#

County Code Region Madison 154 07 Marion 155 04 Martin 156 09 Mason 157 09 Matagorda 158 06 Maverick 159 08 McCulloch 160 09 McLennan 161 07 McMullen 162 11 Medina 163 08 Menard 164 09 Midland 165 09 Milam 166 07 Mills 167 07 Mitchell 168 02 Montague 169 02 Montgomery 170 06 Moore 171 01 Morris 172 04 Motley 173 01

(mepd-appendix-vii)(block-15)N#

County Code Region Nacogdoches 174 05 Navarro 175 03 Newton 176 05 Nolan 177 02 Nueces 178 11

(mepd-appendix-vii)(block-16)O#

County Code Region Ochiltree 179 01 Oldham 180 01 Orange 181 05

(mepd-appendix-vii)(block-17)P#

County Code Region Palo Pinto 182 03 Panola 183 04 Parker 184 03 Parmer 185 01 Pecos 186 09 Polk 187 05 Potter 188 01 Presidio 189 10

(mepd-appendix-vii)(block-18)R#

County Code Region Rains 190 04 Randall 191 01 Reagan 192 09 Real 193 08 Red River 194 04 Reeves 195 09 Refugio 196 11 Roberts 197 01 Robertson 198 07 Rockwall 199 03 Runnels 200 02 Rusk 201 04

(mepd-appendix-vii)(block-19)S#

County Code Region Sabine 202 05 San Augustine 203 05 San Jacinto 204 05 San Patricio 205 11 San Saba 206 07 Schleicher 207 09 Scurry 208 02 Shackelford 209 02 Shelby 210 05 Sherman 211 01 Smith 212 04 Somervell 213 03 Starr 214 11 Stephens 215 02 Sterling 216 09 Stonewall 217 02 Sutton 218 09 Swisher 219 01

(mepd-appendix-vii)(block-20)T#

County Code Region Tarrant 220 03 Taylor 221 02 Terrell 222 09 Terry 223 01 Throckmorton 224 02 Titus 225 04 Tom Green 226 09 Travis 227 07 Trinity 228 05 Tyler 229 05

(mepd-appendix-vii)(block-21)U#

County Code Region Upshur 230 04 Upton 231 09 Uvalde 232 08

(mepd-appendix-vii)(block-22)V#

County Code Region Val Verde 233 08 Van Zandt 234 04 Victoria 235 08

(mepd-appendix-vii)(block-23)W#

County Code Region Walker 236 06 Waller 237 06 Ward 238 09 Washington 239 07 Webb 240 11 Wharton 241 06 Wheeler 242 01 Wichita 243 02 Wilbarger 244 02 Willacy 245 11 Williamson 246 07 Wilson 247 08 Winkler 248 09 Wise 249 03 Wood 250 04

(mepd-appendix-vii)(block-24)Y#

County Code Region Yoakum 251 01 Young 252 02

(mepd-appendix-vii)(block-25)Z#

County Code Region Zapata 253 11 Zavala 254 08

(mepd-appendix-x)Medicaid for the Elderly and People with Disabilities Handbook: Appendix X, Life Estate and Remainder Interest Tables#

(mepd-appendix-x)(block-1)Appendix X, Life Estate and Remainder Interest Tables#

Revision 12-3; Effective September 1, 2012

Age Life Estate Remainder 0 .97188 .02812 1 .98988 .01012 2 .99017 .00983 3 .99008 .00992 4 .98981 .01019 5 .98938 .01062 6 .98884 .01116 7 .98822 .01178 8 .98748 .01252 9 .98663 .01337 10 .98565 .01435 11 .98453 .01547 12 .98329 .01671 13 .98198 .01802 14 .98066 .01934 15 .97937 .02063 16 .97815 .02185 17 .97700 .02300 18 .97590 .02410 19 .97480 .02520 20 .97365 .02635 21 .97245 .02755 22 .97120 .02880 23 .96986 .03014 24 .96841 .03159 25 .96678 .03322 26 .96495 .03505 27 .96290 .03710 28 .96062 .03938 29 .95813 .04187 30 .95543 .04457 31 .95254 .04746 32 .94942 .05058 33 .94608 .05392 34 .94250 .05750 35 .93868 .06132 36 .93460 .06540 37 .93026 .06974 38 .92567 .07433 39 .92083 .07917 40 .91571 .08429 41 .91030 .08970 42 .90457 .09543 43 .89855 .10145 44 .89221 .10779 45 .88558 .11442 46 .87863 .12137 47 .87137 .12863 48 .86374 .13626 49 .85578 .14422 50 .84743 .15257 51 .83674 .16126 52 .82969 .17031 53 .82028 .17972 54 .81054 .18946 55 .80046 .19954 56 .79006 .20994 57 .77931 .22069 58 .76822 .23178 59 .75675 .24325 60 .74491 .25509 61 .73267 .26733 62 .72002 .27998 63 .70696 .29304 64 .69352 .30648 65 .67970 .32030 66 .66551 .33449 67 .65098 .34902 68 .63610 .36390 69 .62086 .37914 70 .60522 .39478 71 .58914 .41086 72 .57261 .42739 73 .55571 .44429 74 .53862 .46138 75 .52149 .47851 76 .50441 .49559 77 .48742 .51258 78 .47049 .52951 79 .45357 .54643 80 .43659 .56341 81 .41967 .58033 82 .40295 .59705 83 .38642 .61358 84 .36998 .63002 85 .35359 .64641 86 .33764 .66236 87 .32262 .67738 88 .30859 .69141 89 .29526 .70474 90 .28221 .71779 91 .26955 .73045 92 .25771 .74229 93 .24692 .75308 94 .23728 .76272 95 .22887 .77113 96 .22181 .77819 97 .21550 .78450 98 .21000 .79000 99 .20486 .79514 100 .19975 .80025 101 .19532 .80468 102 .19054 .80946 103 .18437 .81563 104 .17856 .82144 105 .16962 .83038 106 .15488 .84512 107 .13409 .86591 108 .10068 .89932 109 .04545 .95455

(mepd-appendix-xii)Medicaid for the Elderly and People with Disabilities Handbook: Appendix XII, Nursing Facility and Home and Community-Based Services Waiver Information#

(mepd-appendix-xii)(block-1)Appendix XII, Nursing Facility and Home and Community-Based Services Waiver Information#

Revision 26-1; Effective March 1, 2026

Note: The following information is effective Jan. 1, 2026.

(mepd-appendix-xii)(block-2)Income — Maximum gross monthly income#

$2,982 Individual

$5,964 Couple

Note : The income of parents and spouses is not considered for determining eligibility.

(mepd-appendix-xii)(block-3)What counts as income?#

Social Security benefits

Certain veteran's benefits

Private pensions

Interest or dividends

Royalty and rental payments

Federal employee annuities

Railroad benefits

State or local retirement benefits

Gifts or contributions

Earnings and wages

(mepd-appendix-xii)(block-4)Resources — Maximum countable resources#

$2,000 Individual

$3,000 Couple

(mepd-appendix-xii)(block-5)What is a resource?#

Bank accounts and certificates of deposit (CDs)

Real property

Life insurance policies

Burial funds

Individual retirement accounts (IRAs)

Stocks and bonds

Oil, gas or mineral rights

Jewelry and antiques

Cars and other vehicles

Boats and recreational vehicles

(mepd-appendix-xii)(block-6)What can be excluded?#

A homestead in Texas where the person plans to return.

Life insurance if the face value is $1,500 or less per insured person.

Separately identifiable burial funds of $1,500, less any excluded life insurance or more, if irrevocable, for the applicant and the applicant’s spouse.

One vehicle is excluded, regardless of value.

(mepd-appendix-xii)(block-7)Protected resources amount for a spouse in the community#

$32,532 minimum to $162,660 maximum, excluding value of homestead, household goods, personal goods, one car and burial funds.

(mepd-appendix-xii)(block-8)Nursing Facility#

Be 65 or older or meet SSA’s definition of disability.

Meet medical necessity criteria.

Be a resident of Texas and a U.S. citizen or alien with approved status such as a legalized or permanent resident alien.

Live in a Medicaid-contracted long-term care facility for at least 30 consecutive days.

(mepd-appendix-xii)(block-9)Co-payment#

Individual — Total gross income, less $75 for personal needs.

Individual with a spouse in the community — Total gross couple income, less:

$75 for personal needs;

amount up to $4,066.50 for community spouse; and

certain amount for dependents living with community spouse.

Couple — Total gross income, less $150 for personal needs.

Note: Certain other expenses may be deducted if the person meets program policy requirements. These expenses may include health insurance premiums, guardianship fees and incurred medical expenses if the Medicaid program does not cover direct payment for the services.

(mepd-appendix-xii)(block-10)Home and Community-Based Services#

Be 65 or older or meet SSA’s definition of disability.

Meet nursing facility medical criteria or ICF/IID -RC level of care criteria.

Be a resident of Texas and a U.S. citizen or alien with approved status such as a legalized or permanent resident alien.

Have an approved plan of care within the cost ceiling.

Meet waiver requirements.

(mepd-appendix-xii)(block-11)Co-payment#

A recipient may be required to pay a co-payment based on income in certain situations.

(mepd-appendix-xl)Medicaid for the Elderly and People with Disabilities Handbook: Appendix XL, Medicare and Extra Help Information#

(mepd-appendix-xl)(block-1)Appendix XL, Medicare and Extra Help Information#

Revision 12-3; Effective September 1, 2012

Note: This document is effective Jan. 1, 2010.

(mepd-appendix-xl)(block-2)Medicare#

Medicare is health insurance for people age 65 or older, under age 65 with certain disabilities and any age with permanent kidney failure (called end-stage renal disease). An individual must have entered the U.S. lawfully and have lived here for five years to be eligible for Medicare. Medicare has several parts.

Medicare Part B (Medical Insurance) – Helps pay for medically necessary doctors’ services and other outpatient care. It also pays for some preventive services (like flu shots), and some services that keep certain illnesses from getting worse. Most people pay the standard monthly Medicare Part B premium. See Appendix XXXI, Budget Reference Chart, for the current Medicare Part B premium amount.

Medicare Part C, called Medicare Advantage Plans – An individual must have both Part A and Part B to join one of these plans. The plans provide all of the Part A and Part B services, and generally provide additional services as well. An individual usually pays a monthly premium, and co-payments that likely will be less than the coinsurance and deductibles under the original Medicare. In most cases, these plans offer Part D Prescription Drug Coverage as well. These plans are offered by private insurance companies approved by Medicare. Costs and benefits vary by plan.

(mepd-appendix-xl)(block-3)Prescription Drug Coverage#

Medicare Prescription Drug Coverage, called Medicare Part D – An individual can add Part D by joining a Medicare Prescription Drug Plan (PDP). An individual must pay a deductible and usually is charged coinsurance each time services are received. Insurance companies and other private companies approved by Medicare offer PDPs. Costs and benefits vary by plan.

Enrollment is voluntary. Beneficiaries who have other sources of drug coverage (former employer, union, etc.) may stay in that plan. If their coverage is at least as good as the new Medicare drug benefit (creditable coverage), they will avoid higher premium payments if they later sign up for Medicare Rx.

Medicare drug coverage will help by covering brand-name and generic drugs. Like other insurance, after the individual is enrolled, the individual generally will pay a monthly premium, which varies by plan. The individual also will pay a yearly deductible, which is between $0-$310 in 2010. The individual also will pay a part of the cost of prescriptions, including a co-payment or coinsurance. Costs will vary depending on which drug plan the individual chooses. Some plans may offer more coverage and additional drugs for a higher monthly premium. If the individual has limited income and resources, and the individual qualifies for extra help, the individual may not have to pay a premium or deductible.

For questions about Medicare or the Medicare health and prescription drug plans, visit www.medicare.gov online or call 1-800-MEDICARE (800-633-4227). TTY users should call 877-486-2048.

(mepd-appendix-xl)(block-4)Extra Help for Prescription Drug Coverage#

Extra help for prescription drug coverage is available for people with Medicare who have limited income and resources. If eligible for extra help, Medicare will pay for almost all prescription drug costs. Extra help provides a subsidy based on the amount of income and resources a person has.

Full Subsidy Benefits from Extra Help:

Full premium assistance up to the premium subsidy amount

Nominal cost sharing up to out-of-pocket threshold

No coverage gap

Other Low Income Subsidy Benefits from Extra Help:

Sliding scale premium assistance

Reduced deductible

Reduced coinsurance

No coverage gap

An individual who has Medicare and Medicaid does not need to apply for extra help from Social Security. An individual who is eligible for the Medicare Savings Program (MSP) does not need to apply for extra help from Social Security. The MSP-eligible individual's information is sent to CMS automatically for the extra help.

Eligibility specialists ask, "Can I screen you for eligibility for Medicare Savings Program (MSP) since certification would include eligibility for extra help?"

If the caller does not want to be screened for MSP, refer the caller to the Centralized Benefit Services, 1-800-248-1078, for completion of subsidy application.

If an individual thinks personal information is being misused, call 1-800-MEDICARE ( 1-800-633-4227 ).

Apply for extra help or get more information about extra help subsidy by calling Social Security at 1-800-772-1213 (TTY 1-800-325-0778) or visiting www.ssa.gov .

(mepd-appendix-xv)Medicaid for the Elderly and People with Disabilities Handbook: Appendix XV, Notification to Provide Proof of Citizenship and Identity#

(mepd-appendix-xv)(block-1)Appendix XV, Notification to Provide Proof of Citizenship and Identity#

Revision 07-3; Effective July 1, 2007

(mepd-appendix-xv)(block-2)Insert for Application and Redetermination Packets#

Beginning July 1, 2006, each U.S. citizen eligible for Medicaid will be required to provide proof of citizenship and identity. This is due to a new federal law.

You will not have to provide any additional documents to prove citizenship and identity if you:

Receive SSI or have received SSI in the past.

Are entitled to and/or enrolled in Medicare currently or have been in the past.

Are a newborn to a mother who is Medicaid eligible.

If you are required to provide documents to prove citizenship and identity, the lists below will help you decide the best way to do this. For individuals born in Texas, we may be able to get the birth certificate electronically, and you will not need to provide it to prove citizenship. However you will need to provide proof of identity. The following documents prove both citizenship and identity. You need to provide only one of these documents.

U.S. passport

Certificate of Naturalization

Certificate of U.S. citizenship

If you do not have one of the documents listed above, then you will need to provide one document from each of the lists below. This means you will need to provide two documents with your application or recertification.

To Verify Citizenship To Verify Identity U.S. birth certificate U.S. citizen identification card American Indian card with a classification code "KIC" Northern Mariana identification card Hospital record of birth Religious record of birth with date and place of birth, such as baptismal record Affidavit from two adults, regardless of blood relationship to the individual, establishing the date and place of birth in the United States Current driver license with picture Department of Public Safety identification card with picture Work or school identification card with picture

There may be other documents we can accept to prove citizenship or identity. Please contact your local office to discuss other possibilities. If you are currently receiving Medicaid and are unable to provide proof of citizenship, you may be given extra time to obtain and provide proof before your Medicaid benefits are denied.

You may use an affidavit only as a last resort if you cannot provide any other proof. If you want to provide an affidavit to prove citizenship or identity, you can get a form at your local HHSC benefits office or online at www.hhsc.state.tx.us . You can dial 2-1-1 and request the location of the nearest HHSC benefits office.

(mepd-appendix-xv)(block-3)Anexo para los paquetes de solicitud y de redeterminación#

A partir del 1 de julio de 2006, todos los ciudadanos estadounidenses que reúnan los requisitos para recibir Medicaid deberán presentar pruebas de ciudadanía e identidad. Esto se debe a una nueva ley federal. No tendrá que presentar ningún documento adicional para demostrar su ciudadanía e identidad si:

Recibe SSI o ha recibido SSI en el pasado.

Tiene derecho a Medicare o está o estuvo inscrito en él antes.

Es un recién nacido cuya madre llena los requisitos de Medicaid.

Si tiene que presentar algún documento para demostrar su ciudadanía e identidad, las siguientes listas le ayudarán a determinar cuál es la mejor manera de hacerlo. Quizás podamos obtener un acta de nacimiento electrónica de las personas que nacieron en Texas y usted no necesite presentarla para demostrar su ciudadanía. Sin embargo, deberá presentar pruebas de identidad. Los siguientes documentos demuestran tanto la ciudadanía como la identidad. Solo tendrá que presentar uno de estos documentos.

Pasaporte de Estados Unidos

Certificado de naturalización

Certificado de ciudadanía estadounidense

Si no tiene ninguno de los documentos de la lista anterior, tendrá que presentar un documento de cada una de las siguientes listas. Esto significa que tendrá que presentar dos documentos con su solicitud o recertificación.

Para verificar la ciudadanía Para verificar la identidad Acta de nacimiento de Estados Unidos Tarjeta de identificación de ciudadanía de Estados Unidos Tarjeta de indio americano con un código de clasificación de "KIC" Tarjeta de identificación de Mariana del Norte Registro de nacimiento del hospital Registro religioso de nacimiento con fecha y lugar de nacimiento, como la fe de bautismo Declaración jurada de dos adultos, sin importar el parentesco con la persona, que establezcan la fecha y el lugar del nacimiento en Estados Unidos Licencia para manejar vigente con foto Tarjeta de identificación del Departamento de Seguridad Pública, con foto Tarjeta de identificación del trabajo o la escuela con foto

Puede haber otros documentos que se acepten para demostrar la ciudadanía o la identidad. Por favor, llame a la oficina local para hablar sobre otras posibilidades. Si está recibiendo Medicaid en este momento y no puede presentar la prueba de ciudadanía, es posible que reciba un plazo adicional para obtenerla y presentarla antes de negarle los beneficios de Medicaid.

Solo puede utilizar la declaración jurada como último recurso si no puede proporcionar otra prueba. Si quiere presentar una declaración jurada para demostrar su ciudadanía o identidad, puede conseguir la forma en la oficina local de beneficios de la Comisión de Salud o Servicios Humanos (HHSC) o en línea en www.hhsc.state.tx.us . Puede marcar el 2-11 y pedir la dirección de la oficina de beneficios de la HHSC más cercana.

(mepd-appendix-xvi)Medicaid for the Elderly and People with Disabilities Handbook: Appendix XVI, Documentation and Verification Guide#

(mepd-appendix-xvi)(block-1)Appendix XVI, Documentation and Verification Guide#

Revision 26-2; Effective June 1, 2026

This guide provides documentation expectations and suggested sources for getting information with proven quality, accurate cases. It is comprehensive, not all-inclusive, and subject to change.

Casework Hints: Hints are good, proven casework practices.

Prudent Person Principle: Allows staff to make reasonable decisions based on the best available information using common sense, program knowledge, experience and expertise. Staff should document the decision-making rationale and any applicable handbook references.

Case Record Documentation: The Case Record Documentation column in the chart below includes information entered on the Texas Integrated Eligibility Redesign System (TIERS) data entry screens. Only use case comments as needed and for information not captured by TIERS data entry or to clarify TIERS entries.

Verification and Sources: Each bullet in the Verification and Sources column is an acceptable source of verification unless otherwise stated. Send any documents received or generated in the local office for imaging into the case record.

Electronic Data Verifications: Use information from available electronic sources before trying to request documentation from the person. Do not request more documentation unless the electronic information is not consistent with the person’s statement and the information might make the person ineligible.

Element Policy Section Case Record Documentation Verification and Sources General Acceptable Documentation Documentation must support the eligibility determination and give enough detail so someone unfamiliar with the case will understand computations and eligibility decisions. Client Statement: When selecting client statement as a verification source, the information must be on the application, renewal form or imaged documents. Documentation must be in case comments. Third-Party Contacts by Phone or In Person, including client and authorized representative [AR] contacts: Phone Document the following: phone number called; person called, including title and authority to release information being requested; date of call; and reported information, including dates, values or balances, descriptions, and source the responder references. In Person Document the following: date; and reported information, including dates, values or balances, descriptions, and source the responder references. Other Acceptable: Document the source used to verify the element in case comments if there is no field to enter information on the individual TIERS Logical Unit of Work (LUW) page. Note : Other forms of verification may be acceptable with proper, complete documentation and program approval. Such as: Kelly Blue Book or savings bond verification. Blanks on Most Recent Application or Review: Documentation must address how items left blank on the most recent application or review are cleared. Note: If an application has only client identifying information and a valid signature, phone contact may be needed to get an explanation of the incomplete items. It is not enough to assume a client has no income or resources or that none of the questions apply and to request only a State Online Query (SOLQ) inquiry. Only one type of verification is required unless noted otherwise. Example: If all required information is on the bank statement or available through the Asset Verification System (AVS), Form H1239, Request for Verification of Bank Accounts , is not needed. When verification is available from both client statement and an electronic data source (ELDS) or other acceptable verification sources, ELDS and the other verification source supersede client statement. Case Comments Document the following in case comments: The complete name of the person making the comments. Any open tickets, including the ticket number, date of ticket and the reason for the ticket. The reason for reopening the application, with an explanation of the new file date. Document the reason for denial if a denial was made in error or the previous worker did not clearly document the denial reason. The reviewer, supervisor or worker III must document the reason when approving the reopening of an application with a protected file date. The file date chosen and an explanation if there are several dates stamped or written on the application form or if an incorrect file date was used. Image the email if email correspondence is received. Document the reason eligibility is denied for the correct program if eligibility cascades to an incorrect program. Case Comment Example: Application for waiver Medicaid denied due to excess income, cascaded to Parent and Caretaker Relative Medicaid (TP 08). Sent to Texas Works for disposal. The reason for using the override function. The reason the second-party reviewer does not approve whatever is being reviewed. The reason a contingency processing method (CPM) is needed due to a defect or because the policy was not programmed into TIERS. If the CPM gives instructions on specific information to include in the explanation, then document the information. Document the CPM number. Resolutions to any discrepancies, questionable information or special situations for any eligibility factor. The person’s response to clear discrepant Data Broker information, or a notation that the person disagrees with the information. The request and use of interpreter services, including when and how the services were provided, and the name of the interpreter. Document the date of the call, the phone number and name of the person contacted for any calls made with the applicant, recipient or their AR. Document that person’s relationship to the applicant or recipient and authority to release information. The reason for delays in processing an application and the eligibility specialist’s actions, as explained in B-6420, Missing Information Due Dates , subsection titled Delay in Certification. SOLQ or WTPY Use and Documentation SOLQ or Wire Third-Party Query (WTPY) can verify several things about an applicant’s or recipient’s eligibility and co-payment. Examples: Name on Social Security Administration (SSA) record Date of birth (DOB) Citizenship Medicare Parts A, B, C and D Social Security amounts Dual entitlement to Medicare and Medicaid This list is not all-inclusive. Use SOLQ as the primary verification tool when possible. To comply with SSA safeguarding requirements, do not print, send for imaging or copy and paste SOLQ data directly into case comments. Document the date or dates SOLQ was viewed in case comments. Request a WTPY if SOLQ does not provide all needed information. To comply with SSA safeguarding requirements, do not print, send for imaging, or copy and paste WTPY data directly into case comments. Document in case comments the need for a WTPY, the WTPY request number, date viewed, and information verified by WTPY rather than SOLQ. SOLQ or WTPY Record SOLQ or WTPY correctly on screens using SOLQ or WTPY as a verification source. Document comments when WTPY was used instead of SOLQ in case history. This is because SOLQ is the primary source of verification and TIERS treats SOLQ or WTPY as one verification source. Simplified Methods for Community-Based Applications Use this procedure for community-based programs, including: all cost-of-living adjustment (COLA) disregard programs, such as Pickle, Disabled Adult Child (DAC), and Widow or Widower; all Medicare Savings Programs; and the Community Attendant Services (CAS) program. Do not use this procedure when a person is applying for or requesting a transfer to the following programs: institutional Medicaid; Home and Community-based Services waiver; Medicaid Buy-In; or Medicaid Buy-In for Children. Review the document: Simplification of Documentation & Verification for Community Based Programs (PDF) . Customized Redetermination Driver Flow (CRDF) Use CRDF for MEPD redeterminations when the case is active and in ongoing mode, and the packet received date is on or before the renewal due date. CRDF does not rule out the requirement for documentation and verification of eligibility factors. Guardians and Other Agents F-1231, B-3220, B-3300 If there is no appointed guardian or power of attorney (POA), determine if there is any other fiduciary agent. If there is no family, friends or attorney, Form H0003, Agreement to Release Your Facts , should be completed. Note: When a guardianship exists, only that guardian can act on the person’s behalf to sign applications and review forms. Get a copy of the guardianship or POA document. Citizenship, Identity, Residence, Alien Status D-3000, D-5000, D-8000 Document the reason a more reliable source is not used if Level 1 evidence of citizenship is not used. If citizenship is verified by sources other than SOLQ: Birth Verification System (BVS) — Document the birth certificate number, as TIERS does not automatically keep the certificate number. Birth certificate, naturalization papers or other sources used — Ensure the image is available in the portal. If viewing the original document, be sure to send a copy for imaging. Return the original document to the person. Alien status needs to be verified through Systematic Alien Verification for Entitlements (SAVE) in Data Broker. Identity verification must also be documented. Copies of documents are acceptable if they are legible and not questionable. Hint: Ensure copies of alien status cards are legible by adjusting the print quality on the copier. Refer to Appendix V, Levels of Evidence of Citizenship and Acceptable Evidence of Identity Reference Guide , for acceptable documentation. Do not delay certification or deny the application if citizenship or alien status verification is the only information not provided. Form TF0001, Notice of Case Action, informs the applicant that citizenship or alien status verification is required within 95 days. It lists the name of each person who must provide citizenship or alien status verification. Excess Income or Resources Excess Resources: If excess resources can be designated as burial funds, allow the person the opportunity to do so. Refer to F-4227, Burial Funds . If a person is determined ineligible because of excess funds in a joint account, allow the person an opportunity to disprove the presumed ownership of all or part of the funds. The person must also be allowed to disprove ownership of joint accounts that do not currently affect eligibility but may in the future. Refer to F-4121, Joint Bank Accounts . Excess Income: Refer to the following: B-2500, Explaining Policy vs. Giving Advice G-6200, Special Income Limit for the Eligibility Budget F-6800, Qualified Income Trust Appendix XXXVI, Qualified Income Trusts (QITs) and Medicaid for the Elderly and People with Disabilities (MEPD) Information Hint: If denial is based on applicant or recipient declaration, both the notification of denial and case comments should include the name and type of contact, date and any other comments to substantiate the decision. Third-Party Resources D-7000 Ensure that the TPR LUW is completed fully and accurately to ensure correct information is submitted to Provider Claims. State or MEPD Specialist Judgment Call: Assignability of the policy may be pursued on a follow-up basis if it appears reasonable that the policy is assignable. Casework Hints: Check bank drafts for premiums for third-party resource (TPR) policies. Check employment history or retirement income for possible TPRs. Verify the names, addresses and policy numbers of insurance policies (assignability). Sources to verify insurance policies: Copy of policy Form H1253, Verification of Health Insurance Policy Copy of insurance card Verify the amount of the premium. Get proof that premiums are being paid and that the policy is in force. Copies of canceled checks are very good proof of payment of an insurance premium. Incurred Medical Expenses Chapter H, Co-Payment Properly determine incurred medical expenses (IMEs) to calculate the co-payment. Is the IME being paid by the applicant or recipient? Do not allow an IME deduction without proof that the applicant or recipient paid the insurance premium or incurred other medical expenses. If someone else has been paying the insurance premium or medical expenses and the applicant or recipient clearly plans to make the payment, schedule a special review to consider the IME deduction. Request a completed, signed and dated Form H1263-A, Certification of Medical Necessity – Durable Medical Equipment or other IME , or Form H1263-B, Certificate of No Medical Contraindication - Dental, if necessary . Verify the names, addresses and policy numbers of insurance policies. Verify the names and addresses of other medical providers the applicant or recipient may be paying, such as a dentist. What is the charge for? Is it for an allowable medical expense? How many payments are required for complete payoff? How much was agreed to be paid? Is there any private health insurance that might pay the expenses? If there is no documentation field present in TIERS, use case comments to record this information. Verify the name and address of any other source of payment. Copies of canceled checks are good proof of payment of a medical bill. Do not allow deductions for nonassignable health or nonassignable dental insurance policies. Assignable insurance policies must be reported on Form H1039, Medical Insurance Input, a nd sent to the Office of Inspector General (OIG), Third-Party Resources Unit. Remember to set a special review date to monitor IMEs. Transfer of Assets Chapter I Determine if a potential transfer of assets occurred during the look-back period. Do this by reviewing the application, information provided by the applicant, bank statements if available, and information available through AVS. Document: the when, what, and how much was it worth as of 12:01 a.m. on the first day in the month of transfer; how much was received; who each transfer is from and to; and the date of transfer. Establish the look-back period. Were assets transferred within the look-back period? Presume the transfer took place for Medicaid eligibility. Is there any value that is uncompensated? Evaluate the transfer for exceptions. Document applicable exceptions as needed. Document the value of the resource at the time of transfer and the amount of income being transferred. Offer an opportunity for rebuttal. Document the compensation received to offset the value transferred. Document that an opportunity for rebuttal was offered and record the time frames observed. Were the rebuttal notices properly sent? If the person attempts a rebuttal, document the evidence used during the rebuttal process. Document the elements used to determine the validity of the rebuttal. Document supervisor concurrence of the rebuttal decision. Bank statements that are provided or requested must be reviewed for possible transfers. If transfers are noted, more bank statements and other verification can be requested to determine and verify if other transfers happened. Refer to I-3000, Exceptions to the Transfer of Assets . Refer to: F-6500, Irrevocable Trusts F-6800, Qualified Income Trust (QIT) F-7000, Annuities E-4400, Other Annuities, Pensions and Retirement Plans E-3320, Alimony and Support Payments E-3370, Cash Gifts and Contributions E-3372, Effective Date of Receipt of Inheritance; Disclaimers Sources to verify validity of a transfer: Use copies of documents transferring assets. Documentation from viewing documents is okay if one cannot get copies. Document the reason one cannot get a copy. Contact with companies or firms, such as a financial institution, that are knowledgeable of the transfer. The contact must be documented using phone contact documentation. Verify the fair market value per handbook requirements for the asset transferred. A person can request up to 60 months of bank statements or other verification if there was a transfer. Sources to verify the amount of compensation offered: Document the formula used to determine the value of the tendered compensation if compensation is other than cash. Verification should include a copy of the sales document or agreement. If a verbal agreement was made, get a written statement from the applicant or recipient, and the person who received the transferred asset. If more than one source of verification is needed, such as verifying transfer and another to verify compensated value, document the other sources and related information in case comments. Receipts used to verify compensation: Bank deposit slips or bank statements for verification of the amount only. Cash F-4110 Cash is a countable resource. Accept the person's statement about the amount of cash on hand. Address the amount as of 12:01 a.m. on the first day of the month. Accept the person’s statement as verification. Bank Accounts F-4120 The following information must be documented in the case record: name of the financial institution; complete account number; account accessibility by the person; account balance as of 12:01 a.m. on the first day of the appropriate month(s); and interest paid on account. Applications: Explore financial management and potential transfers of assets if bank statements for the month of application and the three prior months are given. If there were transfers, request up to 60 months of bank statements to determine how far back the transfers may go. Do not request bank statements if balances for the month of application and three prior months are obtained through AVS and: no potential transfer of assets is identified; and AVS information does not result in potential ineligibility. Reviews: Verify resources as of 12:01 a.m. on the first day of: the month the renewal form was received; the previous two months; or any month up to the month the review is completed. Reminder: All resources must be verified as of 12:01 a.m. on the same month. Note: Burial Funeral, as reported through AVS, is a type of savings account. AVS provides reports on Custodial Other/UGMA/ UTMA and Custodial Retirement. At application, AVS is not a valid verification source because legal review is needed. If needed, request more information to determine if they are a countable resource. At renewal, if there are no changes and no potential transfer of assets exist, AVS can be used as verification. Sources of verification include: AVS response. Bank statement Completed Form H1239, Request for Verification of Bank Accounts . Letter from the financial institution. Phone contact with an employee of the financial institution. Pursue written follow-up if cannot get information by phone or if the information results in ineligibility. The following three pieces of information must be captured in the case record: Name of the financial institution Account number Balance as of 12:01 a.m. for the appropriate test month(s) Joint Bank Accounts F-4121 Document the name of the financial institution and the complete account number. Document the name of the person with access to the account. If disproving ownership, get a completed Form H1299, Request for Joint Bank Account Information , or a written statement by the applicant or recipient. A written statement from the applicant's or recipient's AR is also acceptable if the AR is not an owner on the account, disproving the applicant’s or recipient's ownership of the account funds. Accept an AR’s statement if no other statement is available, and there is more evidence to support the statement, such as deposits and canceled checks. Whose funds were used to establish the account? Whose income was used to make subsequent deposits, and who made withdrawals? Use case comments to document how and when ownership is disproved. Request written statements from co-holders of the account verifying the person’s statement. A third party's statement may be necessary if either party is mentally incompetent. Request evidence that a change was made to restrict the applicant or recipient's accessibility to the account (funds) or to establish separate accounts. If the ownership of funds is not disproved, follow policy for case record documentation for bank accounts. If all monies belong to the applicant or recipient, no Form H1299 is required. Follow the guidelines for case record documentation for bank accounts. Verify the name of the financial institution and account number. Verify the name of the owner or owners of the account. The applicant or recipient must be given the opportunity to disprove or prove ownership of part or all funds or income in the account, before denial. Trusts F-6100 through F-6900 Document the type of trust. Is the trust revocable or irrevocable? Document if the trust is revocable or irrevocable. If it is irrevocable, review the transfer of assets treatment in F-6500, Irrevocable Trusts , F-6713, Transfer of Assets , and Chapter I, Transfer of Assets . Is the trust a qualifying income trust (QIT)? Are deposits being made to a trust account? Determine the source of each deposit to the account. Who is the beneficiary? Document the value of the trust corpus. Document the amount and frequency of income being produced by the trust, and the amount of the corpus and income available to the applicant or recipient. Determine and document the countability of the corpus and income being produced. Document the source of verification. Send copies of trusts to regional legal staff for interpretation. Sources to verify trusts: Copy of the trust agreement. For special needs trusts, the source of the assets used to fund the trust. Copy of the will, if the trust is a testamentary trust. For wills, a copy of the Order Probating the Will or a copy of the Letters Testamentary issued when the will was probated. This is needed for any resource type where the person may have inherited an interest in property. For example, a will granting a life estate or other interest in property. Statement from the financial institution, trust management company or attorney. Legal staff interpretation. Contact with legal staff should occur by designated procedures. Note: Document the basis for the exemption if the trust is exempt. Patient Trust Funds F-4123 Document if the applicant or recipient keeps a trust fund at the facility and there is a balance in the account as of 12:01 a.m. on the first day of appropriate month(s). Is interest being paid on the account? If so, document the amount and frequency of payment and the source of verification. Refer to the Interest and Dividends section of this chart for information about the treatment of interest paid. Contact the facility to determine if the applicant or recipient owns a trust fund at that facility. Do this if the applicant or recipient lived in another nursing facility and indicates that a trust fund was maintained at the previous facility. Verify that funds were transferred to the current facility. N ote: Patient Trust Fund (PTF) accounts are not available through the AVS. Verify these accounts with the facility. Use one of the verification sources listed below: Documented viewing of the facility's records Copy of the statements provided by the facility Contact with a knowledgeable representative at the facility, such as a phone call to the facility bookkeeper, using phone contact documentation Stocks F-4130 Document the following: name of the company; number of shares and type of shares; calculations of countable value; market value as of 12:01 a.m. on the first day of the appropriate month; and source of verification. Use one of the following sources to verify the closing prices of stocks: Newspaper Statement from a brokerage firm Research department of a local library Documented contact with the issuing company, using phone contact documentation. Use one of the following sources to verify ownership of stock: Copies of stock certificates Written statement from an authorized employee of the brokerage firm or issuing company Documented contact with the brokerage firm or issuing company, using phone contact documentation Bonds F-4140 Document the following: name of the issuing company; type of bond; serial number; Market value as of 12:01 a.m. on the first day of the appropriate month; and source of verification. Note: There is no need to redetermine the value of a bond if there is evidence that the value will not change from year to year. Verify ownership by examining the front of a bond. Use one of the following sources to verify the cash value of municipal, corporate and government bonds: Newspaper report of the closing price on the last day of the month before the test month Statement from an authorized employee of a savings or banking institution or a brokerage or securities firm Research department of a local library AVS response, for convertible bonds Use one of the following sources to verify the cash value of U.S. savings bonds: U.S. Department of the Treasury savings bond online calculator Table of redemption values for U.S. savings bonds Statement from an authorized employee of a savings or banking institution Copy of bond Promissory Notes, Loans and Property Agreements F-4150 (for resource treatment) I-6200 (cross reference for transfer of assets) Document the following: Ownership of the note. Accessibility by the applicant or recipient. If the note is negotiable. If non-negotiable, why? Does a transfer of assets exist? If the note is an excluded resource. If the note is excluded, the reason for exclusion. If the note is a countable resource, the current market value of the note. Amount of income (interest) generated by the note. Source of verification. State or MEPD Specialist Judgment Call: Document your evaluation of the validity of the appraisal if the appraisal value is $0, based on the reason given by the appraising entity. Note: The applicant or recipient must own the note. Notes that the applicant or recipient owes are not a resource. Send copies of notes, loans and property agreements to legal for interpretation. Use one of the following sources to verify ownership of a promissory note, loan or property agreement: Copy of the instrument, note, mortgage or agreement Statement from the purchaser and noteholder Use one of the following sources to verify negotiability of a promissory note, loan or property agreement: Copy of the instrument that shows if it is negotiable Statement from a bank or other financial institution, private investor, or real estate agent Use one of the following sources to verify the value of a promissory note, loan or property agreement: Copy of the instrument Amortization schedule For a statement from a bank or other financial institution, private investor, or real estate agent, if the fair market value is being rebutted, the following information must be included: Current principal owed Appraised market value if value is $0, document the reason Date the original instrument was signed Interest rate Payment schedule Note: If the appraisal value likely will not change, there is no need to reverify the value each year unless circumstances involving the resource change. Home as an Excluded Resource F-3000 Document the address or location description of the home. Verify and document one of the following reasons for exclusion: Principal place of residence Spouse residing in home Dependent relative living in home Home is placed for sale Life estate or remainder interest, also refer to the Life Estates and Remainder Interests section in this chart Intent to return The primary evidence of an applicant's or recipient's intent to return home is the applicant's or recipient's statement. Document this on a signed Form H1245, Statement of Intent to Return to Home , or a written statement from the applicant's or recipient's spouse or AR. Document the source of verification. Remember, a home placed in an irrevocable trust loses its homestead exclusion. A home placed in a revocable trust loses its homestead exclusion, but if it is removed from the trust, it can once again be excluded as a homestead if it meets the exclusion reasons. Refer to F-3200, The Home and Resources in a Trust , through F-3300, The Home as a Countable Resource . Verify the current residence address of the applicant or recipient, and spouse or both, before nursing facility admission. sources to verify the exclusion are as follows: For a spouse or dependent relative living in the home: Document the person’s statement establishing the residence as the spouse's or dependent relative's primary residence. Use case comments for documentation. For intent to return: Form H1245 or comparable written statement on intent to return to the described residence. Document receipt of the form in case comments. For a home placed for sale: Copy of the real estate listing agreement Newspaper ad Picture of a visible for sale sign on the property Collateral contact with someone viewing a visible for sale sign on the property, using phone contact documentation Document these sources in case comments. Review the status of a home placed for sale at each annual review. If a shorter time frame is referenced in the real estate listing agreement, set a special review to monitor at the specified time. The Home as a Countable Resource F-3300 Document the location and ownership of the homestead. If the property does not meet exclusion requirements, determine the current equity value of the homestead or the applicant's or recipient's equity interest in the homestead. Document in case comments the applicant's or recipient's ownership interest, if less than 100 percent, and the formula used for determining the countable equity value. Document the source of verification. Refer to I-3000, Exceptions to the Transfer of Assets , and F-3800, The Home and Transfer of Assets . Use one of the following sources to verify location, ownership and current market value of a home: Tax statement with the current assessment, if using 100 percent evaluation Copy of the appraisal from the local taxing authority or appraisal district Statement from a local knowledgeable source, such as a realtor Phone contact with a previously listed source, using phone contact documentation Use one of the following sources to verify the equity value of a home: Copy of a lien, note or other outstanding debt Statement from the mortgage company or a copy of the amortization schedule Statement from the tax office, if taxes are in arrears In TIERS, court record or other legal document include: a copy of a lien, note or other outstanding debt; a statement from the mortgage company; or a copy of the amortization schedule. Proceeds from Sale of Home or Other Real Property F-3400, F-4260 Determine the type of resource sold and if the recipient received the current market value. Follow transfer-of-resources policy if the current market value was not received. Document the following: Selling price of the home or other real property. Gross amount received from and the expenses involved in the sale of the home or property. Itemize the expenses involved. If the applicant or recipient is purchasing a replacement home and the time frame for excluding the proceeds from the sale of the original home. Set a special review to monitor. Sources to verify the sale and amount received include: Copy of the deed Real estate contract or agreement Statement from the mortgage company or a copy of the amortization schedule Statement from the tax office, if taxes are in arrears Copy of the appraisal from the local taxing authority or appraisal district Statement from a local knowledgeable source, such as a realtor Sales receipt or contract Bank deposit slip or copy of check or form of payment Sources to verify expenses about the sale of a resource include: Bill for repairs or services Copy of a lien or note that had to be paid to effect the sale. The copy should show the final settlement Home Equity F-3600 Treatment of a homestead as a resource in F-3000, Home , continues, but it does not impact the determination of disqualification for vendor payment in an institution or denial of waiver services due to substantial home equity. Evaluation of the substantial home equity is required for institutional or waiver services at application and redetermination. Consider reverse mortgage and home equity loans when determining the equity value. Consider undue hardship. Get verification of the home equity value, such as a copy of the reverse mortgage or home equity loan, if applicable, for the case record. Thoroughly document in case comments the home equity value and information about the reverse mortgage or home equity loan, if applicable. Continuing Care Retirement Community (CCRC) F-3700 The entrance fee in a continuing care retirement community or life care community must be evaluated for consideration as a resource if certain criteria are met. Document the following: CCRC contract date CCRC facility name CCRC entry date Is the resource accessible? Yes or No. Does the contract specify that the fee be used to pay for care? Yes or No. Is the person eligible for a refund upon termination of the contract or departure from the CCRC? Yes or No CCRC entrance fee value Amount of entrance fee spent on care Refundable amount Get a copy of the CCRC contract. Other Real Property F-4210 Document the following: Location and description of the property. Ownership interest in the property. If the property is excluded and the reason for exclusion. Current equity value of the applicant's or recipient's interest in the property . Note: Document in case comments the percentage of ownership and the formula used to determine the value of the applicant’s or recipient’s interest if the applicant's or recipient's ownership interest is less than 100 percent. Source of verification. Sources for verification include: Ownership interest in the property Tax statement with the current assessment, if using 100 percent evaluation Copy of the appraisal from the local taxing authority or appraisal district Statement from a local knowledgeable source about the value, such as a realtor Phone contact with a previously listed source with knowledge of the property in the area, using phone contact documentation Copy of the deed or will to verify ownership State or MEPD Specialist Judgment Call: If the property is inherited by descent and distribution, the recipient's statement on the degree of ownership may be used if no other documentation is available. Get the help of legal staff to determine the degree of ownership. Sources to verify the equity value of other real property are as follows: Copy of a lien, note or other outstanding debt Statement from the mortgage company or a copy of the amortization schedule Statement from the tax office if taxes are in arrears In TIERS, court record or other legal document includes: a copy of a lien, note or other outstanding debt; a statement from the mortgage company; or a copy of the amortization schedule. Life Estates and Remainder Interests F-4212 Document the location of the life estate property. Document if the life estate is excluded as a resource, such as a home. Use life estate as the real property type and document this action in case comments in TIERS, for a remainder interest. Document the reason for exclusion if the resource is excludable. Document the current equity value if the resource is countable. Refer to Appendix X, Life Estate and Remainder Interest Tables , for information about calculating life estate and remainder interest values. Calculate the equity value and document in case comments the formula used for determining the value. Document the source used to verify the value. Note: Clearance of a life estate is required for later reviews if the recipient is over the resource limit and older than when the value was initially determined. Record if: the applicant or recipient chooses to rebut the value; the basis of the rebuttal; the value from a knowledgeable source used for the rebuttal; and the verification used to support the rebuttal. For the purchase of a life estate, refer to I-6100, Purchase of a Life Estate . Refer to F-3800, The Home and Transfer of Assets . Sources to verify ownership of a life estate or remainder interest: Copy of the deed. Copy of the will, court record or other legal document showing that the applicant or recipient was granted a life estate or remainder interest. If the terms of the will, court record or other legal document are difficult to understand, get the help of legal staff. Sources to verify the current market value of a life estate or remainder interest: If a statement from a knowledgeable source is obtained, the MEPD formula for determining value is not necessary. Current tax statement or assessment notice. Statement from a local appraisal district office. Statement from a realtor or an authorized employee of a savings or banking institution. Sources to verify the equity value of a life estate or remainder interest: Copy of a lien, note or other outstanding debt Statement from the mortgagee or a copy of the amortization schedule Statement from the tax office if taxes are in arrears Copies of bills for essential repairs Copy of a bill for legal fees For rebuttals, written verification from a knowledgeable source Note: Life estates cannot be inherited by descent and distribution, as the life estate would end at death. One cannot inherit another person's life estate. Life Settlement Contract F-4225.1 For the life insurance policy, document the following: Name of the life insurance company, the policy number and the face value Date the life insurance policy was converted to a life settlement contract For the life settlement contract, legal review is required. Document the following: Name of the life settlement company Amount of proceeds from the life settlement contract Irrevocable or revocable assignment Name of the financial institution Account number Any allowable disbursements, as shown in the account agreement Amount of funds reserved for the death benefit Send an encrypted email to the HHSC OES MEPD IC Mailbox After certification. Document the date the email was sent in case comments. Title the email LIFE SETTLEMENT in all caps. In the body of the email, include all the following: Case name Case number Document Control Number (DCN) for the life settlement contract and supporting documentation Disposition date Result of the disposition, certified or denied Total proceeds of the life settlement contract Sources of verification include: Copy of a contract or written agreement from the life settlement company Copy of the account agreement from the bank Bank account statement showing deposits and withdrawals Written statement from the life insurance company showing change of ownership Life Insurance F-4223 Document the following: Name of the insurance company, the policy number and the face value. Type of insurance coverage. If the insurance is excluded or not as a resource. If the insurance is excluded, the reason for exclusion. If the insurance is a participating policy or not. If an applicant or recipient has a participating policy, determine and document if the dividends are used to: Purchase more insurance — Treat as other life insurance policy. Increase the value of existing insurance policy coverage — Verify if the face value or cash value is increased. Apply toward the payment of premiums — Disregard the dividends as income or resources. Pay cash to the policyholders — Verify how often cash is paid, the amount of the payment and how the cash is used. Balance of any dividend accumulation and interest. Add the countable value of the dividends to the cash value of the policy for TIERS if dividends are accumulating and are considered in eligibility. Enter this total in the cash value section of the life insurance screen. Use case comments to document the actual value of the policy and the value of the dividends separately. Do not use the interest or dividend field on the life insurance screen. Use the current cash value if the insurance is a countable resource. Source used to verify the value. Casework Hints: Check the bank drafts for life insurance premiums. Check the insurance policy for an Application for Life Insurance page for indicators of other life insurance policies. Sources of verification include: Copy of the insurance policy Completed Form H1238, Verification of Insurance Policies Letter from the insurance company Phone contact with the insurance company's representative, using phone contact documentation. Note: For term insurance, no further verification is needed. Note: On reviews, if a total face value equal to or less than $1,500 was previously verified and the policy is not participating, no further verification is needed. Burial Spaces F-4214 Document the name of the cemetery and the number of spaces. All burial spaces are excluded regardless of designation. However, if the person acknowledges that the spaces are purchased as an investment, count the equity value. Ownership of a burial plot in another state does not affect residency requirements or excludability. Accept the person’s statement as verification if the burial spaces are not an investment. If the burial spaces are an investment, sources to verify the location and number of spaces include: Applicant's or recipient's statement Cemetery association Funeral home if associated with a particular cemetery or if it sells plots Review the purchase contract for the burial spaces. Burial Funds F-4227, F-4228, F-4229 Preneed Contracts F-4160, F-4170 Document the type of resource being designated. Document the total amount of assets being designated. Document the amount of the asset that is excludable under the designated burial fund exclusion. Get a written statement from the applicant or recipient, or their AR designating the assets for burial unless the designated resource is a prepaid burial contract or a bank account styled for burial. Verbal designation is acceptable when the applicant, recipient, or AR is designating life insurance insuring the applicant or recipient, or spouse and the case is due. The recipient or AR must follow up with a written statement, to keep getting the burial fund designation. For preneed contracts, document: the name of the funeral home or insurance company; how the policy is funded, such as life insurance or cash; if the policy is revocable or irrevocable; the face value of the contract and who owns it; the cash value, if it is owned by the applicant or recipient; the face value, if it is irrevocable or owned by someone else; the reason for exclusion, if it is excluded; and the source of verification. May substitute another source of verification. Refer to Appendix XXXIV, Burial Resources , for information about calculating the countable amount of a preneed. Burial spaces can be excluded for anyone. However, only allow the designated burial fund exclusion for the person and the person’s spouse. Use one of the following sources to verify the designation of burial funds: Form H1252, Designation of Burial Funds . A written statement from the applicant, recipient or their representative having the same information requested on Form H1252. For a life insurance designation, use a verbal statement from the applicant, recipient, or their AR with the same information requested on Form H1252. This is to certify a case on a timely basis when a written statement or a completed Form H1252 is not received before the certification deadline. The case also must reflect a special review to follow up for the written statement of designation. If the written verification is not received by the due date, redetermine eligibility based on the resource not being designated. Copy of the ownership papers or the financial institution's record showing the burial fund designation. Get a copy of the burial trust or agreement. Document if the designated burial funds are in the form of an irrevocable trust or arrangement. Note: Burial space items are not excludable on insurance-funded burial contracts. However, if the insurance-funded burial contract is irrevocable and fully paid, the value of the burial space item is disregarded when determining the amount of the irrevocable arrangement that reduces the burial fund designation. Exception: If the irrevocable burial contract is owned by someone other than the applicant or recipient, do not make a deduction for the burial space items whether the contract is paid in full or not. Reduce the burial fund designation by the face value of the contract. For preneed contract verification, request one of the following: Completed Form H1238-A, Verification of Pre-Need Information Copy of the contract or a letter from the funeral home, or document verbal contact with a funeral home representative using phone contact documentation Although contact with a funeral home representative can be used to complete a case near the delinquency deadline, immediately follow up with verification by getting a copy of the contract or a letter from the funeral home. For insurance-funded preneeds, verification such as irrevocable assignment, must come from the insurance company, not the funeral home. Automobiles F-4221 Document the year, make and model of all vehicles. Exclude one vehicle regardless of value. If the household is made up of more than one person and the other household member requires another vehicle for transportation to and from work, exclude the other vehicle for that member for work transportation. For households of more than one person with another household member who requires handicap-accessible transportation, exclude the other vehicle if it is specially equipped for that other member of the household. For all other vehicles, use the current market value. If the applicant or recipient still owes on the vehicle, consider the current market value and equity value. Document the formula used to determine the countable value if the equity value is less than the market value. Show the source used to verify the current market value and equity value. Verify the market value of a vehicle in any of the following situations: The applicant's or recipient's statement is not reasonable. The applicant or recipient owns more than one vehicle. Sources to verify the value of a vehicle include: Kelley Blue Book or NADA guidebook, trade-in wholesale value Hearst Corporation Black Book Statement from an automobile dealer Newspaper ads A source with knowledge about antique cars. In TIERS, use other acceptable and document in case comments Note: If the vehicle is being declared as junk, not running or fixable, a $0 default value may be assigned. Land Resources F-4213, E-3333 This includes: Mineral Rights (oil, gas, etc.) Surface Rights (grass, timber, etc.) Document the following: Location or address of the property - document in case comments. Percentage of ownership interest in the land resources - document in case comments. Applicant’s or recipient’s accessibility to the interest in the land resources. If the land resources are excluded as a resource. If the land resources are excluded, the reason for exclusion. If the land resources are not excluded, the current equity value of the applicant's or recipient's interest in the land resources. Document in case comments the calculation of countable equity value. Clearance of value is not required for subsequent reviews unless circumstances occur that may change the countability or value. If the mineral rights are non-producing, assign a $100 default value. Document in case comments the reason for the $100 default value. If the default value negatively impacts eligibility, verify a specific value. Source of verification. Notes: Clearance of value is not required for subsequent reviews unless circumstances occur that may change the countability or value. If the mineral rights are non-producing, assign a $100 default value. Document in case comments the reason for the $100 default value. If the default value negatively impacts eligibility, verify a specific value. Sources to verify the value of land resources: Tax statement, if assessed. Contact with a knowledgeable source in the community, using phone contact documentation. Sources include oil and gas producers, tax assessors or collectors, and petroleum lease agents or landmen. Form H1242, Verification of Mineral Rights , completed by an authorized employee of the producing company. Internal Revenue Service formula to assess the value of mineral rights for inheritance purposes — 40 times the average monthly payout. Use this only when no other source is available. In TIERS, use other acceptable and document this information in case comments. Sources to verify ownership include: Copies of deeds, wills or leases. If the terms of the deeds, wills or leases are difficult to understand, get the help of legal staff. Copy of royalty statement. Division order, if the mineral rights are producing. Statement from the applicant or recipient about the amount of interest (ownership). Completed Form H1242. Sources of Earned Income E-3100 (includes royalties from book publications) Document the following: Gross-earned income, use amounts for the previous six months or the number of months available if income fluctuates. Source of earnings. Calculations used to determine average earned income, if appropriate. Amount of the protected earned income allowance, if appropriate. Source of verification. Date of special review, if appropriate. Amount of mandatory payroll deductions. Identify these payroll deductions on the expenses screen in TIERS, using case comments. Use one of the following sources to verify the gross earned-income for the immediate past six months or less, depending on the review schedule: Statement from the employer about wages - signed and dated Copies of check stubs - for the entire period if there is fluctuating earned income The Work Number (TWN) earned income and employment information provided through the Federal Data Services Hub (FDSH) Written statement furnished by the ICF or IID provider, only if cannot get verification from the employer Completed and signed Form H1028, Employment Verification In-kind Support and Maintenance (Non-Vendor Only) Situations E-8000 Document the name of the person(s) who provided the support and maintenance and the type of in-kind benefit given to the applicant or recipient. Document the amount of any payment or contribution made or received by the applicant or recipient. Document the countable value of the in-kind benefit and any calculations used to determine the countable value if the applicant or recipient rebuts the presumed maximum value. Verify the stated income is enough to provide for known living expenses. If manipulating entries on the detail screens to calculate in-kind support and maintenance (ISM) correctly, thoroughly document the ISM details in case comments. Sources of verification include: Statement from the owner as to the current market rental value Statements from the applicant or recipient and the head of household or AR. Use statement from Form H1200, Application for Assistance — Your Texas Benefits , if reasonable Copies of checks for payments made by the applicant or recipient Copies of household bills such as utilities, and rent Farm Income E-3130 Document the type of farm income, the applicant's or recipient's interest in the farm income, and the accessibility of the income to the applicant or recipient. Document in case comments the applicant's or recipient's ownership interest if not fully owned by the applicant or recipient. Get the most recent income tax return, Schedule F. Note: Project income based on the countable income declared on the most recent income tax return - depreciation is not an allowable expense. Schedule a review for six months to determine if the farm income for the period has changed significantly. If not, continue the projected income from the tax return until the annual review. A special review may be scheduled to get the next income tax return and put the annual review cycle in line with the filing of the return. Use the amount of gross income and allowable expenses from the previous six months in the absence of a recent income tax return. Get this information from records provided by the applicant or recipient. Document in case comments the reason for the difference in income If the amount of income is expected to change. Document the amount of net countable income and the calculations used to arrive at countable income. Refer to E-3120, Self-Employment , and E-6000, Self-Employment Income , for allowable expenses or deductions. Itemize these expenses or deductions and document them in case comments. Document the source of verification. Verify gross annual income and expenses, as appropriate. Verify that the income is at least six percent of the equity value to ensure the farmland is exempt if the farmland is not part of the applicant's or recipient's homestead. Note: If the farm qualifies as the applicant's or recipient's business, it can be excluded whatever the value or the rate of return. Refer to F-4300, Resources Essential to Self-Support . Sources of verification include: Income tax return Receipts, payments and statements from other knowledgeable sources such as a county agent or a co-op Self-Employment Income E-3120, E-6000 Document the following: type of self-employment income; most recent income tax return; and amount of gross income and expenses from the previous months, if income tax return is not available or earnings are expected to be significantly different. Identify if the earnings are anticipated to change significantly if staff determines earnings using the applicant's or recipient's tax return. Continue to use the earnings determined from the income tax return for the following six months or until the next income tax return is filed. If staff determines earnings using the applicant's or recipient's IRS Schedule C form, staff is directed to the Schedule C page in TIERS to enter the applicable fields from the applicant's or recipient's IRS Schedule C form. TIERS calculates the monthly expense amount automatically. Note: An income tax return should not be used for projecting income for more than one year. If the applicant or recipient fails to file a timely tax return, projected income must be determined based on the income and expenses from the previous six months. Explain the reason if the amount of income is expected to change. Document this information in case comments. Document in case comments the amount of net countable income and the calculations used to arrive at countable income if not using a tax return, an IRS Schedule C form, or an IRS Schedule F form. Document the source of verification. Set a six-month special review for variable earnings income. Verify gross earnings and expenses for the past six months. Refer to E-5000, Variable Income , and E-6000, Self-Employment Income , for the averaging of earned income every six months. Refer to G-2200, Variable Income for treatment in the eligibility budget. Refer to H-3400, How to Budget at Reviews for treatment in the co-payment budget. Note the income tax return exception. Sources for verification include: most recent year's income tax return; IRS Schedule C, Form 1040- Profit or Loss from Business; IRS Schedule F, Form 1040- Profit or Loss from Farming; and receipts maintained by the applicant or recipient. Note: Reconciliation must be done when a new tax return, an IRS Schedule C form, or an IRS Schedule F form is used for projecting the recipient's income or a change in the recipient's income is noted at the six-month review. Hint: If the applicant or recipient cannot provide income records or income tax receipts, have the applicant or recipient provide a written self-declaration of projected income, or use Form H1049, Client's Statement of Self-Employment Income . Use that statement to project income for one month. Explain to the applicant or recipient the information needed to establish the applicant's or recipient's true income. Set a one-month special review to get the necessary information. Use the information gathered at the special review to project the applicant’s or recipient's earnings for six months. Social Security Benefits E-4100 Document the gross benefit amount and, if appropriate, the supplemental medical insurance benefits (SMIB) premium amount. Document the amount of, and reason for the difference such as overpayment or child support if per SOLQ or WTPY , the difference between the RSDI gross and net benefit amounts is greater than the Medicare Part B premium. Document the claim number. Document the source of verification. Verify gross benefits for applications. For reviews, if the recipient's statement agrees with the conversion amount and there is no indication that the RSDI benefit has changed, no further verification is needed. Document in case comments the date SOLQ or WTPY was viewed. Helpful Hint: Check for dual entitlement. Verify the amount of Social Security benefits by one or more of the following methods: View or get a copy of the applicant's or recipient's award notice (letter) from the SSA . Get an SOLQ or WTPY report. Contact a representative of the Social Security Administration, using phone contact documentation. View or get a copy of the applicant’s or recipient's most recent benefit check or direct deposit slip. This method is least desirable, because the check or direct deposit slip may not show the gross benefit amount. At review, use the conversion amount in the system of record if there is no indication that the RSDI benefit is different from the converted amount. Railroad Retirement Benefits E-4200 Document the gross benefit amount and, if appropriate, the SMIB premium amount. Document deductions on the expenses screen and utilize case comments in TIERS to explain the deductions. Check the deductions for potential life or health insurance. Pursue verifying and documenting the insurance policy if a deduction is for health or life insurance. Refer to the Third-Party Resources and Life Insurance sections of this chart. Document the railroad retirement claim number. Document the source of verification. Document the date of the special review If a special review is needed for an annual cost-of-living increase, not automated or an anticipated change in the health insurance premium. Verification sources include: Get a completed Form H1026, Verification of Railroad Retirement Benefits , to furnish information. View or get a copy of the applicant's or recipient's award notice issued by the Railroad Retirement Board. Contact a representative of the Railroad Retirement Board, using phone contact documentation. View or get a copy of the applicant's or recipient's most recent benefit check or direct deposit slip. This method is least desirable, because the check or direct deposit slip may not show the gross benefit amount. Send a follow-up letter to the payor. Department of Veterans Affairs (VA) Compensation and Pensions E-4300 Document the gross benefit amount and, if appropriate, the amount of any VA allowance not considered in the eligibility and co-payment budgets such as aid and attendance [A&A], housebound benefits, or reimbursements for unusual or continuing medical expenses. Make two entries for VA income in TIERS, if the pension is not full A&A: one entry for the VA pension and the other entry for A&A. Document the VA claim number. Document the source of verification. Note: If the recipient's VA compensation is capped at $90, there is no need to reverify it at the recipient's review or at the COLA review. There is no need to reverify old - law benefits at the review if the recipient or AR indicates there has been no change. If a special review is needed for an annual cost-of-living increase, not automated, document the date of the special review. Verify VA benefits by one or more of the following methods: Get a completed Form H1240, Request for Information from Bureau of Veterans Affairs and Client's Authorization . Contact an appropriate VA representative, using phone contact documentation. View or get a copy of the applicant's or recipient's award notice issued by the VA. View or get a copy of the most recent benefit check or direct deposit slip. This method is least desirable, because the check or direct deposit slip may not show if the funds include aid and attendance, a housebound allowance, or reimbursements for unusual or continuing medical expenses. Send a follow-up letter to the payor. Other Annuities, Pensions and Retirement Plans E-4400 Document the source of payments. Document the gross benefit amount and the amounts of any deductions from the gross benefit. In TIERS, document deductions on the expenses screen. Use case comments to explain the deductions. Check the deductions for potential life or health insurance. If a deduction is for health or life insurance, then pursue verifying and documenting the insurance policy. Refer to the Third-Party Resources and Life Insurance sections of this chart. If the source of payment is a civil service annuity, document the claim number. Document tape matches. More verification is not needed if the tape matches agree with the recipient's statement. Document the source of verification. Document the date of the special review if a change in the health insurance premium or an increase in benefits is expected such as a cost-of-living increase for civil service annuities or a potential raise in Teacher Retirement System [TRS] or Employee Retirement System [ERS] benefits. Refer to F-7000, Annuities . Verify payments by one or more of the following methods: Get a letter from the organization providing the payments. Contact a representative of the organization, using phone contact documentation. Get a completed Form H1243, Verification of Civil Services Benefits , if the payments are from that source. Get a completed Form H1297, Request for Information from Teacher Retirement System of Texas , if the payments are from that source. Get a completed Form H1214, Request for Pension Information , for other types of pensions. View or get a copy of the applicant's or recipient's award notice. View or get a copy of the applicant's or recipient's most recent check or direct deposit slip. This method is least desirable, because the check or direct deposit slip may not show the gross benefit amount and or deductions. Send a follow-up letter to the payor. View tape matches, such as ERS or TRS. Interest and Dividends E-3330 Document the following: Name of the financial institution, company or other source of interest or dividend income. If the income is received from a financial institution, the account number. If the income is received from an insurance company, the policy number. The information used for projecting income, including the interest amount and dates paid, must be verified at each review subject to variable income review policy. If the income is excludable, the reason for exclusion. If the income is countable, any calculations used to arrive at an average amount. Source of verification. If a special review is needed, the date of the special review. Sources of verification include: Copies of bank statements Written statement from the company or financial institution making the payments Copies of dividend check stubs Completed Form H1239, Request for Verification of Bank Accounts Contact with a representative of the company or financial institution, using phone contact documentation Completed Form H1238, Verification of Insurance Policies , if received from an insurance company Rents E-3340 Document the type of rental income, the applicant's or recipient's interest in the rental income, and the accessibility of the income to the applicant or recipient. Document in case comments the applicant's or recipient's interest in the income. Get the most recent year's income tax return for people who have established rent records. Depreciation is not allowable. Note: Income may be projected using the most recent year's income tax return, but a review is required at six months to determine if there was a significant change in the applicant’s or recipient's income. Use the amount of gross income and expenses from the previous six months to project the income and expenses for the next six months if not using the income tax return to project income. Document in case comments the reason for the difference in income if the amount of income is expected to change. Document the amount of net countable income and the calculations used to arrive at countable income. Document in case comments the types of expenses or deductions. Document the source of verification. Document the date of the special review if a special review is needed. Sources for verification include: Income tax return Receipts, payments, bank deposit slips and canceled checks Statements from the applicant or recipient and the renter Royalties (from land resources) E-3330 Document the following: Name of the payor and the reason for payment. Verification of the amounts and receipt dates used in the calculation of average income. If the royalties are excludable, the reason for exclusion. If the royalties are countable, the calculations used to arrive at an average amount. Source of verification. If a special review is needed, the date of the special review. Use one of the following methods of verification: Copies of check stubs. Completed Form H1242, Verification of Mineral Rights . Ensure the reported payments reflect when royalties were received and not when they were earned. Contact with a representative of the lease company must be documented using phone contact documentation. Automated phone information is acceptable and a very good source of information, but it must be documented using phone contact documentation. Gifts, Inheritances, Support and Alimony E-3320, E-3370 Cross reference: Chapter I, Transfer of Assets Document the following: Amount of the gift, support, alimony or inheritance. If the income will be treated as a lump - sum payment, infrequent or irregular income, or regular and predictable income. Source of the income. Frequency the income is received. if the income is expected to continue. Verify a gift, an inheritance, or support and alimony payments by one or more of the following methods: Get a statement from the person or organization providing the item. Use other acceptable in TIERS and document in case comments. View or get copies of the court order, court records or will. If the terms or conditions of the agreement do not clearly identify income, get the help of legal staff. Get a fair market value of gift items from a knowledgeable source or through newspaper advertisement. Use other appropriate methods, depending on the nature of the item. Notes and Mortgages E-1750, E-3331, F-4150 Document the following: Name of the person making the note payments and if the income is accessible to the applicant or recipient. Amount of the note payment and the frequency of payments. If the note is negotiable, or not. If payments are countable as income or not and, if so, the portion of the note payment that must be considered as income. Source of verification. If a special review is needed, the date of the special review. Refer to I-6200, Purchase of a Promissory Note, Loan or Mortgage . Sources of verification include: Amortization schedule. Copy of contract. Copy of note or mortgage document giving the terms of repayment. If the terms or conditions of the agreement do not clearly identify income, get the help of legal staff. Statements from the applicant or recipient and the person who makes the payments. Use purchaser or noteholder in TIERS. Contact with the bank, using phone contact documentation. Prizes and Awards E-3360 Document in case comments the type of prize or award and the name of the awarding company. Document on the expense screen or in case comments any legal or medical expenses involved in obtaining the award. Document the value of the prize or award. Verify prizes and awards by one or more of the following methods: Get a copy of the applicant's or recipient's notice of the prize or award. Contact a representative of the organization, using phone contact documentation. View or get a copy of the applicant’s or recipient's check. Get estimates of the value if the prize or award is not cash. Get proof of any legal or medical expenses involved in getting an award. Medical Necessity (MN) or Level of Care (LOC) Determination for Applications B-7420 Hospice A-5200 In TIERS, the interface auto-populates MN or LOC information. If the interface is not responding, the caseworker can populate TIERS screens with information verified by the Texas Medicaid and Healthcare Partnership (TMHP) or by the nursing facility (NF) if the person is receiving Medicare. If a person has elected hospice care, Form 3071, Individual Election, Cancellation or Update , serves as verification of MN. Use one of the following methods for verification: Long-term Services and Supports (LTSS) summary screen in TIERS, populated by the interface Phone contact with TMHP or the NF, documenting the name of the person and the date and time of contact Thirty-Consecutive Day-Stay Rule G-6000, G-6200, O-1100, O-5000 Document in case comments that an applicant or recipient has met the 30 - consecutive - days requirement, including verification and sources. If the person is eligible only because of the special income limit, the person must be admitted to a Medicaid-approved long - term care facility such as Medicare- SNF , NF or ICF or IID for the 30 - consecutive - day time frame to begin. Note: A full or regular Medicaid recipient who enters a Medicaid-approved long - term care facility does not have to meet the 30 - consecutive - day time frame. Verify the applicant's or recipient's stay using one of the following methods: Contact with facility staff no sooner than the 31st day of the applicant's or recipient's stay, using phone contact documentation Proof of admission or discharge due to death by the LTSS summary screen interface Contact with TMHP, using phone contact documentation Contact with providers, using phone contact documentation Contact with waiver staff, using phone contact documentation Special Review Requirement B-8200, B-8430 Hint: This list is not all - inclusive. Special reviews are set for many reasons depending on the information needed. Monitor eligibility at least every three months if the applicant’s or recipient's total countable income is within $10 of the income limit. Monitor eligibility at least every three months if the applicant’s or recipient's countable resources are within $100 of the resources limit. Special reviews are needed every six months for the following: All IMEs Variable income Other situations requiring a special review include the following: Known changes, such as an increase in income or TPR amount or loss of benefits. Enter in case comments the following information: Date of the special review Why a special review is being set What information needs to be requested to complete the special review Include the following information in the case record documentation: If a special review is needed Specific details about the special review Months and source of verification related to the special review Date the special review will be conducted Enter all special reviews into TIERS.

(mepd-appendix-xxix)Medicaid for the Elderly and People with Disabilities Handbook: Appendix XXIX, Special Deeming Eligibility Test for Spouse to Spouse#

(mepd-appendix-xxix)(block-1)Appendix XXIX, Special Deeming Eligibility Test for Spouse to Spouse#

Revision 26-2; Effective June 1, 2026

Note: The following information is effective March 1, 2026.

Step Spouse-to-Spouse Procedure Budget Budget Budget Pretest Person must first be eligible based on their own income in the pretest. Determine if the person passes the pretest. Use G-5100, Individual and Couple Noninstitutional Budgets , or G-7000, Prior Coverage , as appropriate. Use the following steps when deeming from an ineligible spouse to the person if eligible as an individual in the pretest. 1 Determine the appropriate income limit. QMB SLMB 2 Determine the nonexempt and non-excludable gross earned and unearned income of the ineligible spouse. Reference E-1700, Things That Are Not Income , E-2440 , Certain Health-Related Payments , E-3170, Census Bureau Wages , E-4300, VA Benefits , E-4318, VA Contracts , E-7200, When Deeming Procedures Are Not Used , and E-7300, When Deeming Procedures Begin . gross earned unearned gross earned unearned gross earned unearned 3 Determine the number of children. Skip to 4a If no ineligible children and countable income is less than the program-specific living allowance allocation. Program-Specific Living Allowance Allocation: Community MEPD $497,CAS $497, QMB $474,SLMB $568, QI-1 $639, QDWI $947. Determine the non-exempt income of the ineligible children. Refer to MEPD references in Step 2. Deduct the program- specific living allowance for each ineligible child reduced by the ineligible child's gross amount of income from the ineligible spouse's countable income. If the child's own income exceeds the allowance, there is no deduction and the child and their income is disregarded in the budget. The living allowance allocations are first deducted from the ineligible spouse's unearned income. If the ineligible spouse does not have enough unearned income to cover the allocation, the balance of the allocation is deducted from the ineligible spouse's earned income. 4a If remaining income of the ineligible spouse, either unearned or earned, is no more than the program- specific living allowance, stop. No income is deemed. 4b Treat the person and ineligible spouse as an eligible couple in the deeming process if remaining income of the ineligible spouse, both earned and unearned, exceeds the program-specific living allowance allocation. Continue with Step 5. 5 Determine person’s monthly gross earned income and monthly unearned income, including the person’s support and maintenance. Because support and maintenance is exempt for the ineligible spouse, use the appropriate companion amount in Appendix XXXI . gross earned unearned gross earned unearned gross earned unearned Combine the remainder of the ineligible spouse's unearned income with the person’s unearned income. Combine the ineligible spouse's earned income with the person’s earned income. 6 Deduct $20 From the combined unearned income. If there is less than $20 unearned income, the remaining portion of the $20 exclusion is applied to earned income. Note: The $20 disregard is not applicable for Special Income Limit cases for Spouse-to-Spouse Deeming, CAS, institutional and Waiver programs. 7 Deduct up to $65 plus half of the remaining earned income from the combined earned income. Note: The earned income exclusion is not applicable for Special Income Limit cases for Spouse-to-Spouse Deeming (CAS, Institutional and Waiver programs). Deduct person’s COLA(s) for Pickle, DAC or Widow or Widowers. Deduct person’s Social Security COLA for January and February of each year if the current countable income exceeds the appropriate QMB, SLMB or QI-1 Income Limit. Remainder is countable income. 8 Compare to the appropriate income limit for an eligible couple . If 1 cent or more unmet need exists, the person is eligible. For the Special Income Limit or the QMB Limit , if the income is no greater than these limits, the person is eligible.

Refer to Appendix XXXI for income, resource and budget amounts. If eligible on individual pretest for QMB but not eligible for QMB in the special deeming eligibility test, re-budget for SLMB or QI-1 if applicable. The minimum income requirement for SLMB or QI-1 does not apply when the applicant is ineligible due to deeming.

(mepd-appendix-xxix)(block-2)Related Policy#

Support and Maintenance, E-8000 Parent-to-Child Noninstitutional Deeming, G-2312 Twenty-Dollar General Exclusion, G-4110 Earned Income Exclusion, G-4120 Special Income Exclusion for COLA Disregard, G-4300 MSPs and Cost-of-Living Adjustments (COLAs), Q-1400 Budget Reference Chart, Appendix XXXI

(mepd-appendix-xxx)Medicaid for the Elderly and People with Disabilities Handbook: Appendix XXX, Medical Effective Dates (MEDs)#

(mepd-appendix-xxx)(block-1)Appendix XXX, Medical Effective Dates (MEDs)#

Revision 26-3; Effective Sept. 1, 2026

Note: This document is effective Jan. 1, 2012.

(mepd-appendix-xxx)(block-2)Community Based#

Type Program MED ME – Pickle Three months prior (3MP) policy applies (Form H1200, Application for Assistance – Your Texas Benefits, file date). ME – Disabled Adult Child 3MP policy applies (Form H1200, Application for Assistance – Your Texas Benefits, file date). ME – Disabled/Early Aged Widow(er) 3MP policy applies (Form H1200, Application for Assistance – Your Texas Benefits, file date). ME – SSI Prior Medicaid coverage automatically begins with the month before the first month of SSI payment for certified SSI clients. The MED may be as early as the first day of the month, two months before the SSI gap month. (SSI Begin Date = Payment Month) The MED may be as early as the three months before the SSI application month for denied SSI applicants. ME – Waivers For waiver eligibility, the effective date for medical assistance is either the first day of the month: of nursing facility (NF), intermediate care facility for individuals with intellectual disabilities or related conditions (ICF/IID); of state supported living center entry if the applicant filed a Medicaid application during that month, then requested a program transfer before being certified, and met all eligibility criteria; or the first day of the month if the applicant meets all Waiver Eligibility Component and Financial Medicaid Eligibility Component criteria. Refer to Section O-1100, Application for Waiver Programs. Notes: Consider potential eligibility three months before the application file date if the individual entered an NF, ICF/IID or state supported living center and then transitioned into a waiver setting before being certified. Refer to Institutional Based section of this appendix. Also, refer to B-6300, Institutional Living Arrangement ; B-7400, Application for Institutional Care ; and J-4310, Determining the Assessment Date for a Home and Community-Based Services Waiver . The MED information for waivers does not apply if the waiver requires Medicaid eligibility before waiver services consideration. For example, Texas Home Living. ME – Community Attendant Use the first day of the month: that the application was filed, if the provider started services during that month; services started, if the application was filed by that date; or that the eligibility decision was made. MC – SLMB MED is the first day of the month that the application is filed if all eligibility factors are met. MED can be the first of any of the three months prior. MC – Qualifying Individuals (QI-1) MED is the first day of the month that the application is filed if all eligibility factors are met. MED can be the first of any of the three months prior. 3MP cannot include the previous calendar year unless the application was filed in the previous year. MC – QMB MED is the first day of the month following the month the case is processed and disposed in the eligibility system unless ensuring continuous QMB. ME – A and D - Emergency MED is the date the emergency condition began, as documented by the practitioner on Form H3038, Emergency Medical Services Certification. The practitioner will also list the emergency condition end date on Form H3038. These are open and close cases.

(mepd-appendix-xxx)(block-3)Institutional Based#

ME – Nursing Facility, ME – State School, ME – Non-state Group Home, ME – State Group Home, ME – State Hospital

Situation Determination Apply and Enter Nursing Facility (NF) in Same Month Must meet 30 consecutive days in the facility. MED is the first day of the month of entry to the facility. Apply in Month following Month of Entry (Prior Months) MED may be the first day of any of the 3MP to the application file date. Use the SSI income limit unless the person enters the facility during the application month. If facility entry occurs in a prior month, use the institutional income limit. Subsequent Month If the person fails the resource test, the MED is the first day of the subsequent month that all eligibility factors are met.

(mepd-appendix-xxx)(block-4)What to do if:#

Situation Determination Applicant enters extended care facility (ECF) section of NF: MED is the first day of the month of entry to ECF. ECF entry establishes medical necessity (MN). Whenever the person moved from ECF or stopped meeting the Medicare care definition of skilled nursing facility, then MN is required. If time in ECF is in any prior months, the MED is the first day of any of the 3MP. Individual enters NF from the community: MED may be the first day of any of the 3MP to the application file date. Use the SSI income limit for financial eligibility purposes if the person was not in the facility for any part of the month. Individual enters facility from the hospital: MED may be the first day of any of the 3MP to the application file date. Use the special income limit for the month of entry to the facility.

(mepd-appendix-xxx)(block-5)Continuous Coverage#

Type Program Time Frame ME – Pickle Continuous coverage is ensured if the application is filed by the end of April or the end of the fourth month after denial. The person must continue to meet eligibility criteria and have unpaid or reimbursable medical bills during this prior time. ME – Disabled Adult Child Continuous coverage is ensured if the application is filed by the end of April or the end of the fourth month after denial. The person must continue to meet eligibility criteria and has unpaid or reimbursable medical bills during this prior time. ME – Disabled/Early Aged Widow(er) Continuous coverage is ensured if the application is filed by the end of April or the end of the fourth month after denial. The person must continue to meet eligibility criteria and has unpaid or reimbursable medical bills during this prior time. QMB Continuous Qualified Medicare Beneficiary (QMB) Program coverage must be ensured, as well as Medicaid coverage. Retroactivity for continuous QMB may be as early as 24 months before the beginning of the current fiscal year, if appropriate. September is considered the start of a fiscal year.

(mepd-appendix-xxxi)Medicaid for the Elderly and People with Disabilities Handbook: Appendix XXXI, Budget Reference Chart#

(mepd-appendix-xxxi)(block-1)Appendix XXXI, Budget Reference Chart#

Revision 26-2; Effective June 1, 2026

(mepd-appendix-xxxi)(block-2)Community-Based Programs Using SSI Limits (Disabled Adult Child, Pickle, Widow or Widowers)#

Income — Effective Jan. 1, 2026, total countable income must be less than the Supplemental Security Income (SSI) federal benefit rate (FBR) with the exclusion of certain increases in Social Security benefits:

Individual — $994

Couple — $1,491

Deeming amount — $497

Resources — Total countable resources must be no more than the limit:

Individual — $2,000

Couple — $3,000

Companion — $3,000

In-Kind Support and Maintenance (Community Living Arrangement)

Effective Jan. 1, 2026:

One-third of the SSI FBR: Individual — $331.33 Couple — $497.00

One-third of the SSI FBR + $20: Individual — $351.33 Couple — $517.00

One-half of the couple 1/3 SSI FBR: Companion — $248.50

One-half of the couple 1/3 SSI FBR + $10: Companion — $258.50

All Living Arrangements

Effective Jan. 1, 2026, the special income exemption for a student’s earned income, regardless of living arrangement, is:

Monthly earnings — $2,410

Annual earnings — $9,730

Related Policy

Student Earnings, E-2220

Medicare Savings Programs (MSP)

Income limits are based on the federal poverty level (FPL) .

Income — Effective March 1, 2026, total countable income must be:

QMB — Not more than 100% FPL: Individual — $1,330 Couple — $1,804 Deeming amount — $474 Medicaid benefits are: Part A premiums Part B premiums Deductibles Coinsurance

SLMB — Greater than 100% FPL, but less than 120% FPL: Individual — $1,330.01 to < $1,596 Couple — $1,804.01 to < $2,164 Deeming amount — $568 Medicaid benefits are: Part B premiums

QI-1 — At least 120% FPL, but less than 135% FPL: Individual — $1,596 to < $1,796 Couple — $2,164 to < $2,435 Deeming amount — $639 Medicaid benefits are: Part B premiums

QDWI — No more than 200% FPL: Individual — $ 2,660 Couple — $3,607 Deeming amount — $947 Medicaid benefits are: Part A premiums

Note: These income limits do not include the $20 disregard for MSP.

Resources — Effective Jan. 1, 2026, total countable resources must be:

QMB, SLMB, QI-1 — No more than the limit: Individual — $9,950 Couple — $14,910

QDWI — No more than twice the SSI resource limit: Individual — $4,000 Couple — $6,000

Medicaid Buy-In (MBI) Program

Income — Effective March 1, 2026:

Income eligibility is based on earnings.

Countable earned income must be less than the limit: 250% of FPL — $3,325

Resources — Total countable resources must be no more than the limit of $2,000.

MBI Monthly Premiums: Countable Unearned Income Minus (−) SSI FBR of $994 Plus (+) Earned Income Premium

Unearned Income Premium Countable Unearned Income Minus (−) SSI FBR $994

Earned Income Premium

Countable Earned Income Based on FPL Range

FPL Range Earned Income Premium at or below 150% FPL Less than or equal to $1,995 $0 150%–185% of FPL More than $41,995 up to and including $2,461 $20 >185%–200% of FPL More than $2,461 up to and including $2,660 $25 >200%–250% of FPL More than $2,660 up to and including $3,325 $30 >250% of FPL More than $3,325 $40

If the unearned income premium amount plus the earned income premium amount equals or exceeds $500, then the total monthly premium stays at $500.

Medicaid Buy-In for Children (MBIC) Program

Resources — No resource test for MBIC.

Income — Effective March 1, 2026:

MBIC income exclusion — $85 plus one-half of the remaining income.

Eligibility — No more than 150% FPL based on family size.

These amounts do not include the MBIC income exclusion.

FPL Amounts for Income Eligibility

Family Size 150% FPL 1 $1,995 2 $2,705 3 $3,415 4 $4,125 5 $4,835 6 $5,545 7 $6,255 8 $6,965

Ineligible sibling exclusion amount (150% FPL x 2 + $85) = $4,075

FPL Amounts for Premium Determination

Family Size 150% FPL 200% FPL 300% FPL 1 $1,995 $2,660 $3,990 2 $2,705 $3,607 $5,410 3 $3,415 $4,554 $6,830 4 $4,125 $5,500 $8,250 5 $4,835 $6,447 $9,670 6 $5,545 $7,394 $11,090 7 $6,255 $8,340 $12,510 8 $6,965 $9,287 $13,930

MBIC Premiums — No Employer-Sponsored Insurance (ESI)

Family Income Family of 1 or 2 Premium Amount Family of 3 or More Premium Amount At or below 150% FPL $0 $0 151–200% FPL $90 $115 201–300% FPL $180 $230

MBIC Premiums — ESI with State-Paid Health Insurance Premium Program (HIPP)

Family Income Family of 1 or 2 Premium Amount Family of 3 or More Premium Amount At or below 150% FPL $0 $0 151–200% FPL $25 $35 201–300% FPL $50 $70

MBIC Premiums — ESI and No State-Paid HIPP

No MBIC premium.

Medicare Premiums

Effective Jan. 1, 2026

Part A Premium (Hospital Insurance):

$0 — Most people do not pay a monthly Part A premium because they or a spouse have 40 or more quarters of Medicare-covered employment.

$565 — Standard Medicare Part A monthly premium cost — The monthly Part A premium for people who are not otherwise eligible for premium-free hospital insurance and who have less than 30 quarters of Medicare-covered employment.

$311 — Reduced Medicare Part A premium — The monthly Part A premium for people who have 30–39 quarters of Medicare-covered employment.

Part B Premium (Medical Insurance):

$202.90 — 2026 standard Medicare Part B monthly premium.

Staff must use the Medicare Part B amount as verified in the State Online Query (SOLQ).

Part B-ID Premium (Immunosuppressive Drugs only)

$121.60 – 2026 Standard Medicare Part B-ID monthly premium.

Related Policy

Medicare Part B Premium, H-1800

Community Attendant Services (CAS)

Income — Effective Jan. 1, 2026, total countable income must be no more than the special income limit:

Individual — $2,982

Couple — $5,964

Resources — Total countable resources must be no more than the limit:

Individual — $2,000

Couple — $3,000

Institutional Living Arrangement

When people are living in a Medicaid certified long-term care facility or receiving Home and Community Based Waiver services.

Individual or Couple Eligibility Budget

Special income limit — The special income limit for a person is equal to or less than 300% of the SSI federal benefit rate.

Income — Effective Jan. 1, 2026, total countable income must be no more than the special income limit:

Individual — $2,982

Couple — $5,964

Resources —Total countable resources must be no more than the limit:

Individual — $2,000

Couple — $3,000

Substantial home equity — $752,000

Transfer of assets (TOA) divisor — $262.37 daily rate effective Sept. 1, 2025.

Note: The transfer of assets daily rate is reviewed every other year.

Co-Payment

Individual or Couple Co-Payment Budget:

Personal Needs Allowance (PNA) $75 for a nursing facility recipient $75 plus the Protected Earned Income (PEI) amount for a recipient in an ICF/IID facility $85 for a recipient in foster care or assisted living $2,901 for an HCBS waiver recipient

Guardianship Fees — Varies

Dependent Allowance — $967

Incurred Medical Expenses — Varies

Deduction for Home Maintenance — Up to $967

Spousal Co-payment Budget:

PNA $75 for a nursing facility recipient $75 plus the PEI amount for a recipient in an ICF/IID facility $85 for a recipient in foster care or assisted living $2,901 for an HCBS waiver recipient

Guardianship Fees — Varies

Minimum Monthly Maintenance Needs Allowance (MMMNA) also known as Spousal Allowance — $4,066.50

Spousal Impoverishment Dependent Allowance — $2,643.75 effective July 1, 2025

Incurred Medical Expenses — Varies

Calculation of the Spousal Protected Resource Amount (SPRA):

SPRA is the greater of: one-half of the couple's combined countable resources; or $32,532, the minimum resource amount set by federal law; but cannot exceed $162,660, the maximum resource amount set by federal law.

Income-first MMMNA for SPRA expansion also known as Spousal Allowance — $4,066.50

(mepd-appendix-xxxi)(block-3)Related Policy#

Personal Needs Allowance (PNA), H-1500 Guardianship Fees, H-1550 Dependent Allowance, H-1600 Deduction for Home Maintenance, H-1700 Incurred Medical Expenses, H-2000 Spousal Impoverishment Dependent Allowance, J-7400

(mepd-appendix-xxxiii)Medicaid for the Elderly and People with Disabilities Handbook: Appendix XXXIII, Medicaid for the Elderly and People with Disabilities Information#

(mepd-appendix-xxxiii)(block-1)Appendix XXXIII, Medicaid for the Elderly and People with Disabilities Information#

Revision 21-1; Effective March 1, 2021

(mepd-appendix-xxxiii)(block-2)Introduction#

Assistance is available to help pay for medical care and supportive services for people with limited income and resources. The following information explains some of the requirements used to determine if you are eligible for help and what must be done to get help.

If you are interested in getting Medicaid to pay for medical and supportive services, you need to file an application. Depending on your income, you will file an application with either the Social Security Administration for Supplemental Security Income (SSI) or with the Texas Health and Human Services Commission (HHSC). If the Social Security Administration determines you are eligible for SSI, you will also be eligible for Medicaid without having to file a separate application with HHSC.

At HHSC, eligibility staff are responsible for determining the financial eligibility for Medicaid. This Medicaid assistance is available for those who do not have SSI and need care:

in a nursing facility;

in an intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID);

in an institution for mental diseases (IMD); or

through a home and community-based waiver program (these programs offer services and supports to help you live in the community).

Depending on your income, assistance is also available to help pay for your Medicare premiums (Part A, Part B or both), deductibles and coinsurance costs through a Medicare Savings Programs, Qualified Medicare Beneficiary (QMB), Specified Low-Income Medicare Beneficiary (SLMB) or Qualifying Individuals-1 (QI-1).

You or your representative must complete an application for Medicaid and furnish the proof needed to make an eligibility determination. HHSC will determine your eligibility for Medicaid based on the information you provide on the application, documents you send in, and information that you orally explain.

By federal law, HHSC must also use your Social Security number to compare information with other state and federal agencies, such as the Internal Revenue Service, Social Security Administration, Texas Workforce Commission, and any others to ensure that your benefits are correctly determined. If you meet all eligibility requirements, HHSC is required to completely review your circumstances at least once a year to make sure you are still eligible for help.

You have the responsibility to let HHSC know, within 10 days, of any changes in your circumstances, including changes in your address and living arrangements, your income and resources, and your private health insurance premium amounts.

(mepd-appendix-xxxiii)(block-3)Non-Financial Eligibility#

Age and Disability — You must be at least 65 or older or , if under 65, you must get Social Security or Railroad Retirement disability benefits. If you are not getting a disability benefit, HHSC will complete a disability determination using your medical, education, and work history information.

Citizenship — You must be a U.S. citizen or a qualified legal alien. Qualified legal aliens include those who have been lawfully admitted for permanent residence, active-duty military or honorably discharged veterans (or the spouses or dependent children of veterans), certain refugees or asylees, and certain people for whom deportation has been deferred. Unless you already have Medicaid or Medicare, a U.S. public birth certificate showing birth in one of the 50 states, the District of Columbia, Puerto Rico (if born on or after Jan. 13, 1941), Guam (on or after April 10, 1899), the Virgin Islands of the U.S. (on or after Jan. 17, 1917), American Samoa, Swain’s Island or the Northern Mariana Islands (after Nov. 4, 1986) may be necessary to prove your citizenship. You may also need proof of earning 40 quarters of Social Security credit or proof of 10 years of verifiable work credit to prove your alien status.

Residence — You must be a resident of the U.S. and Texas.

Medicare Savings Programs — You must be entitled to Medicare Part A for QMB, SLMB and QI-1. You will need a Medicare card, award letter, or some other document from the Social Security Administration as proof of your Medicare Part A entitlement.

Medical Necessity, Level of Care for Nursing Facility, ICF/IID and Waiver Programs — Your need for medical care available in a Medicaid facility or a Medicaid waiver program will need to be determined.

30 Consecutive Days in an Institution — This applies after admission to a nursing facility, ICF/IID or IMD (if 65 or older). If you want help paying for care in a facility, you must stay in a facility that has a Medicaid contract for 30 consecutive days. If you must go to the hospital before the end of 30 days, but return directly to a Medicaid facility, the hospital stay counts toward the 30 days. If you meet all other eligibility criteria from the day you are first admitted to a facility, Medicaid can pay for care beginning the day of admission, once 30 days has passed.

(mepd-appendix-xxxiii)(block-4)Income#

HHSC must consider your income from all sources. Gross income is usually used for the eligibility determination. Therefore, when comparing your income to the income limit for a program, deductions that are withheld from your income before you get it may be included.

If you get your income less frequently than monthly, it may or may not be countable. An example of income that may not be countable is a small amount of interest you receive quarterly.

Certain types of income may be exempt or excluded for the eligibility determination. An example of exempt income is a refund of federal income taxes relating to the earned income tax credit a person receives from the Internal Revenue Service (IRS).

(mepd-appendix-xxxiii)(block-5)Proof of Income#

HHSC requires proof of income and deductions from income, such as award letters, check stubs from pension checks, check stubs from mineral rights payments, amortization schedules, bank statements listing interest or dividend payments, rent receipts (tax, insurance, and repair expense receipts), and copies of checks.

It may take some time to gather all the needed proof and more proof may be needed to verify your eligibility. Any of the above items that you send in with an application may speed up the eligibility decision.

If you are determined to be eligible, proof of your income may also be needed whenever there is a change in the amounts and at least once a year when your circumstances must be completely reviewed.

(mepd-appendix-xxxiii)(block-6)Resources#

Resources are things that you own or are buying. The resources of both you and your spouse must be reported, regardless if the resources are owned by your or your spouse individually or together. The total value of resources that must be counted cannot exceed certain resource limits. Resource values are determined as of 12:01 a.m. on the first day of the month(s) that eligibility is determined. Some resources may not be counted.

For a waiver program, resources of a parent(s) are not considered.

Examples of Excluded Resources — The following are examples of some resources that HHSC does not count when determining eligibility:

Homestead — If you, your spouse, or a dependent relative live in the home, the value of the home is not counted. Absence from a homestead may result in loss of its homestead status and exclusion unless you have an intent to return. If you have an intent to return to a homestead in another state, you do not meet the Texas residency requirement. If the value of your home exceeds a certain amount, you may not qualify for payment of nursing facility or waiver services.

Vehicle — One vehicle is excluded, regardless of value. If your household has more than one person and the additional member of the household requires an additional vehicle for transportation to and from work, the additional vehicle is excluded for that member for work transportation. If your household has more than one person and there is an additional member of the household who requires disability accessible transportation, an additional vehicle is excluded if the vehicle is specially equipped for that additional member of the household. For all other vehicles, HHSC counts the current market value or, if you still owe on the vehicle, the current equity value as a resource.

Life Insurance — Life insurance policies that you own with a total face value of $1,500 or less per insured person are excluded. If the face value of all policies per person exceeds $1,500, the cash value is counted as a resource. Term insurance is excluded.

Burial Spaces —All burial spaces are excluded, unless you purchased them as an investment, in which case the equity value is counted.

Burial Funds —Up to $1,500 of the funds identified for burial may be excluded, if kept separate from other resources. This exclusion is only for you and your spouse. This amount is reduced by the face value of any excluded life insurance and the value of any irrevocable arrangements for the individual's burial.

Examples of Countable Resources — The following are examples of resources you may own that are counted when determining eligibility:

Checking accounts, savings accounts, certificates of deposit, money market accounts, individual retirements accounts (IRAs), stocks, bonds, land, lots or houses (other than homestead), and oil, gas, and mineral rights.

Prepaid Burial Contracts — Prepaid burial contracts may or may not be excluded depending on the terms of the contract, how the contract is paid, ownership of life insurance, and the value of any other burial arrangements you own or another person owns that is for you.

Other resources may or may not be countable depending on ownership and the use of items. Examples are antiques, jewelry, livestock, promissory notes, loans, property agreements, annuities, and trusts.

(mepd-appendix-xxxiii)(block-7)Spousal Impoverishment#

The term "spousal impoverishment" is used to identify a federal law that allows a spouse still living at home to keep additional income and resources so they can continue to live independently.

If you apply for Medicaid in a nursing facility, ICF/IID, IMD or for a waiver program and have a spouse living in the community, a Spousal Protected Resource Allowance (SPRA) is determined for your spouse. The SPRA is determined as of the month you are admitted to a facility or the month you apply for waiver services.

The value of all resources owned by you and your spouse is combined and divided in half. The value of a homestead, one vehicle, personal goods, and certain burial funds for both you and your spouse is not included in the resource total. Your spouse who continues to live in the community is allowed to keep up to half of the total countable resources subject to the minimum and maximum allowable amounts, which change annually.

The amount of resources not protected for your spouse is your countable resource amount. Your countable resources cannot exceed the $2,000 resource limit to be eligible for medical assistance.

The SPRA exclusion ends at the first annual redetermination of your circumstances. At that time, all resources that remain in your name are considered in determining eligibility. Your total countable resources cannot exceed the $2,000 resource limit for you to stay eligible for medical assistance.

(mepd-appendix-xxxiii)(block-8)Proof of Resources#

Proof of the ownership and value of resources is required. Examples of proof include bank statements, copies of notes, stocks, bonds, property deeds, loans, mortgages, insurance policies, prepaid burial contracts, annuities, letters from appraisers, and trust instruments.

It may take some time to gather all the needed proof and additional proof may be needed to determine the resource amount for specific months. Any of the above items that you send in with your application may help to speed up the eligibility decision. Proof of your resources will also be needed whenever there is a change in the ownership or the value of items you own and at least once a year when your circumstances must be completely reviewed.

(mepd-appendix-xxxiii)(block-9)Transfer of Assets#

Giving away things you own for no compensation or refusing to accept income or reducing income you could receive may result in a penalty of non-payment for nursing facility services, ICF/IID facility services, or ineligibility for waiver program services or state supported living center services.

For income and resources that you transfer, the look-back time is up to 60 months before you apply for institutionalization or waiver services.

(mepd-appendix-xxxiii)(block-10)Cost of Care Responsibility#

If you are eligible for Medicaid in a nursing facility, ICF/IID facility, IMD (if 65 or older) or for waiver program services, you may have to pay toward the cost of your care. This is referred to as your copayment. From your total income, you are allowed to keep a standard personal needs allowance. The amount of this allowance is different for different programs. Certain medical expenses you may pay, such as general health insurance premiums, Medicare premiums, deductibles and coinsurance, certain dental fees or prescription drug costs, may also be deducted. HHSC staff will calculate your copayment and notify you and your case manager or your service provider of the amount. The arrangement for your portion of the payment is between you, your case manager or the service provider. Medicaid payments for your care will be made directly to the service provider.

To access the Medicaid eligibility rules on the Internet, follow the steps below:

Go to www.sos.state.tx.us/tac .

Under Points of Interest , select View the current Texas Administrative Code .

A menu will appear entitled Texas Administrative Code: Titles . Select Title 1, Administration .

Select Part 15, Texas Health and Human Services Commission .

Select Chapter 358, Medicaid Eligibility for the Elderly and People with Disabilities .

Select the subchapter you desire.

This information is a general overview about Medicaid financial eligibility determinations and may not specifically cover your situation. The information is dated because the eligibility policies may be changed by federal, state, and agency rules. If you have questions about your situation, please contact 211.

(mepd-appendix-xxxiii)(block-11)Current Income and Resource Limits#

Current budget limits are available in Appendix XXXI , Budget Reference Chart, of the Medicaid for the Elderly and People with Disabilities Handbook.

(mepd-appendix-xxxvi)Medicaid for the Elderly and People with Disabilities Handbook: Appendix XXXVI, QITs and MEPD Information#

(mepd-appendix-xxxvi)(block-1)Appendix XXXVI, QITs and MEPD Information#

Revision 26-1; Effective March 1, 2026

The Texas Health and Human Services Commission (HHSC) offers this information. It helps people applying for Medicaid and their attorneys. It provides basic information to use a qualified income trust (QIT), sometimes referred to as a Miller Trust, to meet Medicaid for the Elderly and People with Disabilities ( MEPD) eligibility requirements. There is a link to a model instrument at the end of this document. It is an example of a QIT that meets MEPD requirements when properly completed. This form meets the basic MEPD requirements for a QIT, but it is not the only acceptable QIT form. It may have consequences beyond Medicaid eligibility that a person should consider.

HHSC attorneys are prohibited from giving legal advice to the public. HHSC staff, supervisors and other HHSC non-attorneys are prohibited from recommending specific actions to become eligible for Medicaid. Doing so may constitute the unauthorized practice of law.

This information is not intended as legal advice. People seeking information on the legal consequences of these documents should consult an attorney of their choice.

HHSC only reviews trust documents related to the processing of a Medicaid application. The review by HHSC is limited to a determination that the trust meets the requirements for a Medicaid QIT.

People with low or limited income may be able to get legal counsel through their local legal aid office, local area agency on aging, local bar association, National Academy of Elder Law Attorneys, lawyer referral service, Advocacy Inc. or the State Bar of Texas.

(mepd-appendix-xxxvi)(block-2)Background#

Eligibility for Medicaid institutional or home and community-based waiver services in Texas includes a requirement that the person’s countable income not exceed the special income limit. The special income limit for a person is equal to or less than 300 percent of the full individual Supplemental Security Income (SSI) benefit rate. The special income limit for a couple is twice the special income limit for an individual. Effective Jan. 1, 2026, the monthly special income limit is $2,982 for an individual and $5,964 for a couple.

The current estimate of the average daily cost of a private pay nursing home stay in Texas is $262.37. This amount is more than the individual special income limit.

Texas residents who need nursing home care and have monthly income above the special income limit but below the private pay cost of the care may have insufficient funds to pay for the needed care. In 1993, Congress addressed this problem by amending Section 1917 of the Social Security Act which provides for an income diversion trust or QIT. Refer to 42 USC Section 1396p(d)(4)(B). The proper use of a QIT allows a person to legally divert income into a trust, after which the income is not counted to determine Medicaid eligibility for institutional or home and community-based waiver services.

(mepd-appendix-xxxvi)(block-3)Caution#

Do not confuse a QIT with other types of trusts often used for the receipt of Medicaid or other public benefits. This information does not apply to other types of trusts, such as a special needs trust. A special needs trust may be created for a person with a disability under 65 who wants to shelter assets to become or stay eligible for Medicaid or other public benefits. HHSC does not count income that is properly diverted through a QIT to determine Medicaid eligibility for institutional or home and community-based waiver services. This income is counted when determining eligibility for other Medicaid benefits, such as:

non-institutional assistance other than home and community-based waiver services; or

Medicare Savings Programs.

The income may count to determine eligibility for non-Medicaid public benefits programs.

Although the use of a QIT can overcome the special income limit for Medicaid eligibility, a QIT will not address other eligibility requirements for institutional and home and community-based waiver services, such as:

citizenship;

residency;

medical necessity; and

the person’s countable resources.

A person with more than $2,000 in countable resources is not eligible for benefits. The use of a QIT does not affect this resource eligibility requirement.

This information is based in part on informal guidance by the federal Centers for Medicare & Medicaid Services (CMS). CMS has not adopted any federal regulations relating to QITs. Therefore, CMS' guidance and interpretations could change without advance public notice or opportunity for advance public comment.

(mepd-appendix-xxxvi)(block-4)Necessity#

The special income limit applies only to a person’s countable income . To determine the need for a QIT, determine if the income is countable for the purposes of Medicaid eligibility if the person's income will stay the same after approval for Medicaid. For example, certain types of Veterans Affairs (VA) benefits do not count toward eligibility for Medicaid. Also, some types of income, such as VA pensions, are subject to an automatic reduction when a person living in a Medicaid-certified nursing facility becomes eligible for Medicaid. In addition, when retirement income was legally divided between spouses through a Qualified Domestic Relations Order and each spouse gets a check in their own name, the income of one spouse is not counted for the eligibility determination of the other spouse. HHSC follows a name on the check rule to determine the countable income of a person applying for nursing home Medicaid.

(mepd-appendix-xxxvi)(block-5)Characteristics of the Trust#

Only the person’s pension, Social Security and other income may be placed in a QIT. The person’s resources may not be deposited into a QIT account. Since the QIT has no corpus as that term is generally understood in the trust field, the need for much of the standard trust language about management of the trust principal is eliminated, and the language of the written trust instrument may be shortened accordingly. A person applying for Medicaid may divert all their income into a QIT, or if they have income from multiple sources, divert only the income from certain sources. All income received from the source must go into the QIT.

VA aid and attendance benefits, housebound allowances, and reimbursements for unusual or continuing medical expenses are exempt from both eligibility and co-payment. If a person deposits these types of payments into a QIT account, the income is countable for the co-payment budget. If a person receives a VA pension that includes aid and attendance benefits, housebound allowances, or reimbursements for unusual or continuing medical expenses, the person may separate the aid and attendance benefits, housebound allowances, or reimbursements for unusual or continuing medical expenses from the VA pension before depositing the VA pension into the QIT account. Aid and attendance benefits, housebound allowances, or reimbursements for unusual or continuing medical expenses are not income for Medicaid eligibility determinations.

The QIT must be irrevocable. Per CMS, a trust instrument that indicates the trust is irrevocable but allows the trust to be revoked through court action does not meet the irrevocability requirement.

The QIT instrument may provide for successor or co-trustees, waive bond, and incorporate the Texas Trust Act provisions for the powers of the trustees. The statutory authority for a QIT is silent on who may serve as the trustee. But, HHSC recommends that the beneficiary not be a trustee. The beneficiary may lose Medicaid eligibility if all the trust requirements are not met.

The QIT instrument must have a reversion clause. The clause says that at the death of the trust beneficiary, the state of Texas is paid the remaining funds from the trust account. The amount is up to the full amount of Medicaid assistance provided to the beneficiary and not repaid in another way. Payments made to HHSC as the residuary beneficiary should be in whole dollar amounts and by cashier's check, money order or personal check. These payments are receipted on Form H4100, Money Receipt .

A QIT instrument must require that the trustee pay:

a monthly personal needs allowance to the beneficiary;

court-ordered guardianship fees;

a sum enough to give a minimum monthly maintenance needs allowance to an existing spouse of the beneficiary; and

the cost of medical assistance given to the beneficiary, from the funds remaining after the beneficiary’s death.

The income must be deposited into the QIT account the same month it is received. The trustee must make distributions from the QIT account by the last day of the following month.

HHSC does not allow deductions for trust administration costs when determining the amount of the beneficiary's income that must be applied to the cost of the beneficiary's medical assistance. The amount that must be applied to the cost of the beneficiary's medical assistance is based on the beneficiary's total income, including any income that is not diverted to the QIT. If there are funds in the QIT account after the above distributions are made, the funds may be applied to the cost of trust administration.

Income paid from the QIT account to purchase institutional services, home and community-based waiver services, or other medical services for the beneficiary is not countable income for eligibility purposes. Income paid from the QIT account directly to the beneficiary or otherwise spent for their benefit is countable income for eligibility purposes.

(mepd-appendix-xxxvi)(block-6)Establishing a Bank or Other Financial Account as the QIT Account#

In addition to a completed, signed and dated trust instrument that meets the HHSC determined QIT requirements, a trust account must be set up. A trust account is a bank account or an account at another financial institution such as a credit union used to deposit the income from the sources listed in the QIT instrument. As noted above, the QIT account must only have income and cannot contain resources. The bank account must only be used to deposit the income from the sources listed in the QIT instrument.

A person may use an existing account only if the specified QIT income is deposited into the account. A new account may be necessary if the existing account includes money from sources other than the QIT income. A new account is also necessary if the existing account is a joint account and other account holders make deposits and withdrawals from the account using the joint account holders' income and resources. If a joint account holder is on the account for convenience and does not use the account for their personal use, the account may be used for the QIT.

Some banks may require small deposits, such as $10 to $20, to open a new account. HHSC allows a small amount of the beneficiary's money or money from another person for this initial deposit. The money that a bank requires as a deposit to open a new account is not counted as a resource or income to the beneficiary.

After the trust account is opened, only the beneficiary's income may be directed to the trust account. If sources of income other than those identified in the QIT instrument are deposited into the QIT account, but the entire source is deposited and the countable income remains within the special income limit, eligibility is not affected. Any deposits made to the QIT account from the person’s resources will result in the QIT account becoming a countable resource. Any deposits to the QIT account from another person may be countable income. This may result in all deposits to the account being countable income and the bank account becoming a countable resource.

(mepd-appendix-xxxvi)(block-7)Effective Date#

HHSC disregards income for Medicaid eligibility purposes the first month that:

a valid written QIT trust instrument is signed and properly executed;

a QIT account with the beneficiary's Social Security number is set up; and

enough of the beneficiary's income is placed into the QIT account to reduce any remaining income below the special income limit.

The QIT may be set up with any or all sources of a beneficiary's income, but an entire income source must be deposited. In some cases, the entire source(s) may not be available to open the QIT account because part of the person’s monthly income may have been used to pay expenses before the date the QIT is established. For the initial month, a partial deposit of the income the QIT is established. It will not invalidate the QIT and the entire amount of the income source(s) will be disregarded from countable income for that month. The entire amount of the income source(s) for the established QIT must be deposited into the QIT account in all later months or the QIT is considered invalidated.

These actions may occur before the beneficiary applies for Medicaid. If the person has set up a qualifying QIT, the effective date of the income disregard may be up to three months before the application file date if all other program eligibility requirements are met.

(mepd-appendix-xxxvi)(block-8)Transfer of Assets#

Transfer of assets refers to the general prohibition against a person applying for or receiving Medicaid from transferring assets without compensation. A transfer of assets may result in a penalty period for Medicaid payment for institutional care or ineligibility for Medicaid.

Income that is diverted to a QIT is not a transfer of assets when used for payment of institutional services or home and community-based waiver services for the beneficiary. Any distributions to the recipient's spouse and allowable payments for trust administration as described above are not considered a transfer of assets. Distributions from the QIT that are not made to or for the benefit of the beneficiary or their community-based spouse are considered a transfer of assets.

Also, if the trustee fails to make distributions from income deposited into the trust account in the month of receipt by the end of the following month, such failure to timely distribute the income is considered a transfer of assets.

Sample QIT (PDF)

(mepd-appendix-xxxvii)Medicaid for the Elderly and People with Disabilities Handbook: Appendix XXXVII, Master Pooled Trust and Medicaid Eligibility Information#

(mepd-appendix-xxxvii)(block-1)Appendix XXXVII, Master Pooled Trust and Medicaid Eligibility Information#

Revision 16-3; Effective September 1, 2016

This information assists Medicaid applicants and their attorneys in gaining a basic understanding of the Master Pooled Trust. The Texas Health and Human Services Enterprise attorneys are prohibited from providing legal advice to the public. The only circumstances under which legal staff will review trust documents is when HHSC agency staff have questions about a trust that has been submitted along with a Medicaid application.

(mepd-appendix-xxxvii)(block-2)Background#

The Omnibus Budget Reconciliation Act of 1993 (COBRA 93), 42 USC 1396(d)(4)(c), allows nonprofit corporations such as the Arc of Texas to establish and manage a pooled trust for the benefit of individuals with disabilities. Pooled trust provisions are found in 1917(d)(4)(c) of the Social Security Act. A pooled trust:

contains the assets of individuals with disabilities;

maintains for each beneficiary a separate subaccount established by the disabled individual, parent/grandparent/guardian, or a court from the disabled individual's funds;

is managed by a nonprofit association that pools the subaccounts for management/investment purposes; and

includes a provision that, to the extent that amounts remaining in the individual's account at the individual's death are not retained by the trust, the state is reimbursed in an amount equal to the total amount Medicaid paid on the individual's behalf.

(mepd-appendix-xxxvii)(block-3)Caution#

This information applies only to an individual who meets the definition of disabled according to the Social Security Administration. Based on a medical determination, an individual is considered disabled if they are unable to engage in any substantial, gainful activity because of a medically determinable physical or mental impairment that can be expected to result in death or has continued or can be expected to continue for at least 12 months. A child who is not engaged in substantial, gainful activity is considered disabled if the child suffers from any medically determinable physical or mental impairment of comparable severity to which would preclude an adult from engaging in substantial, gainful activity.

(mepd-appendix-xxxvii)(block-4)Transfer of Assets#

Transfer-of-assets policy does not apply when a pooled trust is established for the benefit of an individual under age 65. Transfer-of-assets policy does apply when a pooled trust is established or when contributions are made to the pooled trust for an individual who is age 65 or older. Transfer-of-assets policy applies to individuals of any age when an individual's assets in the pooled trust are transferred to another party.

(mepd-appendix-xxxvii)(block-5)Necessity#

The principal purpose and objective of this trust is to provide a system for the management, investment, and disbursement of trust assets to promote a beneficiary's comfort and happiness by providing supplemental care. It is not the purpose nor objective of this trust to provide for or to make expenditures for beneficiary's basic maintenance, support, medical, dental, or therapeutic care, or any other appropriate care or service that may be paid for or provided by other sources. It is not the trust's purpose or objective to provide disbursements for the support of any beneficiary.

(mepd-appendix-xxxvii)(block-6)Characteristics of the Trust#

Disbursements for "special needs" or "supplemental needs" or "supplemental care" shall mean nonsupport disbursements and shall not include cash to the beneficiary or payments for food, clothing or shelter. It is not the intention to displace public or private financial assistance that may otherwise be available to any beneficiary. The trustee shall make disbursements only for the supplemental needs as directed by the manager within the manager's sole discretion. The trust is irrevocable upon acceptance of assets by the trustee. A separate trust subaccount shall be maintained for each beneficiary.

(mepd-appendix-xxxvii)(block-7)Disbursements#

The assets in the trust are to be used only for supplemental needs of the beneficiary and shall not include cash to the beneficiary or payments for food, clothing or shelter. Distributions of income or principal from the trust for medical and social purposes are not counted as income. Distributions to the beneficiary of cash or payments for food, clothing and shelter will be treated as income to the beneficiary.

(mepd-appendix-xxxvii)(block-8)Reporting Procedures#

The primary representative of the subaccount is responsible for reporting the establishment of a master pooled trust subaccount. The pooled trust manager maintains records of each disbursement for each subaccount. Medicaid eligibility specialists request records of disbursements made for the beneficiary as part of the eligibility determination process.

Examples of pooled trusts include:

The ARC of Texas Master Pooled Trust, established in 1997; and

the Declaration of Trust for the Travis County Master Trust; Founders Trust Company, Trustee, adopted by decree of the District Court of Travis County, Texas, 201st Judicial District, effective Aug. 1, 1993.

(mepd-b-2500)Medicaid for the Elderly and People with Disabilities Handbook: B-2500, Explaining Policy vs. Giving Advice#

(mepd-b-2500)(block-1)B-2500, Explaining Policy vs. Giving Advice#

Revision 09-4; Effective December 1, 2009

Explaining policy is appropriate. The law requires that Medicaid rules, policies and procedures be freely available to the public. The rules governing MEPD are contained in the Texas Administrative Code (TAC), Title 1, Part 15, Chapters 358, 359 and 360. This handbook also contains the MEPD rules, as well as policies, procedures and examples. Both the TAC and MEPD Handbook are available online. MEPD eligibility specialists act properly in explaining the rule or policy that applies to an applicant's or recipient’s situation, and in referencing the applicable rule or handbook sections.

Giving advice is contrary to HHSC policy. Giving advice includes suggesting options for how to become eligible or how to avoid Medicaid estate recovery, as well as expressing any opinion of what is preferable or more advantageous to the applicant or recipient. Giving advice is contrary to HHSC policy because it:

usually constitutes the unauthorized practice of law (which can subject the eligibility specialist to legal penalties);

encroaches on the contractual relationship that may exist between the applicant or recipient and attorney or financial advisor; and

can subject the eligibility specialist to personal liability for giving advice that is incorrect or that fails to take into account issues other than eligibility (attorneys and financial planners take into account other issues, such as tax laws, in giving estate planning advice relating to Medicaid eligibility).

The approach taken by MEPD eligibility specialists should be to explain policy but not to make recommendations. If an MEPD eligibility specialist is asked for advice, an appropriate response would be to provide the policy that applies to the situation, and to otherwise decline the request. The MEPD eligibility specialist should explain that agency policy prohibits giving advice, and may suggest that the applicant or recipient seek the assistance of an attorney or other estate planning professional of their own choosing.

(mepd-b-2500)(block-2)Excess Income#

See Appendix XVI , Documentation and Verification Guide, and Appendix XXXVI , Qualified Income Trusts (QITs) and Medicaid for the Elderly and People with Disabilities (MEPD).

If an applicant is income ineligible in an institutional living arrangement, Appendix XXXVI may be shared with applicants and their representatives to assist them in understanding the purpose of and requirements for a QIT.

To prevent allegations that MEPD staff are engaging in the unauthorized practice of law, the following instructions are provided. Use the instructions on the chart regarding the appropriate actions to take and the actions to avoid.

(mepd-b-2500)(block-3)MEPD Staff#

May May Not Provide applicants or their representatives with a copy of Appendix XXXVI for informational purposes only. Tell applicants or their representatives that they need a QIT. Provide applicants or their representatives with applicable policy and procedures. Recommend specific actions applicants or their representatives should take to become eligible for Medicaid. Refer applicants or their representatives to the following allowable referral list: local legal aid office, local Area Agency on Aging, National Academy of Elder Law Attorneys, local bar association or lawyer referral service, Advocacy Inc., or State Bar of Texas for a list of attorneys who practice elder law in the area. Tell applicants or their representatives whether or not they must have an attorney to establish a QIT. Recommend that an applicant or representative consult with a specific attorney or organization. (See allowable referral list.) Speak with their supervisor or regional services attorney about any questions they have regarding the use of Appendix XXXVI. Recommend that an applicant or representative call an HHSC attorney for legal advice.

(mepd-b-2500)(block-4)Excess Resources#

See Appendix XVI , Documentation and Verification Guide.

If excess resources can be designated as burial funds, allow the individual the opportunity to do so. See Section F-4227 , Burial Funds.

If a person is determined ineligible because of excess funds in a joint account, allow an opportunity to disprove the presumed ownership of all or part of the funds. The person also must be allowed to disprove ownership of joint accounts that currently do not affect eligibility but may in the future. See Section F-4121 , Joint Bank Accounts.

(mepd-b-2600)Medicaid for the Elderly and People with Disabilities Handbook: B-2600, Medicaid Estate Recovery Program Notification Requirements#

(mepd-b-2600)(block-1)B-2600, Medicaid Estate Recovery Program Notification Requirements#

Revision 18-1; Effective March 1, 2018

Medicaid Estate Recovery Program (MERP) is not part of the eligibility determination process for Medicaid.

MERP recovers from a Medicaid recipient’s estate the cost of Medicaid assistance paid for an individual who:

1) was age 55 or older at the time Medicaid services were received; and 2) initially applied for certain types of long-term care (LTC) services on or after March 1, 2005.

Individuals whose estate may be subject to MERP recovery include:

an applicant for a Medicaid program that covers these LTC services; or

a recipient who requests a change to a Medicaid program that covers these LTC services.

Individuals applying for or receiving these LTC services must be informed about MERP.

A signed Form 8001 , Medicaid Estate Recovery Program Receipt Acknowledgement, or documentation the Form 8001 was provided, must be in the case record of each applicant whose estate is subject to MERP recovery.

(mepd-b-2600)(block-2)B-2610 Types of MEPD Groups Subject to MERP#

Revision 18-1; Effective March 1, 2018

On March 1, 2005, Texas implemented MERP in compliance with federal Medicaid and state laws. The program is managed by HHSC. Under this program, the state may file a claim against the estate of a deceased Medicaid recipient who: 1) was age 55 or older when Medicaid services were received; and 2) first applied for certain long-term care services and supports on or after March 1, 2005. The most complete, current and accurate source of information regarding MERP is the HHS website: Medicaid Estate Recovery Program . MERP Claims include the cost of Medicaid assistance paid for the following services:

nursing facilities;

intermediate care facilities for individuals with an intellectual disability or related conditions (ICF/IID), which include state supported living centers;

Home and Community-Based Services waiver programs. See Chapter O , Waiver Programs, Demonstration Projects and All-Inclusive Care;

Community Attendant Services; and

related hospital and prescription drug services.

Notes :

A person who is placed on an interest list for a Home and Community-Based Services waiver program is not considered to be an applicant.

As of Jan. 1, 2010, states are prohibited from recovering the value of Medicare cost-sharing paid under Medicare savings programs as a result of the Medicare Improvements for Patients and Providers Act (MIPPA) signed into law on July 15, 2008.

(mepd-b-2600)(block-3)B-2620 HHSC MERP Notification Requirements#

Revision 18-1; Effective March 1, 2018

HHSC staff must inform anyone requesting Medicaid assistance for long-term services and supports that may be subject to MERP recovery. Complete the following to document this requirement:

Form 8001 , Medicaid Estate Recovery Program Receipt Acknowledgement, is mailed with all Form H1200 application requests received on or after March 1, 2005.

Ensure the signed MERP Receipt Acknowledgement (Form 8001) is imaged in the case record.

Include the MERP documentation with SSI monitoring requirements outlined in Section B-7100 , SSI Monitoring.

Record information (name, address, telephone number) of any of the following individuals representing the applicant: guardian of the person or guardian of the estate of the applicant; agent under a durable power of attorney or a medical power of attorney; or if none of the above individuals are known, family members acting on behalf of the applicant.

If a signed MERP Receipt Acknowledgement form is not returned by the applicant/recipient, send Form 8001 and document in case comments that the MERP information was sent to inform the recipient about MERP and the potential for estate recovery. Include in the documentation the date the form was sent to the recipient.

If a Form H1746-A , MEPD Referral Cover Sheet, has a mark in the box "MERP shared," do not send MERP notifications to the individual. The agency making the referral has shared MERP information with the individual.

The MERP notification requirement applies to any individual, age 55 or older, who is applying for Medicaid assistance for long-term care services and supports that are subject to MERP on or after March 1, 2005, either through an application or program transfer. Individuals transferring to long-term care services and supports subject to MERP must have documentation of Form 8001 in the case record. If there is no documentation in the case record, send Form 8001 and follow documentation guidelines outlined in this section.

Example: Mr. Andy Allen applied for a Medicare Savings Program (MSP) before Nov. 1, 2004, and was certified, but did not receive Form 8001 since Mr. Allen was on an MSP before March 1, 2005. Mr. Allen entered a nursing facility this month and requested a program transfer. Based on Section B-7450 , Medicaid Certified Person Enters Nursing Facility or Home and Community-Based Services Waiver Program, the program transfer is complete, and Form 8001 is sent to Mr. Allen. Staff document in case comments the date the Form H8001 was mailed.

(mepd-b-3200)Medicaid for the Elderly and People with Disabilities Handbook: B-3200, Application Requirements#

(mepd-b-3200)(block-1)B-3200, Application Requirements#

Revision 24-4; Effective Dec. 1, 2024

Federal law requires allowing anyone wanting to apply for a Medicaid program be allowed to file an application immediately, regardless of the person's ultimate eligibility for assistance.

An application form must be mailed within two working days from the receipt of the request for an application.

Applications can be submitted through any of the following channels:

online through YourTexasBenefits.com;

in the local office;

by mail, fax or phone

Use an application form to test eligibility for all Medicaid programs when a person meets the criteria. A separate application form is not required for each of the different Medicaid programs for the elderly and people with disabilities.

Consider the application complete with a name, address and signature.

(mepd-b-3200)(block-2)B-3210 Who May Complete an Application for Assistance#

Revision 23-2; Effective June 1, 2023

A person who may complete or sign an application for an applicant may not be on the list of people to whom the Texas Health and Human Services Commission (HHSC) can release the applicant’s individually identifiable health information. See section C-5000 , Personal Representatives, for people who may receive or authorize the release of an applicant's individually identifiable health information under Health Insurance Portability and Accountability Act (HIPAA) privacy regulations.

An authorized representative may accompany, help and represent an applicant or recipient in the application or eligibility redetermination process.

Anyone may help the applicant, guardian, power of attorney or authorized representative complete an application form. If someone helps complete the application for assistance, the name of the person completing the form must appear as requested on the application.

See section B-3220 , Who May Sign an Application for Assistance, to determine who may sign an application for assistance form. The requirements for signing a redetermination form are the same as the requirements for signing an application.

See section C-1100 , Responsibility of Applying.

Most applicants in an institutional setting such as a nursing facility are signed into the facility by someone else. An application and information from the applicant or the person(s) having knowledge of the applicant's financial circumstances are required.

(mepd-b-3200)(block-3)B-3220 Who May Sign an Application for Assistance#

Revision 16-3; Effective Sept. 1, 2016

An individual who may complete or sign an application for an applicant may not be on the list of people to whom HHSC can release the applicant’s individually identifiable health information. See section C-5000 , Personal Representatives, for individuals who may receive or authorize the release of an applicant’s individually identifiable health information under HIPAA privacy regulations.

An applicant, authorized representative or someone acting responsibly for the applicant (if the applicant is incompetent or incapacitated) may sign an application for assistance. The application for assistance must be signed under penalty of perjury.

If an applicant has a guardian, the guardian must:

sign the application for assistance;

obtain a copy of the guardianship papers; and

work with the guardian in the eligibility process.

If an application is signed by someone other than the applicant or the applicant’s guardian, power of attorney, family member, or a friend who is knowledgeable of the applicant’s finances, the individual must provide a Form H1003 , Appointment of an Authorized Representative , signed by the applicant, or evidence of:

authority to complete and sign an application on behalf of an applicant;

the individual’s relationship to the applicant; and

responsibility for the applicant’s care.

If an applicant makes an "X" on the signature line for applicant/recipient, a witness must sign on the witness signature line.

(mepd-b-3200)(block-4)B-3221 Valid Signatures#

Revision 24-1; Effective March 1, 2024

All applications and renewals must be signed under the penalty of perjury statement.

Valid signatures include only the following:

a traditional written signature;

a faxed written signature;

an electronic signature submitted through YourTexasBenefits.com;

an electronic signature submitted through an account transfer from the Marketplace; and

a telephonic signature submitted by calling 2-1-1.

(mepd-b-3200)(block-5)YourTexasBenefits.com#

Applications submitted online through YourTexasBenefits.com by a person or authorized representative (AR) are considered electronically signed. A traditional written signature is not required before the person can be certified.

(mepd-b-3200)(block-6)Federal Marketplace Applications#

The Marketplace sends a person's information electronically to HHSC through an account transfer. Applications from the Marketplace are received by staff in the same way as an application from YourTexasBenefits.com and are considered electronically signed.

(mepd-b-3200)(block-7)Other Electronic Signatures#

Other electronic signatures not specifically mentioned above, including those captured or copied by electronic devices, are not valid signatures.

(mepd-b-3200)(block-8)Calling 2-1-1#

A person may apply for Medicaid by calling 2-1-1. A person or AR may complete and sign an application over the phone by:

providing their information over the phone to a customer care representative (CCR); and

signing the application telephonically by stating their name and agreeing to the penalty of perjury statement read by the CCR.

The CCR enters and submits the information provided by the person or AR through YourTexasBenefits.com.

(mepd-b-3200)(block-9)Unsigned Applications#

An application or renewal form is considered invalid when:

it is received without a signature below the penalty of perjury statement; or

the agency receives an application without a signature and does not accept the application by giving the application an established file date.

Staff must return the application with a letter and a self-addressed return envelope explaining that the application must be signed before the agency can establish a file date.

If the agency receives and accepts an application without a signature and the application is given an established file date in error, the date the application is received is considered a valid file date. Staff must send Form H1020, Request for Information or Action , along with the signature page requesting a signature. If the person applying for Medicaid fails to provide a signed application by the final due date, staff must deny the application for failure to provide information.

(mepd-b-3200)(block-10)Related Policy#

Processing Deadlines, B-6400 Who May Sign an Application for Assistance, B-3220

(mepd-b-3200)(block-11)B-3230 Receipt of Duplicate or Identical Applications#

Revision 20-3; Effective Sept. 1, 2020

(mepd-b-3200)(block-12)Duplicate Application#

An application filed after another application has already been filed is a duplicate application if it:

does not include a request for a new program (i.e.: a type of program not requested on the initial application or a type of program not currently received by the applicant); and

is not needed for a redetermination of the active program(s).

Example: An application is received on January 2 and a second application for the same program is received on January 5. The second application is considered a duplicate application.

If a duplicate application is received while the first application is being processed:

treat the duplicate application as a report of change; and

assign to the eligibility staff currently processing the case.

If a duplicate application is received after the first application has been processed, review the application to ensure the person is not applying for a different type of program and that a redetermination is not due. If a new program is not being requested:

consider the duplicate application as a report of change; and

assign as a change indicating "duplicate application."

If the person is applying for a new program, the application is not a duplicate application. Process the application as a new request for assistance.

(mepd-b-3200)(block-13)Identical Application#

An identical application is an exact copy of an application previously submitted by an applicant.

Example: An application is received by fax on January 2 and an exact copy of the same application (with the same signature and date of the previously submitted application) is received by mail on January 5. The second application is considered an identical application.

(mepd-b-3200)(block-14)Required Action on Identical Application Received#

If an identical application is received, write "Identical Application" on the front page of the application and route for imaging. The identical application will be imaged and added to the electronic case record. No other action is needed.

(mepd-b-3200)(block-15)B-3240 Electronic Correspondence#

Revision 22-3; Effective September 1, 2022

At any time, an applicant, recipient, or authorized representative (AR) for a case may view available eligibility correspondence electronically through YourTexasBenefits.com instead of receiving them by mail. By selecting this option, applicable forms and notices are posted to the recipient’s or AR’s YourTexasBenefits.com case account. A text message or an e-mail reminder is sent to the recipient each time a new form or notice is posted to their account. The recipient may print a copy of the correspondence from their YourTexasBenefits.com account or request a paper copy be mailed to them. Forms and notices that are not available electronically will continue to be mailed to the recipient or AR.

(mepd-b-3200)(block-16)Related Policy#

Notices, R-1300

(mepd-b-3300)Medicaid for the Elderly and People with Disabilities Handbook: B-3300, Authorized Representative#

(mepd-b-3300)(block-1)B-3300, Authorized Representative#

Revision 21-1; Effective March 1, 2021

An authorized representative (AR) is a person who is familiar with the applicant and knowledgeable of the applicant’s financial affairs.

An applicant, person receiving benefits, head of household (HOH), or someone with legal authority to act on their behalf (e.g., legal guardian or power of attorney) may designate a person or organization as an AR.

When applying for benefits, an AR must be verified using one of the following:

applicant's or recipient’s signature on one of the following HHSC applications for benefits containing the AR designation: Form H1200, Application for Assistance — Your Texas Benefits ; Form H1200-MBI, Application for Benefits — Medicaid Buy-In ; Form H1200-MBIC, Application for Benefits — Medicaid Buy-In for Children ; or Form H1206, Health Care Benefits Renewal;

applicant's signature on a Marketplace application for health care benefits that is transferred to HHSC and contains the AR designation;

legal documentation that the AR has authority to act on behalf of the applicant or recipient under state law (e.g., legal guardianship or power of attorney);

letter designating AR authority and containing the applicant's or recipient’s signature, in addition to the name, address and signature of the AR;

completed Form H1003, Appointment of an Authorized Representative ;

applicant’s or recipient’s electronic signature designating the AR on an application, renewal or reported change submitted through YourTexasBenefits.com ; or

applicant’s or recipient’s telephonic signature submitted by calling 2-1-1.

If a person or organization submits an application on behalf of an applicant and indicates they wish to be the AR but the application is not signed by the applicant, send correspondence to both the unverified AR and the applicant to request the verification.

Send the following to the applicant: Form H1020, Request for Information or Action , listing the missing information needed before eligibility can be determined. Form H1003, to capture the AR designation and the signatures of the applicant and the AR.

Send the following to the unverified AR: Form H1004, Cover Letter: Authorized Representative Not Verified , explaining what is needed to verify the AR. Form H1003, to capture the AR designation and the signatures of the applicant and the AR.

For the AR to be verified, either the AR or the applicant must return the completed Form H1003 within 10 days (or 39 days from the file date). All missing information listed on the Form H1020 must also be returned timely. If the AR verification is not received by the due date, do not designate an AR.

The AR designation is effective from the date the AR is verified until:

the applicant or recipient notifies HHSC that the AR is no longer authorized to act on their behalf;

the AR notifies HHSC that they no longer wish to act as the AR for the applicant or recipient; Note : The AR will not be able to do this during the redetermination process if the AR is the person completing and signing the redetermination.

there is a change in the legal authority (i.e., legal guardianship or power of attorney) on which the AR’s designation is based; or

the applicant or recipient designates a new AR to act on their behalf. If there is an existing AR designated on a case, the person or organization most recently designated as the AR will replace the existing AR on the case.

Requests to end the designation of an AR must include the signature of the applicant, the recipient or the AR as appropriate.

Note : An AR is not automatically a personal representative.

An AR is designated at the case level to have access to all benefit information for that case. A verified AR may:

sign an application on behalf of an applicant;

complete and submit a renewal form;

receive copies of notices or renewal forms in the preferred language selected on the application, and other communications from HHSC;

designate a health plan; and

act on behalf of the applicant or the recipient in all other matters with HHSC.

The applicant, recipient or AR may also request that the AR receive the recipient’s Medicaid ID card and enrollment-related agency correspondence.

(mepd-b-3300)(block-2)Mailing Address for AR#

When processing the application, obtain the AR’s complete mailing address if not included on the application form. Record the AR’s address on the TIERS Data Collection page, Household – Authorized Representative . If the applicant cannot provide a complete mailing address for the AR, do not pend the case. Record the applicant’s mailing address as the AR’s address in TIERS.

When an applicant or recipient and their designated AR have the same mailing address, correspondence will be sent only to the AR.

When an applicant or recipient has a legal guardian, correspondence will be sent only to the guardian, even if the applicant or recipient and the guardian have different mailing addresses.

Applicants, recipients or ARs who have chosen to receive eligibility correspondence electronically will continue to receive correspondence electronically.

(mepd-b-3300)(block-3)Related Policy#

Who May Complete an Application for Assistance, B-3210 Who May Sign an Application for Assistance, B-3220 Prior Coverage for Deceased Applicants, G-7210

(mepd-b-3500)Medicaid for the Elderly and People with Disabilities Handbook: B-3500, Coordination with the Federal Marketplace#

(mepd-b-3500)(block-1)B-3500, Coordination with the Federal Marketplace#

Revision 25-2; Effective June 1, 2025

Eligibility determinations for Medicaid must be coordinated with the federal Marketplace . A person who applies for health care coverage through the Marketplace at HealthCare.gov is also assessed for Medicaid eligibility. If the Marketplace assessment does not show the person may be eligible for Medicaid, the person can still request their information be transferred to HHSC for a full eligibility determination.

The Marketplace assesses a person as:

potentially eligible for Medicaid based on Modified Adjusted Gross Income (MAGI) rules; or

potentially eligible for Medicaid on a non-MAGI basis if the person is 65 or older or reports having a disability or blindness.

If the assessment shows the person may be eligible for Medicaid, the person’s application information is transferred to HHSC.

For non-MAGI account transfers, evaluate the person’s eligibility for Medicaid and the Medicare Savings Program (MSP) without requiring a new application.

(mepd-b-3500)(block-2)Information Sent to the Marketplace#

After HHSC determines a person is not eligible for ongoing Medicaid, the person's account information is sent to the Marketplace to be assessed for other health care coverage programs.

Form TF0001, Notice of Case Action, informs the person their information was transferred to the Marketplace.

(mepd-b-3500)(block-3)B-3510 Applications Received from the Marketplace#

Revision 24-1; Effective March 1, 2024

The federal Marketplace sends a person’s application information to HHSC through an electronic interface when:

the Marketplace assessment shows the person may be eligible for Medicaid; or

the person requests a full eligibility determination for Medicaid.

The electronic transfer of application information is called an account transfer. The account transfer includes information provided by the person on the Marketplace application and information verified by the Marketplace.

The account transfer process generates a PDF application with the information the Marketplace provides. Verifications completed by the Marketplace are included in the Verifications section of the PDF. Like an application from YourTexasBenefits.com , enter applicant information into the appropriate logical unit of work (LUW) following the verification policies. This includes any required documentation about blanks or discrepancies on the PDF application.

(mepd-b-3500)(block-4)B-3520 Verifications Provided by the Marketplace#

Revision 24-1; Effective March 1, 2024

(mepd-b-3500)(block-5)Medical Programs#

Marketplace account transfer PDFs also include a Verifications section. Enter information from the verification section as follows:

If the Marketplace verified the person's Social Security number (SSN) or citizenship status using data from the Social Security Administration (SSA), accept the information as Verified by SSA.

If the Marketplace verified the person's alien status using data from the Department of Homeland Security (DHS), accept the information as Verified by DHS.

If the Marketplace verified other eligibility criteria, such as income or resources, per HHSC verification policy, accept the information as verified.

All other applicant information must be verified as required by the applicable HHSC verification policy. Do not request additional verification for information verified by the Marketplace per HHSC verification policy.

(mepd-b-3500)(block-6)Related Policy#

Documentation and Verification Guide, Appendix XVI

(mepd-b-5000)Medicaid for the Elderly and People with Disabilities Handbook: B-5000, Previously Completed Application#

(mepd-b-5000)(block-1)B-5000, Previously Completed Application#

Revision 20-4; Effective December 1, 2020

A previously completed application for assistance is valid for 90 days. It may be used to reopen the application or renewal in the following situations.

(mepd-b-5000)(block-2)Failure to Provide Requested Information#

An application is denied for failure to provide information and all requested information is provided within 90 days of the date of denial.

A renewal is denied for failure to provide information and all requested information is provided after the date of denial but within 90 days of the last day of the last benefit month.

Reopen and re-evaluate eligibility using the information provided and the previously submitted application or renewal form. A written request to reopen is not required.

The date all the information and verification that was originally requested is provided is the new file date. If additional information is needed to make an accurate eligibility determination based on the new file date, request the needed information following regular policy and process.

(mepd-b-5000)(block-3)Failure to Provide Verification of Level of Care (LOC) or Medical Necessity (MN)#

If an application is denied for failure to provide verification of LOC or MN and all other eligibility criteria are met:

Reopen and re-evaluate eligibility using the previously submitted application if verification of LOC or MN is received within 90 days of the date of denial. A written request to reopen is not required. The date the verification is received is the new file date.

If additional information is needed to make an accurate eligibility determination based on the new file date, request the needed information following regular policy and processes.

(mepd-b-5000)(block-4)Application or Renewal Denied for Reasons Other Than Failure to Provide Information#

If an application or renewal is denied for a reason other than failure to provide information and the person requests to reapply:

Obtain a written, dated and signed statement of request to reapply from the person or authorized representative to establish the file date.

The previously completed application for assistance is valid for 90 days from the date of denial.

The previously completed renewal form is valid for 90 days from the last day of the last benefit month.

Verification must be updated if circumstances have changed.

(mepd-b-5000)(block-5)Application or Renewals Denied in Error#

If an application is denied in error, the original file date of the application must be used regardless of the age of the application.

If a renewal is denied in error, the receipt date of the renewal packet must be used regardless of the age.

If the application or renewal denial is determined to be agency error, do not require a new application or statement to reapply from the person or authorized representative to reopen the application if supervisory approval is obtained.

(mepd-b-5000)(block-6)Applications Received from Other HHSC Areas#

Applications for assistance may be received by other areas within HHSC, including Community Care Service Eligibility (CCSE) staff or waiver staff. Regardless of the signature date, the applications must be forwarded to Medicaid eligibility staff for an eligibility determination. Staff must contact the applicant or authorized representative to obtain current information.

Example: CCSE staff refer a person receiving Family Care to MEPD for a financial eligibility determination for Community Attendant Services (CAS). The application was signed and dated two months prior. MEPD staff must contact the person to obtain current income and resource information.

(mepd-b-5000)(block-7)Related Policy#

Date of Application, B-4000 Processing Deadlines, B-6400

(mepd-b-6200)Medicaid for the Elderly and People with Disabilities Handbook: B-6200, Financial Management#

(mepd-b-6200)(block-1)B-6200, Financial Management#

Revision 25-4; Effective Dec. 1, 2025

If a person does not report a bank account, trust fund or similar account on Form H1200, Application for Assistance – Your Texas Benefits , or other application for assistance, ask the person or the authorized representative to explain how the person's financial affairs are handled. This includes determining who:

cashes the checks and where;

pays the bills and how; and

keeps the money and how the funds are kept.

If the person reveals earlier unreported liquid resources, request verification to determine:

the value;

ownership; and

accessibility per the requirements for the resource involved.

Note: For AVS-applicable types of assistance (TOAs), review the Asset Verification System (AVS) response before requesting more information from the person.

Sources for verifying financial management are as follows:

Statements from the applicant and the person who handles the applicant's funds.

Statement from a knowledgeable third party such as an administrator or bookkeeper in the facility who knows how the applicant receives benefit payments and pays the bills.

Information received through AVS.

Use Appendix XVI, Documentation and Verification Guide , for sources of required verifications.

Document the following information in the case record:

Where checks are cashed and how bills are paid.

Who handles the person's checks, pays the person's bills and maintains the person's money.

How much money, if any, the person or anyone else keeps.

How much has accumulated.

Source of information.

Note: If the person's bank account is dormant, financial management must be verified and documented. For applications, explore financial management if a reported account does not show activity during the month of application and the month before.

(mepd-b-6200)(block-2)Related Policy#

Asset Verification System (AVS), R-3740 Documentation and Verification Guide, Appendix XVI

(mepd-b-6300)Medicaid for the Elderly and People with Disabilities Handbook: B-6300, Institutional Living Arrangement#

(mepd-b-6300)(block-1)B-6300, Institutional Living Arrangement#

Revision 26-3; Effective Sept. 1, 2026

Determine the first day a person’s eligibility can be established under the special income limit. The following forms provide adequate verification of dates of admission to a Medicaid facility:

Form 3618, Resident Transaction Notice ;

Form 3619, Medicare/SNF Patient Transaction Notice ; and

Form H0090-I, Notice of Admission, Departure , Readmission or Death of an Applicant/Recipient of Supplemental Security Income and/or Assistance Only in a State Institution.

Eligibility staff may contact the administrator, bookkeeper, or office manager for the date of admission, in the absence of the above-listed forms.

Use the special income limit for the month of entry to a Medicaid-certified long-term care facility (Medicare-SNF, NF or ICF/IID). Do when anticipating that the person will stay in a Medicaid-certified facility for at least 30 consecutive days. Eligibility under the special income limit cannot be approved until the applicant has lived in an institutional setting for at least 30 consecutive days. Application processing may start on receipt, including pending for more information. Suspend the case or delay certification, as appropriate, until the requirement is met if the applicant meets all other eligibility factors before meeting the 30-day stay requirement. Refer to the MEPD Due Date Chart job aid on The LOOP to determine the 31st day.

The 30-day requirement begins with confinement to one or more Medicaid-certified facilities (Medicare- SNF , NF or ICF/IID ) for at least 30 consecutive days. The date of admittance to an institution is day zero.

Example 1: Mr. Smith entered the nursing facility on March 27. He stayed there for 30 consecutive days and did not go home, to the hospital or to another nursing facility during that time. The earliest staff can certify the case is the 31st day, which is April 27.

Example 2: Mr. Lopez entered the hospital on Feb. 10 and entered the nursing facility on Feb. 19. He stayed there for 30 consecutive days and did not go home, to the hospital or to another nursing facility during that time. The start of the 30 consecutive days started on Feb. 19, not Feb.10.The earliest staff can certify the case is the 31st day, which is March 22.

Example 3: Mr. Johnson entered the nursing facility on March 1. He went to the hospital on March 5. He returned to the nursing facility on March 10. The 30 consecutive days started on March 1 and was not interrupted by the hospital stay. The earliest staff can certify the case is the 31st day, which is April 1.

Example 4: Mr. Brown entered the nursing facility on May 10. The 31st day is June 10. He went home on June 1. He did not stay the required 30 consecutive days. Staff cannot certify the case.

Example 5: Mr. Leo entered the nursing facility on April 20. The 31st day is May 21. He died on May 10. He did not stay the required 30 consecutive days. Staff can certify the case if the person meets all other eligibility requirements, including medical necessity.

Example 6: Mr. Smith entered the hospital on Feb. 15 and then went directly to the nursing home on March 10. His wife continues to live in their home in the community. The 30 consecutive days starts on March 10, not Feb. 15. The earliest staff can certify the case is the 31st day, which is April 10th.

Note: The hospital stay in February is the start date for the continuous period in an institution for the spousal resource assessment. This is different than the 30-consecutive day requirement. Refer to Chapter J, Spousal Impoverishment , regarding the resource assessment and spousal protected resource amount (SPRA).

Consider both the days in a medical facility and the days in a Home and Community-Based Services waiver setting when determining the 30 consecutive day requirement.

It may be necessary to verify the living arrangement for prior months. Do this by contacting the applicant or authorized representative to make sure the appropriate income limit is used for determining eligibility for prior months. It may also be necessary to contact the facility, Home and Community-Based Services waiver provider or hospital, if an applicant was discharged to a hospital. This is to make sure that the 30 consecutive day requirement is met.

The case record must include the following documentation :

Date the applicant entered the Medicaid facility.

Date the applicant met the 30 consecutive day requirement or date of death.

Source of verification.

Refer to Appendix XXX, Medical Effective Dates (MEDs) . Use the information under the Institutional Based area to determine the appropriate income limit for the month of application and the prior months.

The 30 consecutive day requirement does not apply to a regular Medicaid recipient who:

is eligible for SSI; or

was eligible for SSI and continues regular Medicaid eligibility through one of the cost-of-living adjustment (COLA) disregard programs.

The COLA disregard programs are:

ME-Pickle

ME-Disabled Adult Child

ME-Disabled Widow(er)

ME-Early Aged Widow(er)

(mepd-b-6300)(block-2)Related Policy#

Medical Effective Dates (MEDs), Appendix XXX Medicaid Certified Person Enters Nursing Facility or Home and Community-Based Services Waiver Program, B-7450 Institutional Eligibility Budget Types, G-6000 Prior Coverage, G-7000 Establish Processing Deadlines, R-3100

(mepd-b-6400)Medicaid for the Elderly and People with Disabilities Handbook: B-6400, Processing Deadlines#

(mepd-b-6400)(block-1)B-6400, Processing Deadlines#

Make and document an eligibility decision on an application as soon as all required verification is received.

Time frame for eligibility determination:

Make an eligibility decision within 45 days on applications from applicants 65 years or older.

Make a decision within 45 days on applications from applicants under age 65 who have had disability established based on the Social Security Administration criteria for RSDI Title II or SSI Title XVI disability.

Make a decision within 90 days on applications from applicants who must have disability established by the HHSC Disability Determination Unit.

(mepd-b-6400)(block-2)References:#

See section B-4000 , Date of Application, for clarification of date of application and complete application.

See section R-3100 , Establish Processing Deadlines, for automation procedures to follow when applications cannot be completed within the normal 45/90-day limit and for requirements to request a delay in certification.

See section D-2100 , When a Medical Determination Is Not Required, and section D-2200 , When a Medical Determination Is Required, for further information regarding a medical determination for applicants under age 65.

(mepd-b-6400)(block-3)B-6410 Application Due Dates#

Applications must be processed in a timely manner. For timeliness and processing purposes:

The timeliness count begins the date the completed and signed application for assistance is received by HHSC.

The file date of an application is day zero for application processing.

If a person applies for multiple programs and all requested information is provided for one program and not the other(s), make an eligibility determination for the program in which all the information has been received. Continue to allow for the opportunity to provide the remaining missing information for the other program(s) until the final due date.

Reminders:

The date of application is established when HHSC receives the completed and signed application form.

For applications submitted after the close of business for the day, or on days when HHSC is closed (including weekends and holidays), the date of application is the following business day .

If an application is denied in error, the original date of application must be protected no matter how old the original date on the application for assistance. A new application processing date must be established.

(mepd-b-6400)(block-4)Related Policy#

Date of Application, B-4000 Previously Completed Application, B-5000

(mepd-b-6400)(block-5)Applications#

Use Form H1020 , Request for Information or Action (PDF) , to request missing information or verifications. The final due date for missing information for applications on Form H1020 is the:

39th day from the date of application, or

84th day from the date of application for a person who needs a disability determination.

Do not send a second request for missing information. Take appropriate case action based on the original request for missing information.

(mepd-b-6400)(block-6)Delay in Certification#

When there is an approved delay in certification, the 39th and 84th days are extended 90 days.

Always send notification to the applicant/authorized representative and nursing facility, using Form H1020 and Form H1247 , Notice of Delay in Certification (PDF) .

Use Form H1020 to indicate the needed information and the re-established due dates during the delay in certification. See section B-6510 , Failure to Furnish Missing Information.

Re-established due dates are based on the reason for the delay in certification and reasonable MEPD specialist judgment. For example, if the delay is due to the 30-day consecutive requirement not being met, the re-established due date would not automatically need to be the full 90-day extension. However, if the delay is due to the facility pending certification, the full 90-day extension may be necessary. When unsure of the re-established due dates based on the reason for the delay in certification, consult the supervisor to determine the re-established pending period. Do not send a second request for missing information during the re-established due dates based on the delay in certification. Take appropriate case action based on the Form H1247 and Form H1020 used to notify the applicant of the delay in certification and the needed verification.

(mepd-b-6400)(block-7)Redeterminations#

Use Form H1020 to request missing information or verifications. The due date for missing information or verifications for redeterminations should be 10 days from the date on Form H1020.

(mepd-b-6500)Medicaid for the Elderly and People with Disabilities Handbook: B-6500, Denials#

(mepd-b-6500)(block-1)B-6500, Denials#

Revision 25-2; Effective June 1, 2025

Before denying a Medicaid application for any reason explore eligibility for all Medicaid and Medicare Savings Programs. This includes both Modified Adjusted Gross Income (MAGI) and non-MAGI types of assistance (TOAs).

Example: An applicant for nursing facility coverage must also be tested for Qualified Medicare Beneficiary (QMB) coverage. If the applicant is ineligible for nursing facility coverage but eligible for QMB, certify the applicant for QMB. Indicate on the notice that the applicant is ineligible for nursing facility coverage but eligible for QMB coverage.

(mepd-b-6500)(block-2)Related Policy#

General Information for Denials and Terminations, B-9100

(mepd-b-6500)(block-3)B-6510 Failure to Provide Missing Information#

Revision 20-4; Effective December 1, 2020

(mepd-b-6500)(block-4)Applications#

For applications, initiate the written request for verification within 30 calendar days from the date the application is received by the Texas Health and Human Services Commission (HHSC).

If more information or verification is required to complete an application, the applicant or the applicant’s authorized representative (AR) is allowed at least 10 days to provide the information or verification. The final due date must be a workday.

Send Form H1020, Request for Information or Action (PDF) , to request the needed verification. The Form H1020 provides:

the information or verification needed;

the date the information or verification is due; and

the final decision date.

Note: The final decision date is the date the application may be denied if the required information or verification is not received.

The day Form H1020 is sent is considered day zero of the pending period.

Deny the application if the requested information is not received by close of business on the final decision date provided on the H1020.

If the required information is requested more than 30 days after the file date, allow at least 10 days to provide the required verification. Do not deny the application for the missing information before close of business on the 10th day.

Do not send a second request for missing information for applications.

(mepd-b-6500)(block-5)Delay in Certification#

Delay in certification procedures may be necessary if the applicant or the AR is attempting to obtain the information but cannot meet the deadline.

Note: If Asset Verification System (AVS) information impacts eligibility, pend the case and send Form H1020. Allow at least 10 days to provide verification of the new information. Delay in certification procedures may be necessary if the missing information due date is after the application due date.

(mepd-b-6500)(block-6)Redeterminations#

All information and verification needed to make an eligibility redetermination decision must be provided.

Send Form H1020, Request for Information or Action, to request the needed verification. The Form H1020 provides:

what is required;

the date the verification is due; and

the date the renewal could be denied if the verification is not received.

The day Form H1020 is sent is considered day zero of the pending period.

Allow at least 10 days to provide the requested verification. The system-generated due date is 10 days from the date of the H1020.

Do not send a second request for previously requested information for redeterminations.

If all previously requested information is returned and new information that impacts eligibility is discovered before disposition, send a new Form H1020 and allow at least 10 days to provide verification of the new information.

Deny the redetermination if the information or verification is not provided by the close of business on the final decision date indicated on the H1020.

Do not deny the redetermination for missing information before close of business on the 10th day.

(mepd-b-6500)(block-7)Related Policy#

Date of Application, B-4000 Missing Information Due Dates, B-6420 Establish Processing Deadlines, R-3100 Consideration of AVS Information, R-3744

(mepd-b-7100)Medicaid for the Elderly and People with Disabilities Handbook: B-7100, SSI Applications#

(mepd-b-7100)(block-1)B-7100, SSI Applications#

Revision 11-1; Effective March 1, 2011

The Social Security Administration (SSA) determines Medicaid eligibility for all persons who apply for SSI cash benefits. When SSA makes a determination on an application for SSI cash benefits (either approved or denied), HHSC is notified by means of the SSA/State Data Exchange System (SDX).

SSA is responsible for redetermination of SSI Medicaid eligibility. See section H-6000 , Co-Payment for SSI Cases, for other special handling of SSI eligible individuals.

(mepd-b-7100)(block-2)B-7110 Medicaid Coverage After SSI Termination#

Revision 25-3; Effective Sept. 1, 2025

Medicaid recipients who stop meeting the eligibility requirements for Supplemental Security Income (SSI) benefits may still be eligible for Medicaid under another eligibility group. Explore eligibility for all other medical programs before ending SSI Medicaid.

(mepd-b-7100)(block-3)Modified Administrative Renewal Process#

The system initiates a modified administrative redetermination process before ending Medicaid when notified of an SSI denial. The modified redetermination process uses information from the existing case record and electronic data sources (ELDS) to determine if the person is eligible for any other type of Medicaid benefits. The SSI Medicaid Eligibility Determination Group (EDG) is maintained during the redetermination process.

The Texas Integrated Eligibility Redesign System (TIERS) requests ELDS information on the eighth of the month after the loss of SSI eligibility. The system runs eligibility to test for all non-SSI Medicaid programs, including the Medicare Savings Programs (MSPs) on the third of the next month.

The case is auto-disposed, and TIERS generates a TF0001, Notice of Case Action, if enough information is available to verify all eligibility criteria for another type of Medicaid. The person does not need to submit other information, and no staff action is required.

An eligibility packet is automatically generated and must be completed and returned within 30 days if:

the system is unable to determine ongoing eligibility based on existing information and available ELDS information; or

the person is only eligible for a lesser Medicaid or MSP.

Note: Eligibility for Medicaid and MSP is determined separately. For example, if eligibility for ME-Waivers is approved but eligibility for MC-QMB is pending, the approved ME-Waivers EDG is disposed. An eligibility packet is generated for the MC-QMB EDG.

If the person might be eligible for an MEPD or MSP program, the packet includes the following forms:

Form H1233P, Redetermination Notice, populated with the maintained EDG number or numbers

Form H1200, Application for Assistance – Your Texas Benefits

Notice H1296, Notice of SSI Medicaid Ending

Form H1020, Request for Information or Action , if TIERS cascaded to a pending EDG

If the person might be eligible for a Texas Works (TW) Medicaid program or the Children's Health Insurance Program (CHIP), the packet includes the following forms:

Form H1830P, TW Renewal Packet , populated with the maintained EDG number or numbers

Form H1010R, Your Texas Works Benefits - Renewal Form

Notice H1296, Notice of SSI Medicaid Ending

Form H1020, Request for Information or Action , if TIERS cascaded to a pending EDG

If the person returns an eligibility form before the 31st day, process the case and explore eligibility for all Medicaid programs, including MSP. Maintain SSI and any SSI-associated QMB coverage until processing is complete.

If the person does not return the eligibility form on or before the 30th day, the maintained SSI EDG and any SSI-associated QMB EDGs are automatically terminated, and a Form TF0001 is generated.

(mepd-b-7100)(block-4)Adults Receiving Waiver Services#

If the person was receiving waiver services before the loss of SSI eligibility, a new Form H1746-A, MEPD Referral Cover Sheet , is not needed to explore ongoing waiver eligibility. If it is indicated that the person was receiving waiver services, verify ongoing enrollment. Use the chart below to send an email to the appropriate mailbox based on the type of waiver program in the Long-Term Services and Support (LTSS) Summary screen.

The subject line of the email must be: SSI Termination: Client Initials -XXX where XXX is the last 3 digits of the person’s Medicaid ID number. Example: SSI Termination: JG-123

Waiver Program Email STAR+PLUS Waiver (SPW) Medically Dependent Children Program (MDCP) HHSC Managed Care Program Support Community Living Assistance and Support Services (CLASS) Home and Community-based Services (HCS) Texas Home Living (TxHML) HHSC IDD-Program Eligibility and Support Deaf Blind with Multiple Disabilities (DBMD) Patrick Koch and Casey Zwerneman Youth Empowerment Services (YES) HHSC Yes Waiver

Include the following information in the body of the email:

• Full name of recipient

• Full Medicaid ID number

• Full Social Security number

• The following statement: This person’s SSI benefits have been terminated. Case history indicates this person was previously receiving [insert name of Waiver program] services. Please confirm current Waiver enrollment status.

Suspend the case pending a response. Document the program response in case comments and take appropriate action to complete the case when a response is received.

(mepd-b-7100)(block-5)Children Receiving Waiver Services#

Determine ongoing eligibility for ME-Waiver Medicaid if a Form H1200 is received by the 30th day. If eligible, ME-Waiver Medicaid remains active through the end of the month the child turns 18.

Applications submitted by the child, or their parent or authorized representative do not need an associated Form H1746-A.

Applications submitted by program providers, including managed care organizations (MCOs), local intellectual and developmental disability authorities (LIDDAs) and local authorities (LAs), on behalf of a child must include an associated Form H1746-A.

If SSA reinstates SSI benefits while the child is active under ME-Waiver Medicaid, SSI Medicaid is suppressed, and ME-Waiver Medicaid remains active. This avoids future gaps in coverage.

If SSI benefits are active when the child turns 18, ME-Waiver Medicaid ends. The system automatically reinstates SSI Medicaid.

If SSI benefits are not active when the child turns 18, ME-Waiver Medicaid remains active and follows the regular renewal process.

(mepd-b-7100)(block-6)Related Policy#

Supplemental Security Income (SSI), A-2100 Disabled Adult Children (DAC), A-2310 Pickle, A-2330 Widow(er)s, A-2340 SSI Applications, B-7100 SSI Cash Benefits Denied Due to Entry into a Medicaid Facility, B-7200 When Deeming Procedures Are Not Used, E-7200

(mepd-b-7100)(block-7)B-7120 Pregnancy and 12-Month Postpartum Coverage After SSI Denial#

Revision 24-4; Effective Dec. 1, 2024

Pregnant and postpartum women will automatically transition to Medicaid for Pregnant Women (TP 40) for the remainder of their pregnancy and the 12-month postpartum period if:

they received Supplemental Security Income (SSI) Medicaid while pregnant; and

lose ongoing eligibility for SSI.

A new TP 40 EDG is created without an application for pregnancy Medicaid. A full redetermination of eligibility must occur at the end of the TP 40 certification period.

Continuous Medicaid and CHIP coverage is provided through the pregnancy and the 12-month postpartum period regardless of any change in circumstance unless the woman:

voluntarily withdraws;

moves out of state;

dies; or

is ineligible due to agency error, fraud, abuse or perjury attributed to the person.

Unverified Pregnancy

When a recipient loses SSI eligibility, and pregnancy information is received through an interface, the woman is automatically certified for TP 40 with postponed verification. Form H1020 , Request for Information or Action is sent. If verification is provided, the woman is eligible for TP 40 coverage through her pregnancy and postpartum period. If verification is not provided, or shows the woman does not meet eligibility requirements, TP 40 coverage is terminated unless the woman is under 19.

(mepd-b-7100)(block-8)Related Policy#

Supplemental Security Income (SSI), A-2100 Disabled Adult Children (DAC), A-2310 Pickle, A-2330 Widow(er)s, A-2340 SSI Applications, B-7100 Extending Postpartum Coverage After MEPD Termination, B-9400 When Deeming Procedures Are Not Used, E-7200

(mepd-b-7200)Medicaid for the Elderly and People with Disabilities Handbook: B-7200, SSI Cash Benefits Denied Due to Entry into a Medicaid Facility#

(mepd-b-7200)(block-1)B-7200, SSI Cash Benefits Denied Due to Entry into a Medicaid Facility#

Revision 25-3; Effective Sept. 1, 2025

When a Supplemental Security Income ( SSI ) recipient enters a Medicaid facility, the Social Security Administration (SSA) ends the SSI cash benefit if their income is more than the reduced federal benefit rate (FBR).

The State Data Exchange (SDX) system tells HHSC when SSI cash benefits end because of income more than the reduced SSI federal benefit rate. When HHSC receives the SDX denial, the system maintains the SSI Medicaid coverage, and any SSI-associated QMB coverage. It then initiates the SSI modified administrative redetermination process.

There is no option to overlap coverage in the system. Certification for MEPD benefits cannot occur until the system ends the SSI EDG.

Determine financial eligibility for MEPD using the special income limit beginning with the first month after SSI denial if the person returns a Form H1200, Application for Assistance – Your Texas Benefits . Verify and document that the recipient has an approved medical necessity or level of care (LOC) and meets all other eligibility requirements. If the recipient was denied medical necessity or level of care but remains in the Medicaid facility, or if the recipient does not remain in a Medicaid facility for 30 consecutive days, explore eligibility for Medicaid under another program and refer the recipient back to SSA for reinstatement of full SSI benefits.

Notes:

A Medicaid facility can be a nursing facility (NF) , Medicare skilled nursing facility (SNF) or an intermediate care facility for individuals with an intellectual disability or related condition (ICF/IID) .

When a recipient is eligible for institutional Medicaid coverage, the medical effective date (MED) of the MEPD program is the day after the last day of SSI Medicaid coverage.

Refer to Chapter H, Co-Payment , for exceptions to the reduced SSI payment standard.

(mepd-b-7200)(block-2)Related Policy#

Medicaid Coverage After SSI Termination, B-7110

(mepd-b-7300)Medicaid for the Elderly and People with Disabilities Handbook: B-7300, MEPD Eligibility Pending a Decision of SSI Application#

(mepd-b-7300)(block-1)B-7300, MEPD Eligibility Pending a Decision of SSI Application#

Revision 25-4; Effective Dec. 1, 2025

People who applied for SSI , but had their SSI application delayed more than 90 days, may be certified under the appropriate MEPD program pending the SSI eligibility decision.

The person must meet all applicable non-financial and financial MEPD criteria to be eligible including:

disability; and

institutionalization for 30 consecutive days.

Consider the age of the person when deciding if a disability determination is necessary.

The state office Disability Determination Unit (DDU) needs a disability determination if the person is younger than 65. DDU cannot make a disability determination decision unless 90 days have passed since the SSI date of application, and SSA 's disability decision is still pending. If SSA finds the person is not disabled after DDU has established a disability, DDU must follow SSA’s decision. The staff must deny eligibility. Set a special review for the fifth month to monitor the final SSA decision on disability.

When a MEPD recipient becomes eligible for SSI, SSA reports the SSI eligibility to HHSC by the State Data Exchange (SDX). Upon receipt of the SDX information, the eligibility determination system automatically denies the MEPD benefit and activates the SSI coverage. This is not an adverse action because the person does not lose benefits.

The above policy only applies to situations where the processing of an SSI application was delayed. Verify and document that an SSI application was filed.

Note: If the person is 65 or older, a disability determination is not necessary. Verify that the person has filed an application for SSI.

(mepd-b-7300)(block-2)Related Policy#

SSI Applications, B-7100 Special Reviews, B-8430 Supplemental Security Income (SSI) Applicants and Retroactive Coverage, D-2500

(mepd-b-7400)Medicaid for the Elderly and People with Disabilities Handbook: B-7400, Application for Institutional Care#

(mepd-b-7400)(block-1)B-7400, Application for Institutional Care#

Revision 12-3; Effective September 1, 2012

HHSC is responsible for processing Medicaid applications for certain residents of Medicaid facilities (Medicare SNF , NF , ICF/IID and institutions for mental diseases (IMD)). To qualify for medical assistance for institutional care, a person must:

meet the 30-consecutive-day stay requirement (for verification and documentation requirements, see Appendix XVI , Documentation and Verification Guide);

meet financial criteria; and

have an approved level of care or medical necessity determination.

Reference: Section B-6300 , Institutional Living Arrangement.

HHSC processes:

initial applications from persons whose income is equal to or in excess of the reduced SSI federal benefit rate; and

reapplications for Medicaid from persons who will be or have been denied SSI on the basis of excess income because the SSI federal benefit rate has been reduced after entry into a Medicaid facility.

(mepd-b-7400)(block-2)B-7410 Persons Under Age 22#

Revision 09-4; Effective December 1, 2009

State law (Chapter 242, Health and Safety Code) requires that community resource coordination groups (CRCG) be notified when a recipient under age 22 with a developmental disability enters an institutional setting. HHSC must notify the CRCG in the county of residence of the recipient's parent or guardian within three days of the recipient's admission.

The name and telephone number of the appropriate CRCG can be obtained by calling the CRCG state office at 1-866-772-2724. A CRCG list is available on the Internet at: /services/service-coordination/community-resources-...

Documentation of the notification to the CRCG should be filed in the case record.

(mepd-b-7400)(block-3)B-7420 Level of Care/Medical Necessity#

Revision 20-4; Effective December 1, 2020

To be eligible for Medicaid in an institutional setting, a person must have an approved level of care (LOC) for an intermediate care facility for persons with intellectual disabilities (ICF/IID) or an approved medical necessity (MN) with a nursing facility LOC. Texas Medicaid & Healthcare Partnership (TMHP), the state Medicaid claims administrator, is responsible for determining MN for recipients in Medicaid certified facilities.

Do not approve a person for medical assistance for institutional care unless the person has been in a Medicaid facility for at least 30 days and has an approved LOC or MN determination.

For applicants residing in a Medicare skilled nursing facility, the Medicare determination of need for care is acceptable as verification of a valid MN determination. Form 3071, Recipient Election/Cancellation/Discharge Notice (PDF) , substitutes for the MN determination when hospice is elected as referenced in A-5200 , Hospice in a Long-Term Care Facility.

Use the previous LOC or MN determination if:

a person is being reinstated for assistance (a case that was denied in error or a request for a program transfer from SSI to MEPD institutional care); and

vendor payments were made to the Medicaid facility up to the date of denial based on the previous LOC or MN determination.

Program Support Unit (PSU) staff are responsible for providing verification of an approved LOC or MN determination for a person applying for a Home and Community Based Services (HCBS) waiver program.

An approved MN determination for HCBS waiver eligibility is valid to complete a program transfer from an HCBS waiver Medicaid program to the appropriate institutional care program.

A permanent MN determination remains valid at reapplication if a denied Medicaid recipient is discharged from a Medicaid facility for not more than 30 days.

If the LOC or MN determination is still pending prior to certification and the person meets all other eligibility criteria, place the application on delay pending the approved LOC or MN. If verification of the LOC or MN is not received before the end of the delay period, deny the application for no LOC or MN. If the LOC or MN determination is denied, deny the application.

Reopen the application if verification of an approved LOC or MN is received within 90 days of the date of denial following policy in B-5000, Previously Completed Application.

(mepd-b-7400)(block-4)Related Policy#

Previously Completed Application, B-5000 Establish Processing Deadlines, R-3100 Documentation and Verification Guide, Appendix XVI

(mepd-b-7400)(block-5)B-7430 Reserved for Future Use#

Revision 20-4; Effective December 1, 2020

(mepd-b-7400)(block-6)B-7431 Denial of Level of Care/Medical Necessity Determination#

Revision 13-4; Effective December 1, 2013

If a level of care/medical necessity determination is denied for an MEPD recipient, initiate denial procedures immediately.

A recipient may continue to be Medicaid-eligible as long as the recipient meets all eligibility criteria and:

has a diagnosis of mental illness, intellectual disabilities or a related condition;

no longer meets the medical necessity criteria; and

has lived in a nursing facility for 30 months before the date medical necessity is denied and chooses to remain in the facility.

If the recipient has not been in the facility for 30 months, regular Medicaid denial procedures apply.

If an MEPD recipient in a private Medicaid facility is denied solely because of no level of care/medical necessity determination, refer the person to SSA if available income is less than the SSI full federal benefit rate. Refer SSI recipients who are denied a level of care/medical necessity determination to SSA for rebudgeting to the full federal benefit rate.

(mepd-b-7400)(block-7)B-7440 Alternate Care Services#

Revision 21-3; Effective September 1, 2021

Information about all available long-term services and supports must be provided to long term care recipients, their authorized representatives (ARs) and at least one family member of the recipient, if possible. This allows them to make an informed decision about service options.

Form H1204 , Long Term Care Options (PDF) , provides information on available long-term services and supports. It is included with the TF0001, Notice of Case Action, for all MEPD certifications, except for recipients residing in state supported living centers, state hospitals and state centers.

If an applicant, recipient, AR or family member(s) has questions about available long-term care services, refer them to 2-1-1 for current information.

Form H1746-A , MEPD Referral Cover Sheet (PDF) , includes an "LTSS Information Shared" checkbox. Referring agencies will select the box to indicate that Form H1204 has been shared with the person.

(mepd-b-7400)(block-8)B-7450 Medicaid Certified Person Enters Nursing Facility or Home and Community-Based Services Waiver Program#

Revision 22-2; Effective June 1, 2022

(mepd-b-7400)(block-9)Eligibility Systems and Payment Systems#

Service Authorization System Online (SASO) identifies the recipient as Service Group 1 and allows vendor payment when:

an active recipient with coverage Code R (either Long Term Care or Texas Works) enters a nursing facility; and

has a valid medical necessity and facility admission.

The system also automatically assigns a Code 60 (authorization for unlimited medications). This allows all medications to be paid through the vendor drug benefit.

If the nursing facility stay is temporary and the recipient returns home before being transferred to institutional Medicaid, no action is required. Retroactive coverage code changes are not needed.

(mepd-b-7400)(block-10)Texas Works Medicaid to MEPD#

If an active Texas Works Medicaid recipient enters a facility for a long-term stay, TIERS receives the nursing facility admission information from the HHSC webservice interface. TIERS automatically denies the Texas Works Eligibility Determination Group (EDG) and creates a pending ME-Nursing Facility EDG. An H1200 Application for Assistance - Your Texas Benefits must be received before testing for ME-Nursing Facility Medicaid. Disposition of both EDGs must be coordinated. There is no need for retroactive coverage code changes. Vendor payment and medications are authorized through SASO.

If a facility notifies HHSC that an active Texas Work Medicaid recipient has entered the facility, staff should advise the facility that an application is required. Once the application is received, process as any other application and coordinate with Texas Works.

(mepd-b-7400)(block-11)Community to Nursing Facility or Home and Community-Based Services Waiver Eligibility Considerations#

If an active MEPD Medicaid or Medicare Savings Program recipient enters a facility for a long-term stay or requests waiver services, before completing a program transfer, staff must address all factors that may impact eligibility or co-payment. Staff must explore transfer of assets and substantial home equity and provide required information about annuities, estate recovery and long-term care options.

(mepd-b-7400)(block-12)Related Policy#

Medicaid Estate Recovery Program Notification Requirements, B-2600 Alternative Care Services, B-7440 Notice Requirements for Application and Redeterminations, F-7250 Medicaid Coverage Issues Related to Nursing Facility Costs, H-7300 Medicare Skilled Nursing Facilities, R-1210 Notices, R-1300

(mepd-b-8200)Medicaid for the Elderly and People with Disabilities Handbook: B-8200, Redetermining Eligibility#

(mepd-b-8200)(block-1)B-8200, Redetermining Eligibility#

Revision 25-4; Effective Dec. 1, 2025

Redetermine eligibility at least once every 12 months and:

when a change is anticipated;

within 10 business days after a reported change that may affect eligibility or co-payment, including program transfers;

within 30 business days after a reported change that does not affect eligibility or co-payment; and

at least every six months when income is averaged or an incurred medical expense is budgeted.

Note : Children under 19 receive 12 months of continuous eligibility. Refer to continuous Medicaid coverage policy for exceptions.

Redeterminations can be submitted through any of the following channels:

online through YourTexasBenefits.com;

in the local office; or

by mail, fax or phone.

For couple cases, including cases with spouses who may be certified under different types of programs, align the annual redeterminations to simplify the renewal process. Complete a full redetermination of each spouse's eligibility at least once every 12 months.

Document the following information in the case record:

if a special review is needed;

date special review will occur; and

method of monitoring for special review.

Clearly document:

specific information about the reason for setting a special review;

which person is affected; and

the eligibility criteria subject to the review.

Example: If the person has a private pension and the pension amount is anticipated to increase in the future, set a special review for the anticipated change. The case documentation must specify pension information that needs to be verified at the special review, including:

date that the anticipated change will occur;

type of pension;

source of pension; and

payment frequency of the pension.

Use Form H1020, Request for Information or Action , and Form H1020-A, Sources of Proof , to request information from the person or their authorized representative (AR). When requesting more information during a change or redetermination, allow the person at least 10 calendar days from the date of the notice to provide the information. Deny the case for failure to provide information after the due date listed on Form H1020.

Note: Monitor special reviews for resource or income elements through entry of the special review due date in the eligibility determination system.

Data Broker request is not required on redeterminations.

(mepd-b-8200)(block-2)Related Policy#

Continuous Medicaid Coverage, B-6600 Procedures for Redetermining Eligibility, B-8400 Special Reviews, B-8430 How to Budget Variable Income at Applications, E-5400 Ongoing IME Budget, H-2400

(mepd-b-8400)Medicaid for the Elderly and People with Disabilities Handbook: B-8400, Procedures for Redetermining Eligibility#

(mepd-b-8400)(block-1)B-8400, Procedures for Redetermining Eligibility#

Revision 25-1; Effective March 1, 2025

(mepd-b-8400)(block-2)Administrative Renewal Process#

All MEPD types of assistance (TOAs) go through the annual administrative renewal process. The system begins the administrative renewal process without staff action.

The automated administrative renewal process uses information from the existing case record and electronic data sources (ELDS) to determine if the person remains eligible for Medicaid benefits. The electronic data is requested the weekend before cutoff in the eighth month of the recipient’s certification period. The renewal packets are generated in the ninth month of the recipient’s certification period.

The administrative renewal process uses electronic data to automatically:

assess the verification required by program type;

determine the eligibility outcome; and

send the renewal correspondence to the recipient, the authorized representative (AR) or both.

Note: This automated process does not change the verification requirements for renewals.

If there is enough information to verify continued eligibility, the person’s eligibility is renewed without any staff action, and Form TF0001 is generated. If more information is required, the system automatically generates and mails a renewal form to the recipient, AR or both. The recipient has 30 days to return the signed renewal form and all required verification.

The system generates the applicable correspondence from the list below based on the eligibility outcome of the automated renewal process and the action needed by the person:

Form H1211, It Is Time to Renew Your Health Care Benefits Cover Letter;

Form H1233, Redetermination Cover Letter;

Form H1233-MBIC, Redetermination Cover Letter (Medicaid Buy-In for Children);

Form H1200 , Application for Assistance – Your Texas Benefits;

Form H1200-A , Medical Assistance Only (MAO) Recertification;

Form H1200-EZ , Application for Assistance;

Form H1200-MBIC-R, Application for Benefits – Medicaid Buy-In for Children;

Form H1200-PFS , Medical Application for Assistance (for Residents of State Facilities); or

Form H1206ME, Health-Care Benefits Renewal

The renewal cover letter informs the recipient that it is time to renew benefits, provides instructions on how to complete and return the renewal form, along with any required verification documents, and informs the recipient that the information must be returned within 30 days. If the recipient does not return the renewal form and required verification, eligibility is automatically terminated at cutoff in the 12th month for failure to provide the requested information effective the last day of the 12th month. A Form TF0001 is generated.

Recipients can submit a renewal form through any of the following channels:

online through YourTexasBenefits.com;

in the local office; or

by mail, fax or phone.

Notes: Form H1211 and Form H1206ME are generated when the automated renewal process results in Eligibility Approved. Form H1211 informs the recipient to review the information and only return Form H1206ME if the information is incorrect or if there has been a change to their case.

For MEPD programs that require a resource test, an AVS request is submitted with the ELDS request in the eighth month of the certification period.

When processing a renewal, if the AVS Screen does not include an Asset Verification – Automated Admin Renewal report processed on the 8 th month of the current renewal cycle, submit an AVS request for the month the renewal form was received and three months prior.

If the renewal form shows that the recipient wants to register to vote, complete the Voter Registration Information section of the Citizen tab in the Individual Demographics logical unit of work (LUW). Select Yes in the Send Voter Registration Application? dropdown to send form VR30, Texas Voter Registration Application , to the mailing address on file. If the recipient contacts the office declining to complete form VR30, mail Form H1350 , Opportunity to Register to Vote, to the recipient. Form H1350 records the recipient's decision about registering to vote.

(mepd-b-8400)(block-3)Related Policy#

Redetermination Cycles, B-8200 Who May Complete an Application for Assistance, B-3210 Who May Sign an Application for Assistance, B-3220 Voter Registration, C-7000 Asset Verification System (AVS), R-3740

(mepd-b-8400)(block-4)B-8410 Financial Management#

Revision 24-4; Effective Dec. 1, 2024

For redeterminations, explore financial management if there has been no activity in the person’s bank account other than interest credited since the last redetermination.

If a person does not report a bank account, trust fund or similar account on the application for assistance, ask the person or the authorized representative how the person’s financial affairs are handled. This includes who cashes the checks and where, who pays the bills and how, and who keeps the money and how the funds are kept.

If the person reveals past unreported liquid resources, determine the value, ownership and accessibility per the policy for the type of resource.

Acceptable verification sources for financial management include:

Statement from the recipient and the person who handles the recipient’s funds.

Statement from a knowledgeable third party, such as an administrator or bookkeeper in the facility that knows who receives the recipient’s benefit payments and pays the bills.

Information received through AVS.

Document the following information in the case record:

Where checks are cashed and how bills are paid.

Who handles the person’s checks, pays the person’s bills and maintains the person’s money.

How much money, if any, the person or anyone else keeps.

If any funds have accumulated.

Source of information.

(mepd-b-8400)(block-5)B-8420 Notification of Changes as a Result of Redetermination#

Revision 25-2; Effective June 1, 2025

If a redetermination results in one of the following situations, dispose the case and provide the appropriate notice:

Decrease of co-payment - If the recipient's co-payment is decreasing, dispose the case action and send Form TF0001, Notice of Case Action, and Form TF0001P, Provider Notice, to notify the recipient and the facility. To correct the co-payment for a prior period, complete Form H1259, Correction of Applied Income . Note: Complete Form H1259 manually if a co-payment adjustment involves averaged income or incurred medical expenses. If all amounts are lower in the reconciliation shown on Form H1259, adverse action is not required. If Form TF0001 and Form TF0001P are not automatically generated, ensure a manual Form TF0001, Form TF0001P or both are sent.

Increase of co-payment - If the recipient's co-payment is increasing, dispose the case action and send Form TF0001 and Form TF0001P to notify the recipient and the facility. If the recipient does not request an appeal by the end of the 12-day notification period, the increased co-payment remains.

Denial of benefits - If a redetermination results in the termination of benefits, send Form TF0001 to notify the recipient. Send Form TF0001P to notify the facility, if applicable. If the recipient does not request an appeal by the end of the 12-day notification period, the benefits remain terminated.

For redeterminations, if the information provided indicates the person no longer qualifies for the current type of Medicaid, explore eligibility for all other types of Medicaid and the Medicare Savings Programs.

(mepd-b-8400)(block-6)Related Policy#

Application Process, B-3100 Notices, R-1300

(mepd-b-8400)(block-7)B-8430 Special Reviews#

Revision 10-1; Effective March 1, 2010

A special review occurs between the annual review cycles to evaluate one or more eligibility elements without completing the annual review. The annual review (redetermination) packet is not required for a special review.

The need for a special review is based on policy, a reported change or the eligibility specialist's judgment.

Examples of when special reviews are needed for follow-up:

On the person's action for applying for potential benefits. An initial 30-calendar day special review is required to evaluate if the person made application after the person has been notified to do so. This may occur before the application is completed. Another special review will be needed to follow up to see if the recipient continues to be eligible.

When variable income and/or incurred medical expenses are averaged and projected. Special reviews are required at least every six months unless documentation substantiates an exception.

Within a 90-day time frame when the total countable income is within $10 of the income limit.

Within a 90-day time frame when the total countable resources are within $100 of the resource limit.

When any change is anticipated to occur.

For special reviews, document clearly the detailed reason(s) for the special review. Documentation must include:

specific information regarding the reason a special review is set;

the name of the individual who is affected; and

the eligibility area(s) subject to the review.

Include this information on correspondence sent to the person to request information concerning the special review. No redetermination packet is required.

For example, if someone has a private pension and the pension amount is anticipated to increase in the future, set a special review for the anticipated change. The eligibility area will be income. Documentation must specify pension information that will need to be verified at the special review. Include the:

date on which the anticipated change is to occur;

type of pension;

source of pension; and

frequency of payment of pension that will need to be verified at the special review.

Form H1020 , Request for Information or Action , and Form H1020-A , Sources of Proof , are used to request information from the person or authorized representative. Include the due date on Form H1020 or H1020-A. If the recipient calls with questions, follow Appendix XVI , Documentation and Verification Guide , for acceptable verification sources.

Example:

George Black called this morning saying he received a letter requesting verification that he had applied for Veterans Affairs (VA) benefits. He stated that he had applied and was told that it would take at least six months to hear anything.

Document what Mr. Black said. Recipient declaration is acceptable verification that he has applied for additional benefits. Be sure to tell Mr. Black to call and report if he hears anything about his eligibility from the VA.

(mepd-b-8400)(block-8)B-8440 Reserved for Future Use#

Revision 24-4; Effective Dec. 1, 2024

(mepd-b-8400)(block-9)B-8450 Special Reviews when Facility Contract Closure or Cancellation Occurs#

Revision 21-3; Effective September 1, 2021

When a facility’s Medicaid contract is terminated, the facility notifies the recipient and provides them with the option to move to a Medicaid covered facility.

If the Medicaid recipient continues to live in an uncontracted facility, deny Medicaid eligibility and send Form TF0001, Notice of Case Action, to the recipient and or authorized representative (AR) and TF0001P, Provider Notice of Case Action, to the facility. The person will then be responsible for the full vendor payment for that facility.

If the recipient relocates to a Medicaid contracted facility, process a change of address, verify the person continues to meet all Medicaid eligibility criteria and send out a new TF0001 to the recipient and or AR and TF0001P to the new facility.

(mepd-b-8400)(block-10)Related Policy#

Institutional Living Arrangements, B-6300 Redetermination Cycles, B-8200 Notices, R-1300

(mepd-b-8400)(block-11)B-8460 Changes and Program Transfers#

Revision 25-4; Effective Dec. 1, 2025

(mepd-b-8400)(block-12)Changes#

Changes in circumstances are certain events that may affect a person’s eligibility, continued eligibility or co-payment amount.

All changes must be reported within 10 calendar days of the event, including the following changes in the person’s:

address;

living arrangements;

income;

resources; and

marital status.

Act on reported changes within:

10 business days for changes that may affect eligibility or co-payment; or

30 business days for changes that do not affect eligibility or co-payment.

Send Form H1020, Request for Information or Action , if more information is needed to process the change. Allow the person at least 10 days from the notice date on the Form H1020 to provide the information.

Request verification for the new spouse if an active recipient reports a new spouse. Redetermine eligibility as appropriate for a couple or companion case.

Set a special review to take timely action on a change when it can be reasonably anticipated, such as an increase in pension or retirement income.

(mepd-b-8400)(block-13)Program Transfers#

A program transfer occurs when an active recipient is determined eligible for another type of Medicaid or Medicare Savings Program (MSP).

For a program transfer from a community-based Type of Assistance (TOA) to a full verification TOA, request AVS for 60 months to check for possible transfer of assets.

Example: A Community Attendant Services recipient enters a nursing facility (NF) and is determined eligible for NF Medicaid.

A request for a program transfer is considered a change. Process the program transfer within 10 business days of receiving the request.

Redetermine eligibility and verify all required eligibility criteria for the new program, including 30-day consecutive stay, transfer of assets, substantial home equity and spousal impoverishment. Request 60 months of AVS information if the transfer is from a community program to a full verification program.

Send Form H1020 if more information is needed to process the program transfer. Allow the person at least 10 days from the notice date on the Form H1020 to provide the information.

Note: Do not transfer a child to a Medicaid program with lesser benefits during the 12-month continuous eligibility period.

(mepd-b-8400)(block-14)Continuous Medicaid Eligibility#

Children under 19 receive 12 months of continuous Medicaid eligibility. Coverage is continuous, regardless of changes, unless the child:

turns 19;

moves out of state;

dies;

requests a voluntary withdrawal; or

was invalidly enrolled due to certification in error, or an Office of Inspector General determination of fraud, abuse or perjury.

Do not terminate a child’s eligibility when a change is reported or an agency-generated change is received during the 12-month continuous eligibility period, unless the change is reporting one of the exceptions to continuous coverage listed above. Document the change and address it at the next annual redetermination.

Take action to update the case record if a change of address or a change in contact information is reported during the 12-month continuous eligibility period.

(mepd-b-8400)(block-15)Related Policy#

Missing Information Due Dates, B-6420 Continuous Medicaid Coverage, B-6600 Medicaid Certified Person Enters Nursing Facility or Home and Community-Based Services Waiver Program, B-7450 Redetermining Eligibility, B-8200 Responsibility to Provide Information and Report Changes, C-8000 Asset Verification System (AVS), R-3740

(mepd-b-9100)Medicaid for the Elderly and People with Disabilities Handbook: B-9100, General Information for Denials and Terminations#

(mepd-b-9100)(block-1)B-9100, General Information for Denials and Terminations#

Revision 24-4; Effective Dec. 1, 2024

Although often used interchangeably, denials and terminations are different types of adverse case actions.

A denial refers to a determination of ineligibility for Medicaid benefits that a person is not currently receiving. A denial action may occur when processing an application, a request for a new type of benefit, or a program transfer request.

A termination refers to a determination of ineligibility for ongoing Medicaid benefits that a person is currently receiving. A termination action may occur when processing a renewal or redetermination based on a change in circumstances .

Unless otherwise specified, the policy in the following sections applies to both denials and terminations.

(mepd-b-9100)(block-2)Procedural Denials#

A procedural denial occurs when a person is ineligible for benefits because they failed to provide all information needed to make an eligibility determination. Examples of actual procedural denial reasons on the TF0001, Notice of Case Action, include:

Individuals was sent forms to renew benefits. They didn't return the forms by the due date.

You failed to provide required information by the due date.

(mepd-b-9100)(block-3)Non-Procedural Denials#

A non-procedural denial occurs when a person is not eligible for benefits based on the information provided. They do not meet one or more specific financial or non-financial eligibility requirements, and there are no exceptions that would make them eligible. Examples of non-procedural denial reasons on the TF0001 notice include:

The money Individuals gets (income) is more than allowed for this program.

The value of the things this person is paying for or owns is more than allowed by program rules.

[Client] didn't give proof showing that they live in Texas.

[Client] has not shown that they are either a citizen or a non-citizen who is qualified to receive benefits.

(mepd-b-9100)(block-4)Determine Medicaid Eligibility on All Bases#

Consider Medicaid eligibility on all bases prior to denying or terminating Medicaid eligibility. Determine if the person is eligible for any other Medicaid and Medicare Savings Program (MSP) benefits, including both Modified Adjusted Gross Income (MAGI) and non-MAGI types of assistance (TOAs).

If the person is eligible for another type of Medicaid or MSP program, transfer to the new TOA without requiring a new application. If more information is needed to determine eligibility for another TOA, including transfers from a non-MAGI program to a MAGI program or vice versa, pend the case and request only the information needed. Do not request a new application or verification of information available through an electronic data source.

Example : A person submits Form H1200 , Application for Assistance - Your Texas Benefits, to apply for Waiver Medicaid for a minor child. The child does not have an established disability determination and is not eligible for Waiver Medicaid. Based on the information provided, the system cascades to Children’s Medicaid (CMA). Confirm the eligibility determination is correct and certify the child for CMA without requiring a Form H1010 , Texas Works Application for Assistance - Your Texas Benefits, or Form H1205 , Texas Streamlined Application.

(mepd-b-9100)(block-5)Related Policy#

Previously Completed Application, B-5000 Denials, B-6500 Potential Resource Exclusions, F-5200

(mepd-b-9300)Medicaid for the Elderly and People with Disabilities Handbook: B-9300, Date of Death Denials and Verification Sources#

(mepd-b-9300)(block-1)B-9300, Date of Death Denials and Verification Sources#

Revision 19-3; Effective September 1, 2019

(mepd-b-9300)(block-2)Date of Death Matches#

HHSC matches recipients on active TIERS Eligibility Determination Groups (EDGs) with records from the Social Security Administration (SSA), Texas Bureau of Vital Statistics (BVS), the Centers for Medicaid and Medicare Services (CMS), and HHSC Webservices to identify deceased persons and automatically remove them from active EDGs. If unable to process the death data automatically, TIERS creates tasks for staff to perform more research to determine the validity of the computer match. TIERS will attempt to update the Date of Death (DOD) information for all active and inactive person(s).

(mepd-b-9300)(block-3)Death Verification Sources#

Take action to clear any discrepancies when DOD data is received on an active or inactive person within TIERS and the system is unable to automatically dispose the case. When the system cannot dispose the case, a series of alerts are created for staff to explore and request additional verification of the death data.

Primary source of verification of death is the Bureau of Vital Statistics (BVS).

If BVS is not available, verify the date of death using two of the following sources:

Social Security Administration (SSA);

statement from guardian or other authorized representative;

copy of death certificate;

statement from a doctor;

newspaper death notice (obituary);

statement from a relative or household member;

statement from funeral director; or

records from hospital or other institution where the person died.

Note: If BVS is received but the date of death does not match previously reported information, accept BVS as verification and dispose the case. No additional verification is needed because BVS is considered the primary verification source.

Example: DOD data received from an SSA interface shows a DOD of 01/15/2019 but, the same person had a DOD of 01/13/2019 listed in TIERS. Alert 812, Verify Discrepancy in Date of Death for Individual is created for additional action. Staff verify the DOD by contacting the nursing home where the person was residing prior to death and also locate the person's obituary online. Staff enter the DOD based on the additional information and clear the alert

For detailed processing instructions, staff may review the Eligibility Services State Processes document and the Change and Alert Guide.

(mepd-b-9300)(block-4)Related Policy#

Social Security Administration Deceased Individual Report, R-4110

(mepd-b-9400)Medicaid for the Elderly and People with Disabilities Handbook: B-9400, Extending Postpartum Coverage After MEPD Termination#

(mepd-b-9400)(block-1)B-9400, Extending Postpartum Coverage After MEPD Termination#

Revision 24-4; Effective Dec. 1, 2024

Pregnant or postpartum women who lose eligibility for the following types of assistance automatically transition to Medicaid for Pregnant Women (TP 40) coverage for the remainder of their pregnancy and 12-month postpartum period:

ME - Waivers

ME - State Group Home

ME - Pickle

ME - SSI

ME - State School

ME - Non-State Group Home

ME - State Hospital

ME - Medicaid Buy-In

ME - Medicaid Buy-In for Children (MBIC)

ME - Nursing Facility

ME - Disabled Adult Child

ME - Disabled Widow(er)

ME - Early Aged Widow(er)

Note: ME - Community Attendant is not full Medicaid. Community Attendant Services (CAS) provides payment for attendant care only. Recipients certified on ME - Community Attendant must submit an application to determine eligibility for Pregnant Women (TP 40).

If a pregnant or postpartum woman loses ongoing eligibility for their current Medicaid coverage, a new TP 40 EDG is created without an application for pregnancy Medicaid. A full redetermination of eligibility must occur at the end of the TP 40 certification period.

Continuous Medicaid coverage is provided through the pregnancy and the 12-month postpartum period regardless of any change in circumstance unless the woman:

voluntarily withdraws;

moves out of state;

dies; or

is ineligible due to agency error, fraud, abuse or perjury attributed to the person.

(mepd-b-9400)(block-2)Unverified Pregnancy#

When a recipient loses MEPD eligibility, and pregnancy information is received through an interface, the woman is automatically certified for TP 40 with postponed verification and Form H1020 , Request for Information or Action is sent. If verification is provided, the woman is eligible for TP 40 coverage through her pregnancy and postpartum period. If verification is not provided, or shows the woman does not meet eligibility requirements, TP 40 coverage is terminated unless the woman is under 19 years old.

Children Under 19

If pregnancy verification is not provided by the 30 th day, TP 40 coverage is terminated and the MEPD type of assistance is re-established based on continuous eligibility for children under 19 policy.

If a child who is certified on CHIP during their pregnancy or postpartum period becomes eligible for SSI, MEPD Facility, or MEPD Non-Facility TOA, the CHIP coverage is terminated to allow the transition to SSI, MEPD Facility, or MEPD Non-Facility TOA. The household will receive a denial notice showing the child is not eligible for CHIP for the remainder of their pregnancy and 12-month postpartum period because they are eligible for Medicaid.

(mepd-b-9400)(block-3)Related Policy#

Continuous Medicaid Coverage, B-6600 Pregnancy and 12-Month Postpartum Coverage After SSI Denial, B-7120

(mepd-c-2200)Medicaid for the Elderly and People with Disabilities Handbook: C-2200, Establishing Identity for Contact#

(mepd-c-2200)(block-1)C-2200, Establishing Identity for Contact#

Revision 24-3; Effective Sept. 1, 2024

Keep all information confidential about an applicant, recipient or any person on a case. Confidential information includes, but is not limited to, individually identifiable health information.

Before discussing or releasing confidential information about a person, take steps to ensure the person receiving the information is either the applicant or recipient or someone authorized to receive confidential information, such as an attorney or personal representative.

(mepd-c-2200)(block-2)C-2210 Phone Contact#

Revision 24-3; Effective Sept. 1, 2024

To establish the identity of a person who claims to be the applicant, recipient or personal representative, request the following:

the Social Security number, date of birth or other identifying information for the applicant or recipient, or their representative;

to call the person back at a number that has been verified as belonging to the person or their representative.

Establish the identity of attorneys or legal representatives by asking the person to provide Form H1003 , Appointment of an Authorized Representative, completed and signed by the applicant or recipient.

Contact the HHS Office of Chief Counsel upon receipt of any requests for confidential information from law enforcement, state officials or legislators.

(mepd-c-2200)(block-3)C-2220 In-Person Contact#

Revision 24-3; Effective Sept. 1, 2024

Establish the identity of a person at an HHSC office who states they are an applicant, recipient or personal representative by requesting their:

driver's license;

date of birth;

Social Security number; or

other identifying information.

Establish the identity of other HHSC staff, federal agency staff, researchers or contractors by viewing their:

employee badge; or

government-issued identification card with a photograph.

Verify the need for other HHSC staff, federal agency staff, researchers or contractors to access confidential information through:

official correspondence or phone call from state office or regional offices; or

contact with regional attorney.

Contact appropriate regional or state office staff when federal agency staff, contractors, researchers or other HHSC staff come to an HHSC office without prior notification or adequate identification and request permission to access HHSC records.

Note: Contractors cannot have access to Internal Revenue Service (IRS) Federal Tax Information (FTI).

(mepd-c-2200)(block-4)C-2230 Verification and Documentation#

Revision 25-4; Effective Dec. 1, 2025

When disclosing individually identifiable health information, document the method of verification for the identity of the person if contact is outside an interview.

Verify a person’s identity who requests disclosure of individually identifiable health information using the following sources:

valid driver's license or Department of Public Safety identification (ID) card;

birth certificate;

hospital or birth record;

adoption papers or records;

work or school ID card;

voter registration card;

wage stubs; or

U.S. passport.

As a condition for receiving federal taxpayer information from the IRS, HHSC must, per Internal Revenue Code 6103(p)(4) establish and maintain, to the satisfaction of the IRS, safeguards designed to prevent unauthorized access, disclosure, and use of all returns and return information and to maintain the confidentiality of that information. The IRS security requirements for safeguarding IRS FTI are outlined in Publication 1075, Tax Information Security Guidelines for Federal, State and Local Agencies, Safeguards for Protecting Federal Tax Returns and Return Information .

Income Eligibility and Verification System (IEVS) specialists must independently verify the income and resource information from any data matches to ensure continuous financial eligibility.

When processing the IEVS match of IRS FTI, staff must not enter any IRS FTI into TIERS, including comments. Documentation in the TIERS income or resource screens is limited to the approved language available for staff use on The LOOP .

(mepd-c-2200)(block-5)C-2240 Alternate Means of Communication#

Revision 24-3; Effective Sept. 1, 2024

HHSC must accommodate a person’s reasonable request to receive communications by alternative means or at alternate locations.

The person must specify in writing the alternate mailing address or means of contact and include a statement that using the home mailing address or normal means of contact could endanger the applicant or recipient.

(mepd-c-2300)Medicaid for the Elderly and People with Disabilities Handbook: C-2300, Safeguarding Federal Income Data#

(mepd-c-2300)(block-1)C-2300, Safeguarding Federal Income Data#

Revision 24-3; Effective Sept. 1, 2024

Federal Tax Information (FTI) includes tax returns or return information received directly from the Internal Revenue Service (IRS) or obtained through an authorized secondary source, such as the Social Security Administration. Staff must protect digital and non-digital media containing FTI from unauthorized inspection and disclosure. Digital media includes computers, mobile devices and removable storage, such as CDs, DVDs and external hard drives. Non-digital media includes a paper form, report and log.

HHSC limits FTI access to staff whose duties require access. HHSC agency and non-agency staff access FTI physically and through the Automated System for Office of Inspector General (ASOIG). Staff must handle FTI using the following policies to ensure information does not become misplaced, stolen or made available to unauthorized personnel.

HHSC Income Eligibility Verification System (IEVS) staff must retain electronic IEVS worksheets for five years. Staff may log and destroy any printed IEVS module records using IRS safeguarding requirements once they are no longer needed because the electronic records are available and kept in ASOIG for the applicable retention period.

The following forms must be kept for five years from the date of the last entry on the form:

Form H1861 , Federal Tax Information Record Keeping and Destruction Log;

Form H1862 , Federal Tax Information Transmittal Memorandum;

Form H1863 , Federal Tax Information Removal Log;

Form H1864 , Federal Tax Information Fax Transmittal; and

Form H1866 , Federal Tax Information Visitor Access Log.

(mepd-c-2300)(block-2)C-2310 IRS FTI Security and Awareness Training#

Revision 24-3; Effective Sept. 1, 2024

HHSC and non-HHSC staff who access or may potentially encounter FTI must take and pass the annual Safeguarding IRS Federal Tax Information training to receive and maintain their access permissions to ASOIG. HHSC staff access the training course under System Training Solutions (STS) in the Centralized Accounting and Payroll/Personnel System (CAPPS). Non-HHSC staff may contact the HHSC IRS Coordinator by email at the HHSC AES Federal Tax Info Training Mailbox to get a copy of the training.

HHSC developed the Safeguarding IRS Federal Tax Information training with role-based job aids as an agency resource for security and privacy awareness. HHSC updates this training on an annual basis to reflect any system and policy changes and address audit findings.

HHSC staff submit a confirmation of understanding in STS once the Safeguarding IRS Federal Tax Information training is complete. The confirmation acknowledges staff completed a thorough review of the web-based training and job aids in the resources tab relevant to their professional role. Additionally, it confirms understanding of incident reporting requirements. STS maintains a record of completion for each employee. Non-HHSC staff must review a PDF version of the training, sign Form H4096 , Safeguarding Information Certification, and submit the form to their management. The form confirms completion and understanding of the material within the training, as well as the penalties involved for any unauthorized inspection and disclosure of FTI. Non-HHSC management must maintain a copy of the Form H4096 in the employee’s file.

HHSC staff must also complete the HHS Information Security/Cybersecurity Awareness Training and the HHS Privacy Training within 30 days from their hire date and before accessing ASOIG. These trainings are available in STS in CAPPS.

(mepd-c-2400)Medicaid for the Elderly and People with Disabilities Handbook: C-2400, Custody of Records#

(mepd-c-2400)(block-1)C-2400, Custody of Records#

Revision 24-3; Effective Sept. 1, 2024

Records must be safeguarded. Use reasonable diligence to protect and preserve records and to prevent disclosure of the information they contain except as provided by HHS regulations.

Reasonable diligence for employees responsible for records includes always keeping records:

in a locked office when the building is closed;

properly filed during office hours;

in the office except when authorized to remove or transfer them; and

per the guidelines for electronic file information as referenced in the HHS Computer Usage and Information Security training.

In addition to the measures for custody of records, use the following to safeguard tape match data obtained through the Income Eligibility and Verification System (IEVS) module within the Automated System of Office of Inspector General (ASOIG) application:

Use IEVS data only for the purpose of determining eligibility for MEPD, Medicare Savings Program (MSP), Medical Assistance, Temporary Assistance for Needy Families (TANF) and Supplemental Nutrition Assistance Program (SNAP) benefits.

Verify IEVS tax data before taking adverse case actions.

Review the Annual Safeguarding IRS Federal Tax Information training and the following three laws that explain criminal and civil penalties for unauthorized disclosure of tax data once a year: Section 7213 – Unauthorized Disclosure of Returns or Return Information, a criminal felony punishable upon conviction by a fine up to $5,000 not including the cost of prosecution, imprisonment for up to five years or both. Section 7213A – Unauthorized Inspection of Returns or Return Information, a criminal misdemeanor punishable upon conviction by a fine up to $1,000 not including the cost of prosecution, imprisonment for up to one year or both. Section 7431 – Civil Damages for Unauthorized Disclosure of Returns and Return Information, which permits a taxpayer to sue for civil damages if a person knowingly or negligently discloses tax return information and upon conviction, a notification to the taxpayer.

(mepd-c-2400)(block-2)Related Policy#

Custody of Records, C-2300 System Generated IEVS Worksheet Legends of IRS Tax Data, Appendix XVII IRS Tax Code, Sections 7213, 7213A and 7431, Appendix XVIII

(mepd-c-2400)(block-3)C-2410 Accessing IRS FTI#

Revision 24-3; Effective Sept. 1, 2024

All Programs

HHSC and non-HHSC staff are prohibited from using personally owned media on agency systems or system components. Staff are also prohibited from using portable storage devices in agency systems when such devices have no identifiable owner.

HHSC and non-HHSC staff must adhere to policies and procedures for the handling and protection of FTI to prevent unauthorized access and disclosure. Failure to adhere to the policies or procedures will result in disciplinary action, including warnings, access suspension, permanent access removal or termination.

HHSC and non-HHSC management notify their staff within 72 hours when the formal employee sanction process is initiated. The notification includes the staff member sanctioned and the reason for the sanction.

HHSC and non-HHSC management must remove system and physical access when their staff transfer or are reassigned to a position that no longer requires ongoing operational need to access FTI. HHSC and non-HHSC management submit a modified access request within 24 hours of the transfer or reassignment.

HHSC and non-HHSC management must remove system and physical access and discuss information security during an exit interview when employment is terminated. HHSC and non-HHSC management submit a modified access request within 24 hours of the termination.

Work areas where staff physically access FTI should be limited to authorized personnel only. These areas must be prominently posted and separated from non-restricted areas by physical barriers that control access. FTI must be secured during and after normal operating hours. Staff accessing secured areas must clearly display a picture identification badge. The badge may not be obstructed and must be displayed above the waist.

Staff responsible for protecting access to FTI must mark system media containing FTI to show the distribution limitations, handling caveats and applicable security markings, if any. Additionally, staff responsible for protecting access to FTI must physically control and securely store media containing FTI within agency-controlled areas. Protect system media until it is sanitized or disposed of using approved equipment and methods.

(mepd-c-2400)(block-4)C-2411 Minimum Protection Standards#

Revision 24-3; Effective Sept. 1, 2024

All Programs

Minimum protection standards (MPS) require the agency to use at least two barriers to protect FTI from unauthorized access. These barriers include a combination of secured perimeters, security rooms, badged employees and security containers.

Secured Perimeters are enclosed by slab-to-slab walls constructed of durable materials and supplemented by periodic inspection. Any lesser-type partition must be supplemented by electronic intrusion detection and fire detection systems. All doors entering the space must be locked per Locking Systems for Secured Areas. In the case of a fence or gate, the fence must have intrusion detection devices or be continually guarded. The gate must be either guarded or locked with intrusion alarms.

Security Rooms are constructed to resist forced entry. The entire room must be enclosed by slab-to-slab walls constructed of approved materials, such as masonry brick or concrete, and supplemented by periodic inspection. Door hinge pins must be non-removable or installed on the inside of the room. Access must be limited to specifically authorized personnel.

Badged Employees can serve as the second barrier during business hours between FTI and unauthorized persons. The authorized personnel must wear picture identification badges or credentials. The badge must be clearly displayed and worn above the waist.

Security Containers are storage devices, such as turtle cases, safes, vaults or locked IT cabinets, with resistance to forced penetration and a security lock with controlled access to keys or combinations.

(mepd-c-2400)(block-5)C-2412 Locking Mechanisms#

Revision 24-3; Effective Sept. 1, 2024

All Programs

All buildings, rooms and containers containing FTI must be locked when not in actual use. Key or combination locking mechanisms may secure FTI. Staff not authorized to access FTI may have a key to the building but not the secured room. This includes unauthorized agency staff, contractors, security personnel, custodial staff and landlords.

The following guidelines apply to key locking mechanisms:

The number of keys must be kept to a minimum.

Only authorized staff can access the secured area.

The unauthorized duplication of keys is prohibited.

Keys must be returned before departure for staff who retire, terminate employment or transfer to another position.

Management must conduct annual reconciliation of key records.

The following rules apply to combination locking mechanisms:

The combination is only shared with authorized staff.

The unauthorized disclosure of the combination is prohibited.

Management must change the combination at least annually or upon departure of staff that retire, terminate employment or transfer to another position.

(mepd-c-2400)(block-6)C—2413 Authorized Access, Visitor Access and Authorized Personnel Lists#

Revision 24-3; Effective Sept. 1, 2024

All Programs

HHSC must maintain a visitor log and authorized access list (AAL) to record access to physical work areas containing FTI. Staff maintain Form H1866 as a record of visitor access to a restricted area. Security staff must validate a visitor’s identity by examining a government-issued identification, such as a state-issued identification, driver’s license or passport. An AAL is maintained and MPS enforced to facilitate the entry of staff who have a frequent and continuing need to enter a restricted area but who are not assigned to the area. The AAL must contain the following:

name of employee, vendor, contractor or non-agency personnel;

name of agency or department;

name and phone number of the agency point-of-contact authorizing access;

address of agency, vendor or contractor; and

purpose and level of access.

HHSC management must review the AAL monthly or upon potential indication of an event such as a security breach or personnel change. HHSC management must maintain an authorized personnel list of all staff who have access to information systems areas containing FTI.

(mepd-c-2400)(block-7)C-2414 Access Control Systems#

Revision 24-3; Effective Sept. 1, 2024

All Programs

Access control systems such as badge readers, smart cards or biometrics, that provide the capability to audit access control attempts must maintain access control logs with successful and failed access attempts to secured areas containing FTI or systems that process FTI. Management must review access control logs monthly. Access control logs must contain the following information for each access request:

the name of the access control device owner;

the success or failure of the access request; and

the date and time of the access request.

(mepd-c-2400)(block-8)C-2420 Transporting IRS FTI#

Revision 24-3; Effective Sept. 1, 2024

All Programs

Staff must transport media containing FTI in a way that prevents loss or unauthorized disclosure. The IRS prohibits staff from transmitting FTI by agency email systems, Microsoft Teams or by phone. Staff must not use HHSC email addresses to send confidential or agency-sensitive information to personal email addresses.

Staff must secure computers and electronic media that receive, process, store, access, protect or transmit FTI in an area with restricted access. The agency must use encryption mechanisms on all computers and mobile devices that contain FTI to prevent access if lost or stolen. Staff must label removable media containing FTI.

Authorized staff must keep all computers, electronic media and removable storage containing FTI in their immediate protection and control during use. When not in use, authorized staff must secure the device in the proper storage area or container. Staff may not leave devices unattended in a public area. HHSC management must maintain inventory records of computers, electronic devices and removable media and complete a semi-annual review for control and accountability.

(mepd-c-2400)(block-9)C-2421 In-Person Transport#

Revision 24-3; Effective Sept. 1, 2024

All Programs

Staff transporting media containing FTI must always keep it in their possession. Never leave FTI unattended in a public setting. Use Form H1863 when removing FTI from a file and retain the form for five years from the last FTI removal indicated.

For office relocations, ensure plans include the proper protection and accountability of all FTI. Staff must lock FTI in cabinets or sealed packing cartons while in transit. HHSC staff maintain custody of FTI to ensure cabinets or cartons containing FTI are not misplaced or lost in transit.

(mepd-c-2400)(block-10)C-2422 Mail or Courier Transport#

Revision 24-3; Effective Sept. 1, 2024

All Programs

Double seal all FTI transported through the mail by sealing one envelope within another envelope. On the inner envelope, staff must mark Confidential to indicate that only the designated recipient is authorized to open it. Do not label the outermost envelope as FTI or provide any indication that it contains FTI. Use Form H1862 when mailing all paper documents that contain IRS data. The sender ensures the receiver acknowledges the receipt of the information.

(mepd-c-2400)(block-11)C-2423 Fax Transport#

Revision 24-3; Effective Sept. 1, 2024

All Programs

Fax machines must be placed in a secure area and staff should refrain from faxing FTI, when possible. There must be trusted staff at both the sending and receiving fax machines. When faxing is required, staff must use Form H1864. The form must accompany all faxed documents that contain IRS data when transferred from one office to another or from an office to a banking institution for verification purposes. The sender ensures the receiver acknowledges the receipt of the information and retains this form for five years.

(mepd-c-2500)Medicaid for the Elderly and People with Disabilities Handbook: C-2500, Disposal of Records#

(mepd-c-2500)(block-1)C-2500, Disposal of Records#

Revision 24-3; Effective Sept. 1, 2024

To dispose of documents with an applicant or recipient's information, follow procedures for destruction of confidential data per Texas Health and Human Services (HHSC) records management policies.

(mepd-c-2500)(block-2)C-2510 Internal Revenue Service (IRS) Federal Tax Information (FTI) Sanitization#

Revision 24-3; Effective Sept. 1, 2024

All Programs

The sanitization process removes FTI from media to ensure the information cannot be retrieved or reconstructed. Examples include, but are not limited to, digital media found in scanners, copiers, printers, computers, network components, mobile devices, and non-digital media such as paper and microfilm. Staff must use agency-approved software and methods for sanitizing FTI. The following are acceptable sanitization methods:

Clearing protects the confidentiality of information against a robust keyboard attack. Simple deletion of items is not sufficient. Clearing must not allow information to be retrieved by data, disk or file recovery utilities. It must be resistant to keystroke recovery attempts. Overwriting is an example of an acceptable clearing method.

Purging protects the confidentiality of information against a laboratory attack. This type of attack involves using signal processing equipment and specially trained personnel. Examples of acceptable purging methods are executing the firmware Secure Erase command for ATA drives and degaussing by destabilizing a device’s magnetic field.

HHSC must maintain sanitization records which include the:

control number, file name and contents, or both for each record;

total number of records;

date and method of sanitation; and

date of sanitization verification.

(mepd-c-2500)(block-3)C-2520 IRS FTI Destruction#

Revision 24-3; Effective Sept. 1, 2024

All Programs

The destruction process ensures that media with FTI cannot be reused as originally intended. Examples include but are not limited to disintegration, incineration, pulverizing, shredding and melting. Staff use Form H1861 to record and track the destruction of FTI. If non-HHSC staff destroy FTI, an HHSC employee must witness the destruction. Staff must use the following approved destruction methods for destroying FTI:

Incinerators certified to produce enough heat to burn the entire bundle. If the incinerator cannot burn the entire bundle, separate the pages to ensure all materials are incinerated.

Shredders producing crosscut particles which are a maximum of 1 mm by 5 mm or 0.04 inches by 0.2 inches. If shredding deviates from these specifications, then the FTI must be safeguarded until it reaches the stage where it is rendered unreadable through additional means, such as burning or pulping.

Disintegrator or Pulverizer equipped with a 2.4-mm or 3/32-inch security screen.

HHSC must maintain destruction records which include:

date the records were received;

control number, file name and contents, or both for each record;

name of the person receiving the records;

total number of records, if available;

movement of records from receipt to destruction; and

date and method of destruction.

(mepd-c-2600)Medicaid for the Elderly and People with Disabilities Handbook: C-2600, Reporting Security Incidents#

(mepd-c-2600)(block-1)C-2600, Reporting Security Incidents#

Revision 24-3; Effective Sept. 1, 2024

If information about an applicant or recipient is requested but cannot be released, inform the inquiring person or agency that federal and state laws and HHSC regulations require that the information being requested remain confidential. Refer the questioner to Title 42 of the United States Code, Section 1396a(a)(7); 42 CFR Sections 431.300-431.307; and Texas Human Resource Code, Sections 12.003 and 21.012. For individually identified health information, refer the requestor to 45 CFR sections 164.102-164.534. For tax information obtained through IEVS, also refer the requestor to the Internal Revenue Service (IRS) Code, Sections 7213, 7213A and 7431. Title 26 US Code Section 6103 is the confidentiality statue that prohibits disclosure of FTI. For human services agencies, it is IRC 6103(1)(7). Note: Refer to Appendix XVIII , IRS Tax Code, Sections 7213, 7213A and 7431.

If subpoenaed to appear in court with an applicant's or recipient's record, notify the supervisor immediately. Give the supervisor all the facts about the case and the date and time of the court hearing. The supervisor should contact the lawyer who is requesting the record and determine if the requested information is confidential. If a problem exists, the supervisor should inform the regional attorney about all relevant facts. Usually, the subpoenaed employee must take the record and appear in court as directed by the summons. When requested to disclose information from the record, ask the judge to be excused from disclosing the information because of the statutory prohibitions stated previously in this section. Abide by the ruling of the judge.

If subpoenaed to appear in court, and no time is allowed to follow the steps specified in this section, take the record and appear in court as directed by the summons. When requested to disclose the information from the record, follow the procedure described in Step 2.

For individually identifiable health information, refer the requestor to 45 CFR Sections 164.102-164.534.

FTI security incidents include loss of control, unauthorized access, unauthorized disclosure or unauthorized inspection. Once an actual or possible compromise of IRS FTI or an unauthorized inspection or disclosure of IRS FTI is discovered, including breaches and security incidents, the person observing or receiving the information must immediately contact the HHSC IRS coordinator within 24 hours of initial discovery. Send a secure email with the subject line, URGENT: FTI Data Incident Report to the HHSC IRS Coordinator Mailbox .

The HHSC IRS Coordinator reports the incident by:

contacting the office of the appropriate special agent-in-charge, Treasury Inspector General for Tax Administration (TIGTA); and

following the IRS Office of Safeguards, as directed in Section 10.2 of IRS Publication 1075.

In the event the HHSC IRS coordinator fails to respond by the close of the next business day, staff immediately inform management by sending an email with the subject line, URGENT – POSSIBLE UNAUTHORIZED DISCLOSURE OR INSPECTION OF FTI to HHSC Offices for Information Technology, Privacy Division, Chief Information Security Office and IRS coordinator.

Examples of FTI security incidents include but are not limited to:

leaving an agency computer or laptop with FTI unlocked and unattended;

leaving a file cabinet with FTI unlocked;

allowing contract IT Help Desk support access to an agency device with FTI while the user is accessing ASOIG;

printing FTI on Xerox Multi-Factor Office Devices;

allowing unmonitored contractor access to an FTI hardware server;

discussing FTI on a Voice over Internet Protocol (VoIP) phone with people or other agency employees;

viewing FTI remotely without approval;

sending screenshots of FTI data from the ASOIG application;

screensharing FTI during virtual meetings, which includes meetings conducted through Microsoft Teams, Zoom, Go To Meeting, Webex and Google Meet; and

stealing or losing laptop computers, removable devices or non-digital media containing FTI.

(mepd-c-2600)(block-2)C-2610 Penalties for Disclosing FTI#

Revision 24-3; Effective Sept. 1, 2024

All Programs

People responsible for the willful unauthorized inspection or disclosure of FTI may be subject to criminal and civil penalties in addition to disciplinary action. Security incidents may also result in temporary or permanent suspension from ASOIG access.

Criminal penalties for willful unauthorized inspection of FTI are:

a fine up to $1,000; and

one year in prison, together with the costs of prosecution.

Criminal penalties for willful unauthorized disclosure of FTI are:

a fine up to $5,000; and

up to five years in prison, together with the costs of prosecution.

Civil penalties for willful unauthorized inspection or disclosure of FTI are:

the greater of $1,000 or actual damages for each incident; and

court costs and attorney fees to the plaintiff.

(mepd-c-3000)Medicaid for the Elderly and People with Disabilities Handbook: C-3000, When and What Information May Be Disclosed#

(mepd-c-3000)(block-1)C-3000, When and What Information May Be Disclosed#

Revision 21-4; Effective December 1, 2021

Staff must make reasonable efforts to limit the use or disclosure of individually identifiable health information to determine eligibility and operate the program. Disclosure of medical information from HHSC records must be minimal to achieve the requested disclosure. For example, If a person authorizes release of income verification, including disability income, do not release related case medical information unless specifically authorized by the person.

Case information may be released to Medicaid providers to help in providing services and filing claims for payment.

Only release case information, such as personal information or addresses, to a person who has written permission from the applicant or recipient to get the information.

You must have the applicant’s or recipient’s consent to respond to inquiries from their relatives or friends requesting addresses or personal information. Inform the applicant or recipient of any inquiries. Allow the applicant or recipient to decide if they wish to share the information before providing the information to the inquiring party.

The applicant or recipient authorizes the release of information by completing and signing:

Form H1003, Appointment of an Authorized Representative ;

Form H1826, Case Information Release ; or

A document containing all following information: the case name and case number, or full name, including middle initial, and either their date of birth or Social Security number; a description of the information to be released. If a general release is authorized, provide the information that can be disclosed to the person. Withhold confidential information from the case record, such as names of people who disclosed information about the household without the household's knowledge, and the nature of pending criminal prosecution; a statement specifically authorizing HHSC to release the information; the name of the person or entity to whom the information will be released; the purpose of the release; an event that triggers an expiration of the authorization, or an expiration date of the release; a statement about whether refusal to sign the release affects eligibility for or delivery of services; a statement describing the person's right to revoke the authorization to release information; the date the document is signed; and the signature of the person or Authorized Representative (AR) .

If the case information released includes individually identifiable health information, the document must clearly indicate the applicant or recipient understands any information released may not be private and may be released again by the person receiving the information.

When information is requested from the case records of a deceased person, protect the privacy of the deceased person. Follow policy to determine who can act for the deceased person about individually identifiable health information.

Do not include Form H1826 or other information release authorization documents in application packets.

The HHSC Office of the Chief Counsel handles questions about the release of information under the Open Records Act. Refer all questions and issues encountered by people concerning release of information to the Open Records Division, Office of the General Counsel .

Follow Confidential Nature of Medical Information – HIPAA policy for restrictions on the release of a person's protected health information under the Health Insurance Portability and Accountability Act (HIPAA) privacy regulations.

(mepd-c-3000)(block-2)Related Policy#

Confidential Nature of Medical Information, C-4000 Deceased Individuals, C- 5300 Prior Coverage for Deceased Applicants, G-7210

(mepd-c-6100)Medicaid for the Elderly and People with Disabilities Handbook: C-6100, Appeals#

(mepd-c-6100)(block-1)C-6100, Appeals#

Revision 13-2; Effective June 1, 2013

If an individual is dissatisfied with HHSC's decision concerning his eligibility for any MEPD program, including Medicaid Savings Programs, the individual has the right to appeal through the appeal process established by HHSC. In certain circumstances, the individual is entitled to receive continued benefits or services until a hearing decision is issued. Whether an individual is entitled to continued assistance is based on requirements set forth in appropriate state or federal law or regulation of the affected program. See the Fair and Fraud Hearings Handbook .

Individuals whose medical assistance is denied because of an SSA decision should file an appeal with the appropriate SSA office.

Note: If an individual submits an application during the time the continued benefits are being processed, the application must be processed as normal. See Chapters B-2300 , Eligibility Determination, B-3200 , Application Process, and B-6400 , Processing Deadlines.

(mepd-c-6100)(block-2)C-6110 Program Representation at Fair Hearings#

Revision 18-4; Effective December 1, 2018

If an applicant or recipient requests a fair hearing, the burden of proof to uphold HHSC's decision rests with HHSC. The hearing officer is a neutral party and is restricted by law from presenting HHSC's case.

Form H4800 , Fair Hearing Request Summary, provides a space for the names of HHSC's representative and supervisor. The supervisor is responsible for ensuring that either the HHSC representative participates in the hearing or that a back-up person is assigned. Additionally, the supervisor should ensure that the designated representative is sufficiently prepared and knowledgeable of the case to represent HHSC during the fair hearing process.

The hearing officer has the responsibility of setting the date and time of the hearing. In those program areas where Form H4800 may be completed by someone other than agency staff (contracted case management, HHSC representatives, etc.), it is important that the hearing officer be given the name(s) of those people who are to be notified of the date and time of the hearing. If there is not sufficient space on Form H4800 to provide this information, list the name(s) on Form H4800-A , Fair Hearing Request Summary (Addendum), Item 3, "Additional Information."

In those program areas where Form H4800 is completed by HHSC staff but someone other than, or in addition to, HHSC staff will appear (Attorney General's Office staff, Workforce Commission staff, home health nurses, nursing facility staff, etc.), the person completing Form H4800 is responsible for providing the hearing officer with the name(s) of those people who are to be notified of the date and time of the hearing. If there is not sufficient space on Form H4800 to provide this information, list the name(s) on Form H4800-A, Item 3, " Additional Information."

(mepd-c-7000)Medicaid for the Elderly and People with Disabilities Handbook: C-7000, Voter Registration#

(mepd-c-7000)(block-1)C-7000, Voter Registration#

Revision 21-4; Effective December 1, 2021

HHSC must offer applicants and recipients an opportunity to register to vote at application, redetermination and any time the person has a change of address.

Form VR30, Texas Voter Registration Application , is included with each application and redetermination packet. Additionally, the form VR30 is provided when a person reports a change of address. System-generated application and redetermination packets contain form VR30.

If the person indicates they do not wish to register to vote, mail Form H1350 , Opportunity to Register to Vote. Document that the person declined in the Texas Integrated Eligibility Redesign System (TIERS), Voter Registration Information section of the person Demographics — Citizen page. If the person returns Form H1350, sign and mark the Client Declined box in the Agency Use Only: Voter Registration Status section of Form H1350 and send the form for imaging.

(mepd-c-7000)(block-2)Who Can Register to Vote#

To register to vote, a person must be:

a U.S. citizen; and

at least 17 years and 10 months.

The opportunity to register to vote is not required if a person does not meet these two requirements.

(mepd-c-7000)(block-3)Staff Requirements for Voter Registration#

Staff must tell the person:

HHSC offers the same help and services when aiding the person with voter registration activities as when helping them with agency forms. This can happen whether HHSC provides the service in the office, outside of the office or at the person's home.

The decision to register or to decline to register to vote does not affect eligibility or benefit amount. HHSC will keep all voter registration information confidential and only use it for voter registration purposes.

The person may decide to seek help from staff to fill out the voter registration application form. The person may also fill out the application form in private.

The person may return the completed application form to: the Secretary of State (SOS), by mail using the postage-paid, self-addressed application form; the local voter registrar, by mail or in person; or the advisor.

The person may ask more voter registration questions or file a voter registration complaint by contacting the Elections Division of the Secretary of State, P.O. Box 12060, Austin, TX 78711, 800-252-8683.

Staff must not:

influence a person’s political preference or party registration;

display any political preference or party affiliation;

make any statement to discourage the person from registering to vote;

make any statement to a person or take any action to make the person believe that a decision to register or not to register has any bearing on the availability of services or benefits; or

pend the EDG or delay or deny benefits if the person fails or refuses to complete the voter registration information on any form, or fails to return form VR30 or Form H1350 .

(mepd-c-7000)(block-4)Documentation#

Document all actions taken to provide the person with an opportunity to register to vote at application, redetermination, and change of physical address in TIERS in the Voter Registration Information section of the person’s Demographics — Citizen page.

(mepd-c-8000)Medicaid for the Elderly and People with Disabilities Handbook: C-8000, Responsibility to Provide Information and Report Changes#

(mepd-c-8000)(block-1)C-8000, Responsibility to Provide Information and Report Changes#

Revision 25-4; Effective Dec. 1, 2025

(mepd-c-8000)(block-2)Providing Information#

When a person applies for Medicaid, HHSC asks for verification and any other information needed to make sure all the requirements for Medicaid are met. HHSC asks for information about income, resources and other eligibility requirements.

As a requirement of Medicaid, a person must provide HHSC MEPD staff with the necessary verification and information to determine Medicaid eligibility.

If HHSC sends an applicant or authorized representative (AR) a request for missing information, verification or both, the applicant or AR must provide the requested information to HHSC by the due date given in the request, or eligibility may be denied.

(mepd-c-8000)(block-3)Reporting Changes#

HHSC requires that the person or AR report certain events because they may affect eligibility or the amount of the co-payment for the cost of care.

(mepd-c-8000)(block-4)Who, What, When and How of Reporting Changes#

The person responsible for making required reports to HHSC include the:

eligible person;

eligible spouse;

eligible child; or

applicant waiting for a final determination on an application.

(mepd-c-8000)(block-5)Notes#

If the person has an AR and was not legally deemed incompetent, either the person or the AR must make the required reports.

If the person’s co-payment is impacted by either the community spouse or a dependent family member, the person, AR, community spouse or dependent family member is responsible for making required reports to HHSC.

If the person has a legal guardian and was legally deemed incompetent, the legal guardian is responsible for making required reports to HHSC.

(mepd-c-8000)(block-6)What must be reported?#

Events that must be reported include:

Change of address — Report any change in mailing address and any change in the address where the person, spouse or dependent family member lives.

Change in living arrangements — Report any change in the household including any person who comes to live in the household and any person who moves out of the household.

Change in income — Report any increase or decrease in income and any increase or decrease in the income of: the ineligible spouse who lives with the person; the community spouse or dependent family member; the parent, if the person is an eligible child and the parent lives with the eligible child; or an ineligible child who lives with the eligible child.

Change in resources — Report any resources received or transferred by the: person; ineligible spouse who lives with the person; community spouse or dependent family member; or parent, if the recipient is an eligible child and the parent lives with the eligible child.

Eligibility for other benefits — Report eligibility for benefits.

Certain deaths — the person or the person’s authorized representative must report the death of: the eligible spouse; the ineligible spouse who was living with the person; and any other person who was living in the household including a parent of an eligible child.

Change in marital status — Report the marriage, divorce or annulment of a marriage of an: eligible person; parent who lives with the eligible child; spouse or dependent family member ineligible child who lives with an eligible individual.

Medical improvements — If eligible for Medicaid because of disability or blindness, report any medical condition improvement.

Termination of U.S. residence — Report leaving the U.S. voluntarily with the intention of abandoning residence in the U.S. or leaving the U.S. involuntarily.

Leaving the U.S. temporarily — Report leaving the U.S. for 30 or more consecutive days or for a full calendar month without the intention of abandoning residence in the U.S.

(mepd-c-8000)(block-7)Include in the Reports#

When reporting changes in writing or verbally, include the following:

person’s name and Social Security number;

description of the event;

date it happened; and

reporter’s name.

Reports are due to HHSC: within 10 days of the change or event; or

when HHSC requests a report and provides a due date.

(mepd-c-8000)(block-8)Related Policy#

Failure to Furnish Missing Information, B-6510 Co-Payment, Chapter H-8000

(mepd-d-1200)Medicaid for the Elderly and People with Disabilities Handbook: D-1200, Age#

(mepd-d-1200)(block-1)D-1200, Age#

Revision 09-4; Effective December 1, 2009

In determining age for aged, blind, or disabled individuals, the age is reached the day before the anniversary of birth. This affects the month a disability determination is required for persons born on the first day of the month. Example: The person turns 65 on Jan. 1, and is eligible for Medicare Dec. 1, before the person’s 65th birthday in January. If the person meets all other eligibility criteria, the person can be certified for benefits for December without a disability decision.

Determine a person's age by the person’s statement on the application. Compare the reported information with Social Security Administration records using systems in place to exchange or request data. Other acceptable evidence includes such readily available sources as:

insurance policies;

family Bible;

marriage record;

child's birth certificate;

hospital admission record;

driver's license;

hunting license;

fishing license; or

voter registration card.

(mepd-d-1200)(block-2)D-1210 Definition of a Child#

Revision 09-4; Effective December 1, 2009

A child is neither married nor a head of a household and is either:

under age 18; or

under age 22 and a student regularly attending school, college or training that is designed to prepare him/her for a paying job.

Child status ceases effective with the month after the month of attainment of age 22 (age 18, if not a student) or the month after the month the person last meets the definition of child.

SSI policy defines full-time student as an individual attending at least:

12 hours per week if in high school or under;

12 hours per week if in a technical or vocational school (shop practice is not included in the course);

15 hours per week if in a technical or vocational school (shop practice is included in the course); or

eight hours per week per semester if in a college or university.

A student is deemed to be in regular school attendance during normal vacation periods if he attends regularly during the month immediately following the vacation period. A person may be considered a full-time student without attending the required number of hours per week, if the person is disabled and physically unable to attend full-time, has difficulty obtaining transportation or is taking all that is needed to complete the person's education.

The age requirements involved in identifying a child apply only to a person who is otherwise eligible. A blind or disabled applicant who meets these age requirements, however, can become eligible for Medicaid, even though the person does not meet the definition of a child.

(mepd-d-2100)Medicaid for the Elderly and People with Disabilities Handbook: D-2100, When a Medical Determination Is Not Required#

(mepd-d-2100)(block-1)D-2100, When a Medical Determination Is Not Required#

Revision 12-4; Effective December 1, 2012

Receipt of Medicare is an indication that the person is either:

age 65 or older; or

has been determined blind or disabled based on the Social Security Administration (SSA) criteria for RSDI Title II or SSI Title XVI disability.

A medical determination is not required to establish blindness or disability if the person has Medicare. The receipt of the Medicare is satisfactory verification that the person has been determined to meet the SSA's criteria for aged, blind or disabled. This includes a person determined blind or disabled by SSA in the 24-month period before receiving Medicare. Upon verification of the receipt of a disability benefit, a medical determination is not required to establish blindness or disability if a person is currently receiving disability benefits from:

SSI;

RSDI; or

Railroad Retirement.

For an eligibility determination during the retroactive coverage months, a medical determination is not required to establish blindness or disability during that retroactive coverage period if a person:

has unpaid or reimbursable covered Medicaid expenses during the retroactive coverage months prior to the application;

has a date of onset for RSDI Title II blindness or disability based on SSA query records; and

the date of onset for the RSDI Title II blindness or disability covers the retroactive coverage months prior to the application.

Note: Do not use the Title XVI "Dsblty Onset Date" on the SSI Entitlement screen as the basis to establish blindness or disability for:

retroactive coverage;

current coverage; or

future coverage.

A medical determination is not required to establish blindness or disability if a person:

applies with HHSC for SSI-related medical assistance only (MAO);

is under age 65; and

lost SSI for reasons other than a decision that the disability or blindness has stopped.

(mepd-d-2200)Medicaid for the Elderly and People with Disabilities Handbook: D-2200, When a Medical Determination Is Required#

(mepd-d-2200)(block-1)D-2200, When a Medical Determination Is Required#

Revision 16-4; Effective December 1, 2016

When an individual does not have Medicare or is not receiving a disability benefit from SSI , RSDI , or Railroad Retirement (See E-4200, Railroad Retirement Benefits), a medical determination, including date of onset, of either disability or blindness is required. The date of onset can affect the start date of Medicaid.

The following must not be used to establish disability for MEPD programs:

a Civil Service disability determination;

a medical certification an individual submits to an Achieving a Better Life Experience (ABLE) program or to the Internal Revenue Service as proof of meeting ABLE program requirements.

An individuals under age 65 who lives in an institutional setting and who would, except for income, be eligible for SSI if they lived outside the facility, must meet the SSA 's definition of disability or blindness. These individuals may or may not have applied for SSI cash benefits.

If a medical decision for determining blindness or disability is required, request a decision from the Disability Determination Unit (DDU). See Section D-2300 , Requesting a Decision from the Disability Determination Unit (DDU).

Do not request a decision from the DDU in the following circumstances.

If an individual … then … resides in a state supported living center or the Rio Grande State Center, the staff at these facilities, and not HHSC staff, is responsible for ensuring the completion of the forms for a disability determination. requests an eligibility determination during a retroactive period and the individual: has unpaid or reimbursable covered Medicaid expenses during the retroactive coverage months prior to the application; has a date of onset for RSDI Title II blindness or disability based on SSA query records; and the date of onset for the RSDI Title II blindness or disability does not cover any of the retroactive coverage months prior to the application, the DDU cannot establish an earlier date of onset for RSDI Title II blindness or disability because federal regulations prevent a state's disability determination to conflict with the RSDI Title II date of onset.

A medical determination of disability or blindness is required when RSDI Title II blindness or disability is not established and an individual is:

under age 65;

either under or over age 65 and applying for the Medicaid Buy-In (MBI) program; or

either under or over age 65 and presumed to be a child with a disability to meet exception to transfer penalty.

To determine whether RSDI Title II blindness or disability is established, query the SSA records available.

Do not use the SSI Title XVI "Dsblty Onset Date" as the basis to establish blindness or disability.

(mepd-d-2500)Medicaid for the Elderly and People with Disabilities Handbook: D-2500, Supplemental Security Income Applicants and Retroactive Coverage#

(mepd-d-2500)(block-1)D-2500, Supplemental Security Income Applicants and Retroactive Coverage#

Revision 14-4; Effective December 1, 2014

An applicant for Social Security disability benefits is evaluated for both SSI Title XVI and RSDI Title II disability eligibility. HHSC determines Medicaid eligibility for retroactive coverage for up to:

three months before the date of SSI application for a person who has been denied SSI; or

two months before the month in which an SSI recipient's Medicaid coverage automatically begins.

In these cases, the medical records; Form H3034 , Disability Determination Socio-Economic Report; and Form H3035 , Medical Information Release/Disability Determination, should be imaged in the Texas Integrated Eligibility Redesign System (TIERS). DDU uses this information to make the final decision (disability or blindness) for the retroactive coverage months. DDU enters the disability determination in case comments and in the Disability Determination — DDU page in TIERS, which indicates the decision, including the date of onset of the disability or blindness.

Federal regulations prevent a state's disability determination to conflict with the RSDI Title II date of onset, and DDU cannot establish an earlier date of onset for RSDI Title II blindness or disability. As a result, deny an application based on the person not meeting blind (Not Blind) or disabled (Not Disabled) criteria when a person applies for Medicaid and the person:

has unpaid or reimbursable covered Medicaid expenses during the retroactive coverage months prior to the application;

has a date of onset for RSDI Title II blindness or disability based on Social Security Administration (SSA) query records; and

the date of onset for RSDI Title II blindness or disability does not cover any of the retroactive coverage months prior to the application.

Note: Do not use the SSI Title XVI "Dsblty Onset Date" on the SSI Entitlement screen as the basis to establish blindness or disability for retroactive coverage.

Federal regulations prohibit a state from making a disability decision that conflicts with an SSA decision. DDU cannot make an independent decision until all appeals to SSA regarding the date of disability onset for both RSDI Title II and SSI Title XVI are settled.

Request medical records covering the period for which eligibility is being tested when:

there is no date of onset for RSDI Title II disability; or

90 days have elapsed since the SSI/RSDI file date and SSA has not completed a disability determination.

Submit the following items for imaging to the Texas Health and Human Services Commission, P.O. Box 149027, Austin, TX 78714-9971:

Medical records

Form H3034

Form H3035

Occasionally, Form 4116 , Authorization for Expenditures, is required to provide payment to medical providers for submitting medical records. If Form 4116 is required, submit this form for imaging with the medical records, Form H3034 and Form H3035.

(mepd-d-3300)Medicaid for the Elderly and People with Disabilities Handbook: D-3300, Maintaining Presence in the U.S.#

(mepd-d-3300)(block-1)D-3300, Maintaining Presence in the U.S.#

Revision 18-1; Effective March 1, 2018

A Medicaid recipient is not eligible for Medicaid for any month during all of which the person is outside of the U.S. If a person is outside of the U.S. for 30 or more days in a row, they are not considered to be back in the U.S. until they are back for 30 days in a row. A person may again be eligible for Medicaid in the month in which the 30 days end if they continue to meet all other eligibility requirements.

Note: The U.S. is considered the 50 States, the District of Columbia and the Northern Mariana Islands.

The period of absence begins with the day after the person's departure from the U.S. The period of absence ends for eligibility purposes:

the day before the person's return to the U.S., if the time outside the U.S. is less than 30 consecutive days ; or

30 consecutive days after return to the U.S., including a person newly arrived in the U.S. (that is, for the very first time), if the time outside the U.S. is 30 consecutive days or more .

Develop continuous presence in the U.S. if there is reason to believe the person has been outside the U.S. for 30 consecutive days or a full month.

If otherwise eligible, a person whose eligibility has been denied because of absence from the U.S. can be recertified effective with the day:

following the 30th day of continuous presence in the U.S. after the person's return, if the time outside the U.S. was 30 consecutive days or more; or

the person returned to the U.S., if the time outside the U.S. was a full calendar month, but less than 30 consecutive days (calendar month of February only).

(mepd-d-3300)(block-2)D-3310 Exceptions to U.S. Presence#

Revision 09-4; Effective December 1, 2009

The U.S. residence requirement does not apply to:

a child who is a citizen and is living with a parent who is a member of the U.S. Armed Forces assigned to permanent duty ashore outside the U.S.; or

to certain persons temporarily abroad for study.

(mepd-d-3500)Medicaid for the Elderly and People with Disabilities Handbook: D-3500, Intent to Remain in Texas#

(mepd-d-3500)(block-1)D-3500, Intent to Remain in Texas#

Revision 09-4; Effective December 1, 2009

To be eligible for Texas Medicaid, a person must be a resident of the state of Texas; that is, the person must have established residence in Texas and must intend to remain in Texas.

(mepd-d-3500)(block-2)D-3510 Intent to Return#

Revision 11-4; Effective December 1, 2011

A visit to another state does not terminate Texas residence if the person intends to return when the purpose of the visit is completed.

If a Texas resident visits out of the state (but remains in the United States) with subsequent returns or expressions of intent to return, the person’s Texas residence is not interrupted. A recipient is responsible for requesting a temporary change of address because of an absence from the state. The recipient is also responsible for informing HHSC about the purpose, plans, date of departure and date of planned return.

If the recipient does not contact HHSC before departure, but HHSC learns about the recipient’s absence from some other source, treat this information as a reported change. Attempt to get the recipient’s out-of-state address. After receiving the out-of-state address, contact the recipient to determine whether the absence from the state is temporary, why the recipient left and when the recipient plans to return to Texas.

The length of out-of-state visits is not limited. Review the recipient’s situation every three months to determine where the recipient intends to live permanently.

If the recipient’s absence from the state is temporary and an annual review is scheduled, mail the redetermination packet directly to the recipient at the out-of-state address. If the nature of the recipient’s visit is questionable, additionally request the recipient to:

restate the purpose of the absence; and

indicate the recipient’s official permanent residence.

Review the recipient’s response on the redetermination packet as to residency and intent to remain a Texas resident. Redetermine eligibility based on the recipient’s usual living arrangement unless the recipient no longer indicates Texas residency with the intent to remain a Texas resident.

Reference: Chapter F , Resources, for treatment of a home and out-of-state property.

(mepd-d-3500)(block-3)D-3520 No Intent to Return#

Revision 09-4; Effective December 1, 2009

A recipient leaving the state with no declared intent to return, and without any evidence that would indicate plans to return, is considered to have moved from the state and Medicaid is denied immediately. If the recipient subsequently returns to the state and declares the intent to remain, Medicaid may be resumed if the recipient meets all other eligibility requirements.

(mepd-d-3600)Medicaid for the Elderly and People with Disabilities Handbook: D-3600, Interstate Issues#

(mepd-d-3600)(block-1)D-3610 Interstate Requests for Assistance#

Revision 09-4; Effective December 1, 2009

If a recipient is eligible for Medicaid in another state and receives Medicaid in that state, the person is not eligible for Medicaid from the state of Texas.

If a person is placed in an institution located in Texas by an agency of another state, the person remains a resident of the state that made the placement.

(mepd-d-3600)(block-2)D-3620 Out-of-State Medicaid and Texas Medicaid Recipients#

Revision 09-4; Effective December 1, 2009

Under certain conditions, HHSC makes vendor payment to out-of-state providers on behalf of Texas Medicaid recipients. An out-of-state provider must be contracted with Texas as a Medicaid provider in its own state to provide care or services to Medicaid recipients and the recipients must be eligible for Texas Medicaid for the time involved. No payment commitment can be made until all necessary forms have been completed.

An out-of-state provider can contact Texas' contracted Medicaid claims administrator, currently the Texas Medicaid and Healthcare Partnership (TMHP). TMHP's website for the Texas Medicaid Program is www.tmhp.com .

The provider should furnish as much information as possible about the recipient, including the recipient's full name, Texas Medicaid number, Social Security number, date of birth, date of admission and date of discharge.

Note: If the person receives SSI and intends to live in the other state, inform the person to notify the Social Security Administration immediately about the move.

(mepd-d-3600)(block-3)D-3630 Texas Applicant Outside the State of Texas#

Revision 09-4; Effective December 1, 2009

If a person from Texas wishes to apply for Medicaid while outside the state, the person should contact the other state's Medicaid agency. The other state's Medicaid agency determines whether:

the person plans to live or visit in that state; and

that state's Medicaid is available to the person.

If the other state's Medicaid agency determines that the person is not eligible for that state's Medicaid, the other state's Medicaid agency contacts HHSC.

HHSC sends the person an application to apply for Texas Medicaid.

When the completed application is returned, use the person's Texas address as the residence address and the out-of-state address as the mailing address. Consider the person as a resident of Texas for the month of application and for the retroactive coverage period if appropriate.

After eligibility is determined, a copy of the decision is sent to the other state's Medicaid agency.

(mepd-d-3600)(block-4)D-3640 Applicant from Another State#

Revision 09-4; Effective December 1, 2009

A person from another state may ask to apply for Medicaid in Texas. Although the opportunity to apply for Medicaid cannot be denied to another, ask the following questions to assist the person in determining whether an application in Texas is appropriate:

Is the person visiting or does the person intend to live in Texas?

Is the person receiving Medicaid from another state?

Does the person want to receive Medicaid from Texas or from the other state?

Has the person declared intent to live in Texas with the full knowledge that if the person is eligible for Medicaid in Texas, the person is not eligible to receive Medicaid from the other state?

Is the person aware that if the person declares the intent to live in Texas and is certified for Medicaid in Texas, HHSC notifies the other state?

In some instances, a person might tentatively declare intent to live in Texas but is found to be ineligible for Medicaid in Texas. Be careful to avoid action that might jeopardize a person's continued eligibility for Medicaid from another state. Although a person might at first declare intent to live in Texas, the person might decide to continue receiving Medicaid from the other state (if the person learns of ineligibility for Medicaid in Texas). Consequently, the person might revoke the declaration of intent to live in Texas and keep the person's residence in the other state.

(mepd-d-3600)(block-5)D-3650 Out-of-State Recipient Visiting Texas#

Revision 09-4; Effective December 1, 2009

If a recipient who receives a money grant ( TANF , general assistance, state supplementary payments to SSI ) or Medicaid, including Medicare Savings Program benefits, from another state and applies for Medicaid in Texas, determine whether:

the recipient intends to continue receiving the money grant or Medicaid from the other state; and

Medicaid benefits are available to the recipient from that state.

Declaration to continue living in the other state — If the recipient declares the intent to continue living in the other state, the recipient is not eligible for Medicaid in Texas. Contact the out-of-state Medicaid agency to determine which services are covered and how providers file claims. Have the recipient inform any Texas Medicaid provider to send any claim to the out-of-state Medicaid agency in the recipient's state of residence.

Declaration to live in Texas — If a recipient who receives a money grant from another state (TANF, general assistance, state supplementary payments to SSI) makes a declaration of intent to live in Texas, this declaration does not automatically establish eligibility. Determine eligibility according to the requirements of the Texas Medicaid Program.

Impact on the medical effective date — If the intent to live in Texas is made by the recipient and the recipient meets Texas MEPD requirements, contact the out-of-state Medicaid agency of the recipient's former state of residence to determine the last day Medicaid claims will be paid by that state. The denial effective date is the last day for which the recipient 's former state of residence will pay Medicaid claims. This is not necessarily the denial effective date on the former state's computer system. The medical effective date for the recipient in Texas is no earlier than the day following the date the recipient 's former state of residence will pay Medicaid claims.

(mepd-d-3600)(block-6)D-3660 SSI Recipient Visiting in Texas#

Revision 16-3; Effective September 1, 2016

If an out-of-state SSI recipient indicates an intent to live in Texas, refer the recipient to a Social Security Administration (SSA) office. SSA makes the SSI residence determination. SSA will modify the SSI file indicating the new address. The change in the SSI file will trigger a change in the new address for the Medicaid file.

If the SSI recipient indicates a need for medical care during the month of the move to Texas, give the recipient Form H1300 , Declaration of Texas Residency, and refer the recipient to an SSA office for verification of SSI status. SSA accepts Form H1300 via fax.

When the completed Form H1300 is returned, process under ME – Nursing Facility, to begin Medicaid coverage in Texas effective the day after the last date claims will be paid in the former state. Once the application has been disposed, Form H1027-A , Medicaid Eligibility Verification, covering the recipient's residence in Texas can be issued, if needed.

Example: An SSI recipient moves to Texas on Aug. 10 and needs medical care. After receipt of confirmation of SSI status for the month of August and verification from the former state that it will pay no Medicaid claims after Aug. 9, the eligibility specialist processes the application using ME – Nursing Facility for 8/10/YYYY through 8/31/YYYY and issues Form H1027 for those dates, if needed.

Note: Remember that Medicaid coverage in Texas may begin no earlier than the day after the last date claims will be paid by the former state.

If the request for coverage of medical care received in the month of the recipient's move to Texas is made during a subsequent month (or received in the month of the move, but the application is not disposed until the following month), the procedure is the same as above except that the application is processed using ME-SSI Prior for the month of move to Texas. In this instance, the medical effective date would be the first day of the month of move and the denial date would be the last day of that month. Do not issue Form H1027 for a past month. Instead, inform the recipient that Your Texas Benefits Medicaid ID card will be sent so that receipt is within seven to 14 days. The recipient must notify all providers of the added coverage for purposes of timely claims filing.

Example: An SSI recipient moves to Texas on May 24 and receives medical care on May 26. On June 15, the recipient requests assistance for that expense. After receipt of confirmation of SSI status for the month of May and verification from the former state that it will pay no Medicaid claims after May 23, the eligibility specialist processes the application using ME-SSI Prior for 5/1/YYYY through 5/31/YYYY. Inform the recipient that Your Texas Benefits Medicaid ID card will be sent so that receipt is within seven to 14 days, which the recipient must then use to notify provider(s) of Medicaid eligibility.

(mepd-d-3600)(block-7)TIERS Procedures#

Process as a manual SSI during the month of move. The medical effective date will be the first of the month.

Note: Even though the medical effective date precedes the actual date the recipient moves into the state, Texas medical claims would not have been incurred prior to the move date.

(mepd-d-3800)Medicaid for the Elderly and People with Disabilities Handbook: D-3800, People Confined in a Public Institution#

(mepd-d-3800)(block-1)D-3800, People Confined in a Public Institution#

Revision 21-4; Effective December 1, 2021

A person confined in a public institution , including a jail, prison, reformatory or other correctional or holding facility, is not eligible for Medicaid.;

Permanent Release

A person who enters a Medicaid certified long-term care facility, skilled nursing facility , nursing facility or intermediate care facility for people with an intellectual disability or related condition after a permanent release from a correctional facility is not considered to be in a public institution.

Related Policy

People Confined in a County Jail in Texas, D-3810

(mepd-d-3800)(block-2)D-3810 People Confined in a County Jail in Texas#

Revision 22-2; Effective June 1, 2022

When a Texas county jail reports a Medicaid recipient is confined for more than 30 days, suspend or terminate benefits.

If notified of the person’s confinement from a source other than a county jail in Texas, terminate the person’s Medicaid.

(mepd-d-3800)(block-3)Suspension#

Suspend Medicaid within two business days of receiving a report of confinement from a county jail for the following types of assistance (TOAs):

TA 10, ME – Waivers

TA 88, ME – Medicaid Buy-In for Children

TP 03, ME – Pickle

TP 14, ME – Community Attendant Services

TP 18, ME – Disabled Adult Child

TP 21, ME – Disabled Widow(er)

TP 22, ME – Early Aged Widow(er)

TP 23, MC – SLMB

TP 24, MC – QMB

TP 26, MC – QI-1

The suspension is effective the day after the report of confinement is received.

Provide a new reasonable opportunity period to submit documentation of citizenship or alien status if a person’s original reasonable opportunity period expires during the suspension period. The new reasonable opportunity period is the earlier of:

95 days from the date the reinstatement is disposed; or

the last day of their current certification period.

Keep the original reasonable opportunity period if the person’s Medicaid coverage is reinstated before the reasonable opportunity period end date.

The TF0001, Notice of Case Action, generated at reinstatement will include the reasonable opportunity information to remind the person to submit documentation of citizenship or alien status.

Note: For couple cases, suspend Medicaid for the incarcerated person only. The spouse may continue to receive benefits, if eligible.

(mepd-d-3800)(block-4)Reinstatement#

Reinstate Medicaid that was suspended due to incarceration in a county jail within two business days of receiving notification from any source that a person has been released from a Texas county jail. To reinstate Medicaid:

Perform individual inquiry. Determine if the person has suspended Medicaid.

If Medicaid is suspended, perform a County Jail Release - Search. Determine if: the person’s Medicaid was suspended due to confinement; and there are months remaining in their original certification period.

If yes, create a Process a County Jail Confinement/Release task for all active cases where the person was included before suspension. Enter the release information into TIERS on the County Jail Release - Details page.

Medicaid coverage is reinstated effective the date of the person’s release from the county jail for the remaining months of the original certification period. Form TF0001 is generated to notify the person of the reinstatement.

Consider the report of release as a change report for all other types of assistance. Determine if the person needs to be added to the other types of assistance.

If the person’s health care coverage terminated at confinement or the original certification period has ended, the person is not eligible for reinstatement. Send a Medicaid application to the person’s last known address.

(mepd-d-3800)(block-5)Termination#

Terminate Medicaid within two business days of receiving a report of confinement for the following TOAs:

TA 12, ME – State Group Home

TP 10, ME – State Supported Living Center

TP 15, ME – Non-State Group Home

TP 16, ME – State Hospital

TP 17, ME – Nursing Facility

TP 25, MC – QDWI

TP 87, ME – Medicaid Buy In

Medicaid is terminated effective the day after HHSC receives the notification.

(mepd-d-3800)(block-6)Related Policy#

People confined in a Public Institution, D-3800 Reasonable Opportunity to Provide Verification of Alien Immigration Status, D-8841

(mepd-d-4100)Medicaid for the Elderly and People with Disabilities Handbook: D-4100, Fiduciary Agents#

(mepd-d-4100)(block-1)D-4100, Fiduciary Agents#

Revision 24-4; Effective Dec. 1, 2024

(mepd-d-4100)(block-2)D-4110 Reserved for Future Use#

Revision 24-4; Effective Dec. 1, 2024

(mepd-d-4100)(block-3)D-4120 Transactions Involving Agents#

Revision 15-4; Effective December 1, 2015

Agents act on the person's behalf to sign applications and redetermination packets. When a guardianship exists, only that person can act on the person's behalf to sign applications and redetermination forms.

Guardian of the estate. Under Section 1151.101 and 1151.151 of the Texas Estates Code, it is the duty of the guardian of the estate to take care of and manage the estate as a prudent person would manage the person's own property. The guardian of the estate collects all debts, rentals or claims due to the ward, enforces all obligations in favor of the ward, and brings and defends suits by or against the ward. Only the guardian of the estate can deal with resources.

Guardian of the person. Under Section 1151.051 of the Texas Estates Code, the guardian of the person has the:

right to have physical possession of the ward;

right to establish the ward's legal domicile;

duty of care, control and protection of the ward;

duty to provide the ward with clothing, food, medical care and shelter; and

power to consent to medical, psychiatric and surgical treatment other than the in-patient psychiatric commitment of the ward.

For HHSC purposes, the guardian of the person can sign documents, represent the person at hearings, and deal with small amounts of money. The guardian of the person is like other authorized representatives in that they have the authority to protect the interests of the ward.

Under Section 1151.004 of the Texas Estates Code, a court may appoint the same person to be both guardian of the estate and guardian of the person. If there are two guardians, one of the estate and one of the person, then the eligibility specialist must examine the court orders establishing the guardianships to decide which is the most appropriate to represent the person with HHSC.

A person's resources are available to him if they are being managed by a legal guardian, representative payee, power of attorney or fiduciary agent. If, however, a court denies a guardian or agent access to the resources, HHSC does not consider the resources available to the person.

If a person's guardianship papers do not show that the legal guardian is prohibited access, and if a court has not subsequently ruled a prohibition, the person's resources are considered available. A guardian's routine need to petition the court for permission to dispose of a person's resources is not a prohibition. When the court rules on a petition to dispose of a person's resources, resources are considered available only to the extent to which the court has made them available for the person's benefit.

If a legal guardian exists, obtain a copy of the guardianship or power of attorney document. Identify a fiduciary relationship by the way in which a resource is styled. A bank account established in two names connected by "for" or "by" indicates a fiduciary relationship. Another indication is an account established in two names with the designation of "representative payee" next to one of the names, or an account with the designation "special."

(mepd-d-4100)(block-4)D-4121 Examples#

Revision 15-4; Effective December 1, 2015

A person has resources valued at $1,300, which are being managed by his son. The son claims that as the power-of-attorney, he is the only one who has access to the funds. Because a power-of-attorney is given voluntarily, and management of the resources is with the person's consent and for his benefit, this person's resources are available to him.

Another person's parents used their own funds to purchase a certificate of deposit (CD) for him. The CD was issued as "Person's Name, by Parents' Names, Joint Representative Payees." The CD is an available resource to this person, because the designation indicates that the parents are acting in a fiduciary capacity in controlling funds belonging to him, regardless of the fact that the parents paid the purchase price.

A third person recently left the hospital and entered a long-term care facility. She is in a coma, and there are no known living relatives or friends. After the person had a stroke, her landlady looked through the person's papers and found a $600 term life insurance policy and a checkbook showing a balance of $3,840.65. The eligibility specialist verified the bank balance. Although court action to appoint a guardian would be necessary to allow disposal of the person's excess funds, the resources are available to her. Until a court judges the person to be incompetent and unable to handle her affairs, the eligibility specialist cannot assume that the court will prohibit an appointed guardian from disposing of any of the funds in the checking account. This person is ineligible because of excess resources.

(mepd-d-4200)Medicaid for the Elderly and People with Disabilities Handbook: D-4200, Living Arrangements#

(mepd-d-4200)(block-1)D-4200, Living Arrangements#

Revision 09-4; Effective December 1, 2009

Whether or not a person is married or has children has some bearing on the treatment of income and resources in determining Medicaid eligibility, both in a community setting or an institutional setting.

If the living arrangement is in a community setting, deeming of income and resources affects the budget.

When the living arrangement is in an institutional setting, spousal impoverishment and dependant allowances may have a bearing on the budget. This chapter focuses on the community setting. Chapter J covers spousal impoverishment policy for institutional settings.

(mepd-d-4200)(block-2)D-4210 Deeming#

Revision 09-4; Effective December 1, 2009

When neither a person's spouse nor child is in an institutional setting, deeming from spouse-to-spouse or parent-to-child applies in household situations. Only those residing in the household are considered part of the household for deeming purposes.

Exceptions to deeming:

A person is in an institutional setting, including receiving services through a Home and Community-Based Services waiver program.

Spouse-to-spouse and parent-to-child deeming do not apply in situations where a family does not have a residence. For example, if a family lives in a car because they cannot afford shelter, neither spouse-to-spouse nor parent-to-child deeming would apply.

A person is not a member of the household if he/she is absent from home for a period that is not a temporary absence (for example, confinement in a public institution). Consider absences due to active duty military assignments as temporary.

If a child is born in an institution (for example, a hospital), the child is not a member of the household until the month after the month the child goes home.

Deeming does not apply when either an eligible person or an ineligible spouse is in an institutional setting, even when sharing a room.

Deeming does apply in noninstitutional care situations (for example, adult foster care), if the eligible person is living with an ineligible spouse.

(mepd-d-4200)(block-3)D-4211 Spouse#

Revision 15-4; Effective December 1, 2015

For Medicaid purposes, whether two people are married governs whether:

couple computation rules apply;

spousal or parental deeming applies; and/or

spousal impoverishment rules apply.

Note: Someone who is married cannot be a child for Medicaid purposes.

Accept a person's allegation that he or she is married unless:

the person would otherwise be considered a child for Medicaid purposes;

there is evidence to the contrary; or

the allegation could be self-serving.

Normally, for Medicaid purposes, two people are married as of the first moment of the month. If a marital relationship ends by death, divorce or annulment in the same month it began, treat the marriage as if it had never existed. Otherwise, the termination of marriage is effective the month after the month of death, divorce or annulment.

In Texas, there are three ways to terminate a marriage:

Void marriages — A determination that the marriage could not have existed because of one of the following legal impediments: the parties married within a prohibited degree of consanguinity (for example, nephew or niece), or at least one party has a previous marriage that has not been resolved. Void marriages do not require a lawsuit, and the marriage may be declared void in a collateral action (for example, contest of will). A legal marriage between parties never existed.

Annulments — Also called voidable marriages. Grounds for annulment include, but are not limited to, marrying under the influence of drugs/alcohol, at least one party being incapacitated or the marriage being coerced. Annulments require court action, but under common law, an annulment is retroactive to the date of marriage.

Divorce — Requires court action, and the marriage is dissolved effective the date of the divorce decree.

Persons with void marriages or who have obtained a court annulment of their marriages are treated as though they were always individuals. In the instance of a divorce, persons are considered married through the end of the calendar month in which the divorce is issued.

For spouse-to-spouse deeming purposes, consider the following in the budget:

the eligible individual; and

the spouse; or

any of the couple's children (or children of either member of the couple).

(mepd-d-4200)(block-4)D-4212 Child#

Revision 09-4; Effective December 1, 2009

A child is someone who is neither married nor the head of a household, and is:

under age 18; or

under age 22 and a student.

Eligible child for deeming purposes. For deeming purposes, an eligible child is a natural or adopted child under age 18 who lives in a household with one or both parents, is not married and is eligible for Medicaid.

Deeming to such an eligible child no longer applies beginning the month following the month the child attains age 18.

A person attains a particular age on the day preceding the anniversary of his/her birth. Deeming applies in the month of attainment of age 18 regardless of whether an application filed that month is filed before or after the day of attainment.

Ineligible child for deeming purposes. For deeming purposes, an ineligible child must:

be either a natural or adopted child of: an eligible person or the eligible person's spouse; or an ineligible parent or the ineligible parent's spouse;

live in the same household with an eligible person;

not be married; and

be either: under age 18; or under age 22 and a student.

Verification and Documentation Guidelines

Verify an eligible child's date of birth and document the file. Accept the allegation of an ineligible child's age, absent evidence to the contrary.

Accept a person's statement that a parent-child relationship exists.

If a child under age 18 alleges to have no earnings, accept the allegation of student status. If an eligible or ineligible child under age 18 (or a student child age 18 to 22) alleges student status and earnings, verify school attendance and document.

Document an eligible child's income and verify when necessary following general income rules for an eligible person.

If any ineligible children in the household have income, and the ineligible spouse or parent has income that is subject to deeming, verify and document the ineligible child's income. However, if the alleged income exceeds the amount of the ineligible child allocation (that is, no ineligible child allocation applies for that ineligible child), document the allegation, but do not verify the income unless the income would be subject to the student child earned income exclusion. Accept an allegation when any ineligible child living in the household has no income.

(mepd-d-4200)(block-5)D-4213 Parent#

Revision 09-4; Effective December 1, 2009

A parent whose income and resources are subject to deeming is one who lives in the same household with an eligible child and is:

a natural or adoptive parent of the child; or

the spouse of the natural or adoptive parent (“stepparent”) who lives in the same household as the natural or adoptive parent.

Deeming applies from a parent to a child when they live together in the same household, except in a Home and Community-Based Services waiver situation. Deem a parent's income and resources to an eligible child beginning the month:

after the month the child comes home to live with the parent(s) (for example, the month following the month the child comes home from the hospital);

of birth if a child is born in the parent's home;

after the month of adoption (the month of adoption is the month the adoption becomes final); or

after the month of a parent’s marriage (that is, when a natural or adoptive parent marries) or the month after the month a parent begins living in a “holding out” relationship.

Generally, the same deeming rules that apply to a parent also apply to the spouse of a parent (a stepparent).

Exceptions: Do not deem the income or resources of a stepparent living with an eligible child if the natural or adoptive parent:

is deceased;

is divorced from the stepparent; or

has permanently left the household.

Treat any absence by a natural or adoptive parent as permanent unless it is considered a temporary absence, such as military duty.

For parent-to-child deeming purposes, consider the following in the budget:

the eligible child;

the eligible child's parent(s); and

other children of the parents.

Note: A person whose parental rights have been terminated due to adoption no longer meets the definition of “parent” for Medicaid purposes. This remains true even if the adopted child later lives in the same household with the former parent.

Refer cases involving adopted Native American children who return to the household of a former parent to your regional attorney. The parent-child relationship in these cases is governed by tribal law and likely requires further legal interpretation.

(mepd-a-1000)Medicaid for the Elderly and People with Disabilities Handbook: A-1000, General Information#

(mepd-a-1000)(block-1)A-1000, General Information#

(mepd-a-1000)Medicaid for the Elderly and People with Disabilities Handbook: A-1000, General Information#

(mepd-a-1000)(block-1)A-1000, General Information#

(mepd-a-1000)(block-2)Related Policy#

(mepd-a-1100)Medicaid for the Elderly and People with Disabilities Handbook: A-1100, Reserved for Future Use#

(mepd-a-1100)(block-1)A-1100, Reserved for Future Use#

(mepd-a-2000)Medicaid for the Elderly and People with Disabilities Handbook: A-2000, Mandatory Coverage Groups#

(mepd-a-2000)(block-1)A-2000, Mandatory Coverage Groups#

(mepd-a-2000)(block-2)Related Policy#

(mepd-a-2100)Medicaid for the Elderly and People with Disabilities Handbook: A-2100, Supplemental Security Income#

(mepd-a-2100)(block-1)A-2100, Supplemental Security Income#

(mepd-a-2100)(block-2)Automated System Program Identifier#

(mepd-a-2100)(block-3)Related Policy#

(mepd-a-2200)Medicaid for the Elderly and People with Disabilities Handbook: A-2200, Emergency Medicaid Coverage for Aliens#

(mepd-a-2200)(block-1)A-2200, Emergency Medicaid Coverage for Aliens#

(mepd-a-2300)Medicaid for the Elderly and People with Disabilities Handbook: A-2300, RSDI Cost of Living Adjustment Increase#

(mepd-a-2300)(block-1)A-2300, RSDI Cost of Living Adjustment Increase#

(mepd-a-2300)(block-2)A-2310 Disabled Adult Children (DAC)#

(mepd-a-2300)(block-3)A-2320 Historical 1972 Income Disregard#

(mepd-a-2300)(block-4)A-2330 Pickle#

(mepd-a-2300)(block-5)A-2340 Widow(er)s#

(mepd-a-2300)(block-6)A-2350 Reserved for Future Use#

(mepd-a-3000)Medicaid for the Elderly and People with Disabilities Handbook: A-3000, Optional Coverage Groups#

(mepd-a-3000)(block-1)A-3000, Optional Coverage Groups#

(mepd-a-3000)(block-2)Related Policy#

(mepd-a-3100)Medicaid for the Elderly and People with Disabilities Handbook: A-3100, SSI Denied Due to Entry into a Long-Term Care Facility#

(mepd-a-3100)(block-1)A-3100, SSI Denied Due to Entry into a Long-Term Care Facility#

(mepd-a-3200)Medicaid for the Elderly and People with Disabilities Handbook: A-3200, Special Income Limit#

(mepd-a-3200)(block-1)A-3200, Special Income Limit#

(mepd-a-3300)Medicaid for the Elderly and People with Disabilities Handbook: A-3300, Home and Community-Based Services Waiver Programs#

(mepd-a-3300)(block-1)A-3300, Home and Community-Based Services Waiver Programs#

(mepd-a-3300)(block-2)A-3310 Community Living Assistance and Support Services (CLASS)#

(mepd-a-3300)(block-3)Automated System Program Identifier#

(mepd-a-3300)(block-4)A-3320 Deaf Blind with Multiple Disabilities (DBMD)#

(mepd-a-3300)(block-5)Automated System Program Identifier#

(mepd-a-3300)(block-6)A-3330 Home and Community-based Services (HCS)#

(mepd-a-3300)(block-7)Automated System Program Identifier#

(mepd-a-3300)(block-8)A-3340 Youth Empowerment Services (YES)#

(mepd-a-3300)(block-9)Automated System Program Identifier#

(mepd-a-3300)(block-10)A-3350 Medically Dependent Children Program (MDCP)#

(mepd-a-3300)(block-11)Automated System Program Identifier#

(mepd-a-3300)(block-12)A-3360 Reserved for Future Use#

(mepd-a-3300)(block-13)A-3370 Texas Home Living (TxHmL)#

(mepd-a-3300)(block-14)Automated System Program Identifier#

(mepd-a-3300)(block-15)A-3380 STAR+PLUS Waiver (SPW)#

(mepd-a-3400)Medicaid for the Elderly and People with Disabilities Handbook: A-3400, Medicaid Buy-In for Children#

(mepd-a-3400)(block-1)A-3400, Medicaid Buy-In for Children#

(mepd-a-3500)Medicaid for the Elderly and People with Disabilities Handbook: A-3500, Medicaid Buy-In#

(mepd-a-3500)(block-1)A-3500, Medicaid Buy-In#

(mepd-a-4000)Medicaid for the Elderly and People with Disabilities Handbook: A-4000, Other Service-Related Programs#

(mepd-a-4000)(block-1)A-4000, Other Service-Related Programs#

(mepd-a-4000)(block-2)Related Policy#

(mepd-a-4100)Medicaid for the Elderly and People with Disabilities Handbook: A-4100, Community Attendant Services#

(mepd-a-4100)(block-1)A-4100, Community Attendant Services#

(mepd-a-4200)Medicaid for the Elderly and People with Disabilities Handbook: A-4200, Program of All-Inclusive Care for the Elderly#

(mepd-a-4200)(block-1)A-4200, Program of All-Inclusive Care for the Elderly#

(mepd-a-4300)Medicaid for the Elderly and People with Disabilities Handbook: A-4300, Retroactive Coverage#

(mepd-a-4300)(block-1)A-4310 General#

(mepd-a-4300)(block-2)A-4320 Two Months Prior#

(mepd-a-4300)(block-3)A-4330 Deceased Individuals#

(mepd-a-5000)Medicaid for the Elderly and People with Disabilities Handbook: A-5000, Texas Medicaid Hospice Program#

(mepd-a-5000)(block-1)A-5000, Texas Medicaid Hospice Program#

(mepd-a-5000)(block-2)Related Policy#

(mepd-a-5100)Medicaid for the Elderly and People with Disabilities Handbook: A-5100, Hospice in the Community#

(mepd-a-5100)(block-1)A-5100, Hospice in the Community#

(mepd-a-5200)Medicaid for the Elderly and People with Disabilities Handbook: A-5200, Hospice in a Long-Term Care Facility#

(mepd-a-5200)(block-1)A-5200, Hospice in a Long-Term Care Facility#

(mepd-a-6000)Medicaid for the Elderly and People with Disabilities Handbook: A-6000, People in Institutions for Mental Diseases#

(mepd-a-6000)(block-1)A-6000, People in Institutions for Mental Diseases#

(mepd-a-7000)Medicaid for the Elderly and People with Disabilities Handbook: A-7000, Type Programs and Type Assistance#

(mepd-a-7000)(block-1)A-7000, Type Programs and Type Assistance#

(mepd-a-8100)Medicaid for the Elderly and People with Disabilities Handbook: A-8100, Qualified Medicare Beneficiaries#

(mepd-a-8100)(block-1)A-8100, Qualified Medicare Beneficiaries#

(mepd-a-8100)(block-2)Related Policy#

(mepd-a-8200)Medicaid for the Elderly and People with Disabilities Handbook: A-8200, Specified Low-Income Medicare Beneficiaries#

(mepd-a-8200)(block-1)A-8200, Specified Low-Income Medicare Beneficiaries#

(mepd-a-8200)(block-2)Related Policy#

(mepd-a-8300)Medicaid for the Elderly and People with Disabilities Handbook: A-8300, Qualifying Individuals#

(mepd-a-8300)(block-1)A-8300, Qualifying Individuals#