Texas Health and Human Services Commission
Texas Works Handbook
Revision: 14-3
Effective: July 1, 2014

Part A — Section 800

Medicaid Eligibility

A—810  General Policy

Revision 13-4; Effective October 1, 2013

Medical Programs

Applicants may receive Medicaid during the three months period before the month they apply for Medicaid. See A-831, Three Months Prior Coverage, for eligibility criteria and application procedures.

Some former TP 08 individuals remain eligible for Transitional Medicaid after their TP 08 Eligibility Determination Group (EDG) is denied. See the chart that follows for more information.

Reason for Denial Type Program Who is Covered?
Child support TP 20 (A-850) The household
New or increased earnings TP 07 (A-842) The household
Loss of earned income disregards for TP 08 households TP 37 (A-843) The household

Applicants can apply for Medicaid if the household includes a pregnant woman or minor child under age 19.

Most adopted children receive Medicaid through the Texas Department of Family and Protective Services (DFPS). DFPS works with the Interstate Compact on Adoption and Medical Assistance (ICAMA) to facilitate the timely delivery of Medicaid coverage when a family moves or the adoption involves an interstate placement. If an adopted child is receiving Medicaid in another state, the parent must contact the originating state to coordinate and transfer Medicaid coverage information to Texas. If an adoptive parent has any questions about the adoptive child's Medicaid, inform them to contact their local DFPS office for assistance.

Medical Programs, Qualified Medicare Beneficiaries (QMB) and Specified Low-Income Medicare Beneficiaries (SLMB)

Individuals receiving some Texas Works Medicaid types of assistance may also qualify for the Medicaid for the Elderly and People with Disabilities (MEPD) Medicare Savings Program types of assistance, MC – QMB (TP 24) or MC – SLMB (TP 23), if they meet the eligibility criteria.  See policy in the Medicaid for the Elderly and People with Disabilities Handbook, Q-2000, Qualified Medicare Beneficiaries (QMB) - MC-QMB. 

Individuals may receive QMB and the following types of assistance: 

  • MA – Deceased Prior Medical (TPDE)
  • MA – Earnings Transitional (TP 07)
  • MA – Historical Prior Medical (TPPM)
  • MA – EID Transitional (TP37)
  • MA – TANF Level Families (TP08)
  • MA – Pregnant Women (TP 40)
  • MA – Children Under 1 (TP 43)
  • MA – Newborn Children (TP 45)
  • MA – Children 1-5 (TP 48)
  • MA – Children 6-18 (TP 44)

The above programs cannot be dually eligible for SLMB. Even though these programs may meet SLMB eligibility requirements, the Medicare Part B premium is already paid. An individual can be dually eligible for MA – MN with Spend Down (TP 56) and SLMB.

A—820  Regular Medicaid Coverage

Revision 14-3; Effective July 1, 2014

Medical Programs

Regular Medicaid eligibility begins the day an individual meets all eligibility criteria. It is usually the first day of the application month if all eligibility criteria are met.

The following are situations when the medical effective date (MED) may not be the first day of the application month:

  • The MED cannot precede a newborn's date of birth.
  • The MED cannot precede the date a child enters the home.

    Exception: A child's MED can be earlier than when the child enters the home when the child is born to a woman incarcerated in the Texas Department of Corrections at Gatesville. Assign the date of birth as the MED for the child requiring this coverage when contacted by a special Texas Works advisor housed at the University of Texas Medical Branch (UTMB) Hospital. Document this contact in Case Comments.
  • The MED for the caretaker (and second parent) cannot precede the date of birth of the newborn or a child's entry into the home when the newborn or entering child is the only child.

    TP 08 Exception: The Texas Integrated Eligibility Redesign System (TIERS) will assign an earlier MED if the caretaker has unpaid medical bills and would have been eligible for Medicaid as a pregnant woman from the first day of her infant's birth month.
  • The MED cannot precede the start date of the emergency condition for aliens eligible for Emergency Medicaid.
  • The MED cannot precede the date a disqualified caretaker or second parent complies.
  • The MED cannot precede the month Children's Health Insurance Program (CHIP) coverage ends.

If the only eligible TP 08 child dies before certification, process an application for Medicaid for a Deceased Individual. Provide coverage for the child through the date of death and for the caretaker/second parent through the remainder of that month.

TP 40

Do not begin Medicaid for a pregnant woman before the first day of the month her pregnancy began. Staff must verify the month the pregnancy began. The applicant’s (pregnant woman's, case name's or authorized representative's [AR's]) verbal or written statement of the start month, the number of expected children and anticipated date of delivery is an acceptable source of verification, as are the other sources listed in A-870, Verification Requirements, if unable to obtain the applicant's statement.

If the applicant’s (pregnant woman's, case name's or AR's) statement is not available, use one of the verification sources in A-870 to obtain the pregnancy start date and anticipated date of delivery.

Allow until the 15th workday for the requested information to be submitted to the Texas Health and Human Services Commission (HHSC). If it is not returned by the 15th workday, deny the application. Reopen the application if the individual provides verification by the 60th day from the file date. See B-111, Reuse of an Application Form After Denial.

Exception: Do not require pregnancy verification if the:

  • application is processed after the pregnancy terminates, and
  • applicant provides proof of her newborn child's birth.

A pregnant woman remains eligible through the second month following the month her pregnancy terminates if all other eligibility requirements are met and countable income is below the income limits in:

  • the application month, or
  • one of the three months prior to the application month if in the prior month she:
    • had unpaid Medicaid-reimbursable bills, or
    • received services from the Texas Department of State Health Services (DSHS).

Example: A pregnant woman applies for Medicaid in May 2011. Her expected delivery date is December 2011. She has unpaid medical bills in February 2011 and meets all other eligibility requirements. She does not have any unpaid medical bills in March or April 2011. Certify her for Medicaid from February 2011 through February 2012.

After determining a pregnant woman is eligible for TP 40, the woman remains eligible even if the budget group's income increases above the income limit.

If a woman is certified for expedited benefits, but postponed verifications prove she is not eligible, provide advance notice of adverse action and deny her coverage.

TP 45

Before providing initial TP 45 coverage for a newborn child, verify the:

  • mother was:
    • eligible for and received Medicaid in Texas on the day the child was born, or
    • retroactively eligible for Medicaid for the day the child was born;
  • child resides in Texas; and
  • mother was continuously eligible for Medicaid (or would have been eligible if pregnant) during the child's birth month.

Note: A newborn born to a mother who received Emergency Medicaid coverage (any type of Emergency Medicaid except MA – MN w/ Spend Down – Emergency [TP 32]) at the time of the child's birth is eligible to receive TP 45 coverage from the child's date of birth through the end of the month of the child's first birthday.

The MED for the initial certification is always the child's date of birth.

Before resuming coverage for a newborn whose TP 45 has been denied, verify that the child resides in Texas.

TP 56

Medicaid coverage for children or pregnant women with spend down begins the first day the household meets spend down.

The applicant meets spend down by submitting or having a provider submit medical bills to the Clearinghouse. See A-1532.1, Spend Down EDGs.

The Clearinghouse:

  • determines when the individual meets spend down, and
  • notifies TIERS via an interface. TIERS then sets the MED for the certified group members.

Note: The Clearinghouse may discover a discrepancy while processing a spend down case. Processing is put on hold and the Eligibility Determination Group (EDG) is referred to State Office Data Integrity (SODI) to research. SODI sends a memo to the field asking for information to clear the discrepancy. Staff must respond quickly to these requests so that the Clearinghouse can complete the spend down process.

Emergency Medicaid

Medicaid eligibility begins on the start date of the emergency medical condition verified by the attending practitioner on Form H3038, Emergency Medical Services Certification.

Related Policy
Pregnancy, A-144.5
Medicaid Termination, A-825
How to Determine Spend Down, A-1359

A—821  Types of Coverage

Revision 13-2; Effective April 1, 2013

Medical Programs

The type of coverage determines how recipients access Medicaid services. There are two types of coverage. They are fee for service and managed care.

A—821.1  Fee for Service

Revision 13-2; Effective April 1, 2013

Medical Programs

Fee for service, also known as Traditional Medicaid, allows access to any Medicaid provider and self-referral to specialists. The provider submits claims directly to Texas Medicaid and Healthcare Partnership (TMHP) for reimbursement of Medicaid covered services.

A—821.2  Managed Care

Revision 13-3; Effective July 1, 2013

Medical Programs except TP 56 and Emergency Medicaid

State of Texas Access Reform (STAR) is a Medicaid program that provides acute care medical services in a managed care setting. In STAR, individuals have a health plan and main doctor. The main doctor coordinates care and provides referrals. STAR is available statewide in the following service areas: Bexar, Dallas, El Paso, Harris, Hidalgo, Jefferson, Lubbock, Medicaid Rural Service Area (RSA) West, Medicaid RSA Central, Medicaid RSA Northeast, Nueces, Tarrant and Travis.

Children's dental services provide dental care for most individuals age 0-20. Individuals have a dental plan and a main dentist. The main dentist is considered their dental home and makes referrals to specialist affiliated with the DMO for other services.

See C-1116, Managed Care Plans, for a list of the counties with Medicaid managed care, the choices available and contact numbers.

Texas Works Medicaid recipients who reside in managed care counties and are mandatory must enroll in managed care. Exception: Recipients who are dually eligible for Medicaid and Medicare are excluded from STAR.

MAXIMUS contracts with the state to enroll recipients into Medicaid managed care. MAXIMUS mails newly certified individuals enrollment packets that include information about the plan choices available in their county of residence. If the recipient does not choose a plan and a primary care physician (PCP) by the deadline provided in the enrollment packet, MAXIMUS assigns a plan and a PCP and mails the individual the information.

Special populations are exempt from mandatory enrollment in Medicaid managed care. The special populations include:

  • members of federally recognized Indian tribes;
  • children enrolled in the Department of State Health Services (DSHS) Children with Special Health Care Needs (CSHCN) Program; and
  • unaccompanied refugee minors (URM).

At all Medicaid applications and redeterminations, identify and designate individuals appropriately. If the advisor does not have this information, do not designate an individual as meeting one of the special populations. Do not pend the application or delay an eligibility determination for this information.

Refer newly certified individuals to MAXIMUS to initiate their enrollment into managed care. MAXIMUS staff is available in some local eligibility determination offices. The client can also call the STAR Helpline at 1-800-964-2777 to initiate enrollment, to request a plan change, or to disenroll from managed care if the individual is exempt from mandatory enrollment in Medicaid managed care.

If an individual has difficulty accessing medical services in a managed care plan, refer the individual to the Medicaid Managed Care Helpline at 1-866-566-8989. The Medicaid Managed Care Helpline advocates for managed care recipients experiencing difficulty in getting the medical and dental care they need.

Related Policy
Office of the Ombudsman, B-1420
Managed Care Plans, C-1116

A—822  Medicaid Coverage for New State Residents

Revision 13-2; Effective April 1, 2013

Medical Programs

Determine the correct MED for applicants who

  • move to Texas from another state during the application month or the three months prior to the application month, and
  • are Medicaid recipients in the losing state in the month they move.
Steps If the losing state ... then ...
Step 1 denied the recipient's Medicaid the last day of the month the recipient moved from the state or later, go to Step 2.
- denied the recipient's Medicaid the day the recipient moved from the state, assign a MED = date the applicant became a Texas resident.
- - If ... then ...
Step 2 Did any member of the certified group incur Medicaid reimbursable bills after they moved to Texas? Yes Verify the effective date of denial in the losing state.

Go to Step 3.
- - No Verify the effective date of denial in the losing state. Assign a MED = first day of the month after the month the losing state denied the recipient's Medicaid.
- - If ... then ...
Step 3 Will the losing state pay for the bills incurred in Texas after the day the person became a Texas resident. Yes Assign a MED = first day of the month after the month the losing state denied the recipient's Medicaid.
- - No Assign a MED = date the applicant became a Texas resident.

Note: If the applicant is unable to provide a contact person in the losing state, contact the appropriate state Medicaid director's office. See C-1111, State Medicaid Directors, for telephone numbers.

When a Texas Medicaid recipient moves to another state, staff from the gaining state may contact the local office about effective dates of denial and coverage of bills incurred in the gaining state. Texas Medicaid pays for Medicaid-reimbursable services provided out-of-state if the

  • recipient needs services because of a medical emergency documented by the attending physician or other provider,
  • recipient's health could be jeopardized by not obtaining services, and
  • provider enrolls in the Texas Medicaid Program. Out-of-state providers can obtain enrollment information by calling TMHP at 1-800-925-9126.

A—823  Lock-In Status

Revision 14-1; Effective January 1, 2014

Medical Programs

HHSC identifies fee-for-service individuals who:

  • received duplicative, excessive, contraindicated or conflicting health services, including drugs; or
  • abused, misused or committed fraudulent actions related to Medicaid benefits and services.

These clients may choose one pharmacy and/or one PCP to be their designated provider for Medicaid services.

The duration periods of lock-in status are as follows:

  • The initial period is 36 months.
  • The second period is an additional 60 months.
  • The third period is for the duration of eligibility and all subsequent periods of eligibility.
  • The period of lock-in status for individuals arrested, indicted or convicted of, or admitting to, a crime related to Medicaid fraud differs from the time period listed for initial, second and third periods of lock-in. These individuals will be assigned lock-in status for 60 months or the duration of eligibility and subsequent periods of eligibility up to or equal to 60 months. 

For individuals with enrollment lock-in status, HHSC issues a Your Texas Benefits Medicaid card printed with "Lock-in Doctor" and/or "Lock-in Drug Store" on the front of the card, along with the name of the doctor and/or drug store. If an individual with lock-in status prints a Medicaid card from the Self-Service Portal, the same information is displayed. 

Staff must verify current lock-in status when issuing Form H1027-A, Medicaid Eligibility Verification. To verify an individual’s lock-in status, access the individual’s Lock-In Enrollment page from the Individual – Summary page’s hover menu. If an individual is in lock-in status, the Lock-In Enrollment page will display the provider name and begin date of the status.

Individuals are removed from lock-in status at the end of the specified period if their use of medical services no longer meets the criteria for lock-in status. 

Refer individuals with questions regarding their lock-in status to the HHSC Office of Inspector General (OIG) at 1-800-436-6184.

A—824  Issuance of Form H1027-A, Medicaid Eligibility Verification

Revision 13-3; Effective July 1, 2013

Medical Programs

Issue Form H1027-A, Medicaid Eligibility Verification, to an eligible Medicaid individual only if the individual:

  • needs his eligibility verified to receive medical services;
  • does not have access to a Your Texas Benefits Medicaid card; and
  • is unable to reprint the Medicaid card from YourTexasBenefits.com.

The individual may not have a Your Texas Benefits Medicaid card if the individual:

  • is newly certified and has not received it,
  • lost or accidentally destroyed the card, or
  • is temporarily separated from other eligible family members who have their card.

Before issuing a Form H1027-A, staff must verify the individual's current eligibility, enrollment lock-in status and managed care enrollment by accessing the Individual - Summary and Individual – Medicaid History page. If inquiry is unavailable, follow regional procedures.

Medicaid with No Enrollment Lock-in or Managed Care Coverage

Issue Form H1027-A for current eligibility if the most recent medical coverage period on the Individual-Summary and Individual-Medicaid History page:

  • is open (no close date shown), and
  • reflects regular Medicaid coverage.

Enrollment Lock-in

If an individual is in enrollment lock-in status, "Yes" will display after Lock-In on the Individual-Summary page. Select Lock-In Enrollment from the hover menu over the individual's client number. The Individual-Lock-In Enrollment page provides information regarding the provider(s) to which the individual is currently or was once locked in.

If an individual is currently in lock-in, issue a separate Form H1027-A for the individual, and print LIMITED and the name(s) of the provider(s) to which the individual is locked in. Form H1027-A generated in TIERS is printed with "LIMITED" in the "Type of Coverage" field.

Managed Care Coverage

If an individual is in a managed care service area, "Yes" will display after Managed Care on the Individual-Summary page. Select Managed Care from the hover menu over the individual's client number. Select the Individual-Managed Care page to view the individual's plan to which the individual is enrolled.

Issue a Form H1027-A for everyone on the case in the same managed care plan by printing STAR and the name and telephone number of the plan. This information is in C-1116, Managed Care Plans.

After staff verify eligibility, enrollment lock-in status and managed care enrollment, advisors complete, sign and date Form H1027-A. The unit supervisor or other second party must approve the form indicating he verified eligibility and lock-in status.

Do not issue Form H1027-A if the most recent medical period:

  • is closed, or
  • shows institutional coverage.

Form H1027-A instructions include detailed information for completing the form.

TP 42

Before the qualified provider submits the presumptive eligibility packet, issue Form H1027-A if the pregnant woman:

  • needs medical care, and
  • provides Form H1266, Notice of Presumptive Eligibility for Pregnant Women, verifying her eligibility.

Do not issue Form H1027-A later than two workdays after the date on Form H1266, Notice of Presumptive Eligibility for Pregnant Women.

Form H1027-A instructions include detailed information for completing the form.

State Paid Medicaid

State Paid Medicaid coverage shows in the Medicaid History screen when the individual was not eligible for Medicaid and staff have issued Form H1027-A in error. State Paid Medicaid is 100% state-funded.

A—825  Medicaid Termination

Revision 13-4; Effective October 1, 2013

TP 08

TIERS runs Mass Update on the fifth, sixth or seventh day of the month in which the review due date falls for the TP 08 Eligibility Determination Group (EDG). TIERS automatically denies the EDG effective the end of the month if a packet received date is not entered by that date.

Related Policy
Denial at Redetermination, A-2342

Emergency Medicaid

Medicaid eligibility for Emergency Medicaid ends the earliest of either the:

TP 36

Medicaid eligibility for TP 36 ends the earliest of either the:

  • end date of the emergency medical condition verified by the attending practitioner on Form H3038 or, Form H3038-P, CHIP Perinatal – Emergency Medical Services Certification; or
  • last day of the application month.

The individual is not eligible to receive two months post coverage once the pregnancy terminates.

Related Policy
Regular Medicaid Coverage, A-820

TP 40

Medicaid eligibility for pregnant women ends on the last day of the second month following the month the pregnancy terminates.

If the pregnancy terminates early because of molar pregnancy, abortion or premature delivery, deny the coverage effective the last day of the second month following the month the pregnancy terminated.

If the pregnancy ends in a month later than expected, change the end date to reflect the new termination date.

TP 43, TP 44, TP 47 and TP 48

A child is continuously eligible for six months. If a household fails to report required information at application that causes a child to be ineligible for Medicaid, deny the EDG and send a fraud referral to the Office of Inspector General. This does not apply if the household provides verification required by policy. For example, the household applies for Medicaid for a child, provides one pay stub, and is determined eligible. If providing more income verification would result in the child being ineligible, do not deny the Medicaid EDG. The child remains continuously eligible for the six-month period, because policy requires only one pay stub to verify income for a child's Medicaid EDG. Address the income discrepancy at redetermination.

EDGs with end dates do not require an action to close the EDG when the individual does not return a renewal form. These will close at cutoff in the sixth month of the continuous eligibility period.

Note: Independent children residing in state hospitals are continuously eligible for six months, even if the child is released from the state hospital. If a child is released from the facility prior to the end of the six-month period, process the address change and continue coverage.

For households that return a redetermination form, the advisor must process the form to determine eligibility. If the child is still eligible for Medicaid, the child is assigned a new six-month continuous eligibility period. If the child is no longer eligible for Medicaid, the advisor must process a denial action to close the EDG and record workload activity. Advisors must process the action before cutoff in the sixth month to ensure the denial code reflects the specific reason for denial.

A child is eligible through the month of the:

  • first birthday for TP 43,
  • sixth birthday for TP 48, and
  • 19th birthday for TP 44 or TP 47.

When a child ages out of the current type of assistance, TIERS denies the TP 43 or TP 48 EDG through mass update and opens a new EDG for the next type of assistance if the adjusted gross income (AGI) is equal to or below the corresponding Federal Poverty Income Limits (FPIL). If the AGI is more than the FPIL for the next type program, the one or six-year-old child remains in the current program through the sixth month of their continuous eligibility period. At redetermination, the advisor determines the correct AGI, and either extends Medicaid for another six months or certifies the child for CHIP, if eligible.

Exception: Children aging out of TP 44 or TP 47 are eligible through the month of their 19th birthday.

If a child is ineligible for the next type of assistance or turns 19, the child may continue to receive Medicaid if the child:

  • is hospitalized on the child's birthday,
  • remains hospitalized through the end of the six-month eligibility period, and
  • meets all eligibility requirements except age.

The advisor must verify the child’s hospitalization and update the child’s living arrangements to “hospital” to prevent TIERS from denying the child’s coverage. The advisor must verify the hospitalization each month and update the child’s living arrangement when the hospitalization ends.

Reminder: Redetermine a younger sibling's eligibility at renewal when removing a 19 year old from the family's budget group.

Related Policy
Processing Children’s Medicaid Redeterminations, B-123

TP 45

A child's eligibility terminates the month of the child's first birthday. Deny the TP 45 EDG before the child's first birthday if the:

  • child's mother was presumptively eligible and received TP 42 at the time of the child’s birth, but was not eligible for regular Medicaid at the time of the child’s birth. The child is eligible for TP 45 through the end of the birth month; or
  • child no longer resides in Texas. The child is eligible for TP 45 through the month the change occurs.

Note: If the child's mother received TP 56 at the time of the child's birth, the child is eligible for TP 56 for the same period the child's mother received TP 56. The mother's coverage is limited to the birth month and the two months following the birth month. If the child's mother received TP 32 at the time of the child's birth, the child is eligible for TP 56 the month in which the mother met spend down.

Related Policy
Regular Medicaid Coverage, A-820

A—830  Medicaid Coverage for the Months Prior to the Month of Application

Revision 13-2; Effective April 1, 2013

A—831  Three Months Prior Coverage

Revision 13-2; Effective April 1, 2013

Medical Programs

Applicants may be eligible for Medicaid coverage during the three-month period before the month they apply for Medical Programs. Prior coverage may be continuous or there may be interrupted periods of eligibility involving all or some of the certified members.

A—831.1  How to Apply for Three Months Prior Coverage

Revision 14-3; Effective July 1, 2014

Medical Programs Except TP 45

A person applies for three months prior Medicaid coverage by completing Form H1113, Application for Prior Medicaid Coverage. Give this form to applicants who indicate on Form H1010, Texas Works Application for Assistance — Your Texas Benefits, or Form H1205, Texas Streamlined Application, or during the application interview that the family has unpaid medical bills incurred during the three months before the application month. Exception: For Children’s Medicaid, do not require Form H1113 if the family provides enough information to determine eligibility for prior months.

Related Policy
Continuous Medicaid Coverage, A-832
TP 45 Retroactive Coverage, A-833

A—831.2  Eligibility for Three Months Prior Coverage

Revision 13-2; Effective April 1, 2013

Medical Programs except TP 40

Advisors certify the applicant for Medicaid only for the month(s) the individual meets all eligibility requirements and has

  • unpaid medical bills for Title XIX-covered services, or
  • received Medicaid services from the Texas Department of State Health Services.

Provide prior Medicaid coverage even if the

  • family is not currently eligible for Medical Programs, or
  • person with unpaid medical bills is deceased.

TP 40

Gaps do not apply to TP 40. Once eligibility is determined in one of the prior months, it continues even if there are no unpaid medical bills in a subsequent prior month.

A—831.2.1  Reopening Three Months Prior Applications

Revision 14-1; Effective January 1, 2014

Medical Programs

Reopen three months prior applications for one or more month(s) in the three month prior period when:

  • the applicant requests the application be reopened within two years after the application file date, and
  • Medicaid eligibility (certification with or without spend down) for the individual and/or month(s) of coverage requested was not previously established.

Use any application the household previously filed within the past two years as a basis for determining eligibility for prior Medicaid coverage, even if the application did not request ongoing Medicaid or prior month’s coverage or claim unpaid medical bills.

The advisor must verify an application was filed.

Note: Do not reopen an application for prior Medicaid for a month in which Medicaid eligibility (certification with or without spend down) was established, even if the spend down was closed by the Clearinghouse.

A—831.3  Income Computation

Revision 13-2; Effective April 1, 2013

Medical Programs

When determining eligibility for each prior month, include only the needs and income of people who would have been considered if the household had applied for benefits in that month.

Determine eligibility for each month in which there are unpaid medical bills using actual income and expenses.

Note: For EDGs with annual or seasonal self-employment income, use annualized income.

Exception: For Children's Medicaid, do not request more income verification for prior Medicaid coverage than what is required for ongoing eligibility. See A-1371, Verification Sources, for Children's Medicaid.

A—831.4  Determining the Appropriate Type Program for the Prior Month

Revision 13-2; Effective April 1, 2013

Medical Programs

Use the following chart to determine the type program to use for eligibility in the prior month:

If the type program is ... and the adjusted gross income for the prior month is ... then ...
08, 47 less than the TANF recognizable needs amount and there is no gap in coverage, certify the application for the prior month.
- less than the TANF recognizable amount and
  • there is a gap in coverage, or
  • the individual is not currently eligible,
certify the application for the prior month(s).
- more than the TANF recognizable needs amount, do not certify the application for the prior month in this type program. Check eligibility for another type program.
40, 43, 44, 48 less than or equal to the federal poverty income limit (FPIL) amount for that program, certify the application for the prior month.
- more than the FPIL amount for that program, do not certify the application for the prior month in this type program. Check eligibility for TP 56.
45 not applicable these applicants are always eligible back to the date of birth.
56 more than the medically needy income limit (MNIL), determine if the household has enough medical expenses to meet spend down for the prior month.
- - If ... then ...
- - Yes, certify the children or pregnant woman.
- - No, deny the application for prior coverage.
Emergency Medicaid Less than
  • or equal to 185% FPIL for pregnant women and children under age one,
  • or equal to 133% FPIL for children age one through five,
  • or equal to 100% FPIL for children ages six through 18, or
  • the TANF recognizable needs amount,
certify the applicant for the prior month only for the dates of emergency medical condition verified on Form H3038, Emergency Services Certification.
-TA 32 above the income limits as stated above (applies only to children [under age 19] and pregnant women), determine if the household has enough medical expenses to meet spend down for the prior month.
- - If ... then ...
- - Yes, certify the child or pregnant woman.
- - No, deny the application for prior coverage.

A—831.5  Medical Eligibility Date for Three Months Prior Coverage

Revision 13-2; Effective April 1, 2013

Medical Programs

The MED for a month of prior coverage begins the earliest day in the month the individual met all eligibility criteria. It is the first day of the month unless all eligibility criteria were not met.

Related Policy
Regular Medicaid Coverage, A-820

A—831.6  Applications Based on Incapacity

Revision 13-2; Effective April 1, 2013

TP 08 and TA 31

If the applicant claiming incapacity meets the other eligibility requirements for prior Medicaid coverage, document information according to A-1080, TANF and Medical Programs.

A—832  Continuous Medicaid Coverage

Revision 13-2; Effective April 1, 2013

TP 40

Provide continuous Medicaid coverage without a Form H1010, Texas Works Application for Assistance — Your Texas Benefits, or an interview for a pregnant woman through the second month after the pregnancy terminates regardless of income increases if she:

  • received Medicaid on a program other than TP 40 and was ineligible because of income;
  • provides verification that she was pregnant in the month she becomes ineligible for Medicaid. Accept the individual's (pregnant woman's, case name's or AR's) verbal or written statement of pregnancy as verification. The statement must include the name of the woman who is pregnant, pregnancy start month, number of expected children and anticipated date of delivery. The individual also may provide Form H3037, Report of Pregnancy, or another document containing information specified on Form H3037; and
  • received Medicaid within 11 months prior to the application month.

Note: Provide continuous Medicaid coverage to a pregnant woman who was denied with an administrative denial reason (such as, but not limited to, failure to keep appointment and voluntary withdrawal) if her Medicaid would have been denied because of income if the income had been reported.

The continuous coverage policy applies to women who were receiving benefits from the following programs:

  • Supplemental Security Income (SSI) or Medicaid Eligibility for the Elderly and Persons with Disabilities (MEPD). Note: When an SSI Medicaid recipient is denied, TIERS sends Form H1296, SSI Denial Letter, informing the recipient that she may be potentially eligible for other medical programs within HHSC.
  • a caretaker or child certified on TP 08 who is not eligible for TP 07, 20 or 37.
  • a caretaker or child certified on TP 07, TP 20 or TP 37.
  • a child certified on TP 44 or TP 47.

TP 43, TP 44, TP 47 and TP 48

A child under age 19 is continuously eligible for Medicaid for six months or through the month of the child’s 19th birthday, whichever is earlier.

Exceptions:

  • During the continuous eligibility period, if a household reports a sibling has moved into the household and requests Medicaid for the sibling, add the sibling to a current EDG or create a new EDG if the child is in a different age group from the other sibling(s). If a new EDG is created, TIERS aligns the end of the newly created EDG with the end date of the existing EDG(s).
  • A child is not eligible for continuous coverage if a household fails to report required information at application that causes a child to be ineligible for Medicaid. See A-825, Medicaid Termination.

If the household is eligible in the application month, process month, or ongoing month, the child is eligible for continuous coverage beginning the first month the household meets the eligibility criteria. Note: This includes situations where the household is eligible in the application or process month, but not in an ongoing month.

If the household is eligible only in a month prior to the application, certify the child for the prior month only. The child is not eligible for continuous coverage.

Note: Explore TP 56 for the child if the individual indicates the child has unpaid bills in a month of ineligibility.

Related Policy
Medicaid Termination, A-825
What to Report, B-621

A—833  TP 45 Retroactive Coverage

Revision 14-3; Effective July 1, 2014

TP 45

Provide retroactive TP 45 coverage for newborn children without Form H1205, Texas Streamlined Application, or an interview with the child's mother if all of the following conditions are met:

  • There are unpaid Title XIX bills for the newborn child.
  • The mother of the child is unwilling, unable or refuses to apply for current benefits for the child, or the child is not eligible for current benefits.
  • The advisor has verification of the following eligibility factors for the newborn child:
Eligibility Factor Eligibility Requirement
Age Coverage must be initiated within one year of the child's birth.

The child's coverage cannot continue after the child becomes 13 months old.
Residence Child must be residing in Texas.
Natural mother's Medicaid coverage dates Child's mother must be eligible for and receiving Medicaid on the day the child is born. The mother's eligibility can be determined retroactively. See A-820, Regular Medicaid Coverage.

The file date is the day the advisor is notified about the unpaid bills for the child.

TIERS will allow a:

  • file date as late as the month of the child's first birthday, and
  • medical effective date as early as the child's date of birth.

A—834  Retroactive Medicaid Coverage for Abandoned Children

Revision 13-2; Effective April 1, 2013

Medical Programs

If a newborn or child is abandoned at the hospital, Department of Family and Protective Services (DFPS) requests a court order for custody. Once the court order is obtained, DFPS provides Medicaid coverage from the day in which custody is granted. The MED is the date DFPS takes conservatorship. This may result in the newborn or child having unpaid medical bills if DFPS takes conservatorship after the date of birth or the date of admission to the hospital.

A designated DFPS representative completes Form H1113, Application for Prior Medicaid Coverage, requesting coverage on behalf of the abandoned child, and forwards the request to a designated Texas Works advisor within Centralized Benefit Services (CBS).

CBS advisors provide retroactive Medicaid coverage only during the following situations:

  • A newborn is taken into foster care conservatorship after the date of birth but before the child is released from the hospital, creating a gap in coverage from the date of birth through the day before the foster care conservatorship date.
  • A child of any age is taken into foster care conservatorship while in the hospital, but after the admission date, creating a gap in coverage from the date of admission to the day before the foster care conservatorship date.

Note: The MED for a child of any age (not a newborn) cannot precede the month of abandonment.

A—840  Transitional Medicaid Coverage

Revision 02-6; Effective July 1, 2002

A—841  General Eligibility Information

Revision 13-4; Effective October 1, 2013

TP 08

Some TP 08 household members may be eligible for transitional Medicaid. There are two transitional Medicaid type programs: TP 07 and TP 37.

When a TP 07 or TP 37 EDG has been created, other eligible household members may be added to the EDG. See A-846.1, Caretakers and Parents Enter or Already Live in the Home, and A-846.2, Child Enters or Already Lives in the Home.

A household member is not eligible for TP 07 or TP 37 if the member was ineligible for TP 08 because the individual committed fraud during any of the six months before the TP 07 or TP 37 EDG was opened. The fraud must be determined by a court or through a hearing. If the TP 07 or TP 37 EDG was opened before the fraud determination was known,

  • disqualify the household member using advance adverse action notice procedures, and
  • notify transitional child care staff that the member should not have received transitional benefits because of TANF or Medicaid fraud.

TP 08 households denied for any reason (such as excess resources or failure to keep an appointment) may request TP 07 or TP 37 during the adverse action time frame and have their eligibility determined. For example, a household who failed to keep their appointment because of a new job may be eligible for TP 07.

Individuals may request Medicaid on TP 08, anytime after denial. These individuals and their household members may also request TP 07 if they go to work.

The number of months of transitional coverage is 12 months.

A—841.1  Multiple Changes that Cause TP 08 Ineligibility

Revision 13-2; Effective April 1, 2013

TP 08

If two or more changes cause loss of TP 08 eligibility for the same month and the household has not been notified that members are eligible for TP 07 or TP 37, follow the steps below:

Step Action
1 If all other case factors remain the same, is the household ineligible solely because of
  • new or increased earnings, or
  • a loss of the 90% earned income deduction.
  • Yes. The family is eligible for TP 07 or TP 37 if members meet the other eligibility requirements.
  • No. Go to Step 2.
2 Is the household ineligible as a result of a change other than
  • new or increased earnings, or
  • a loss of the 90% earned income deduction.
  • Yes. The family is not eligible for TP 07 or TP 37.
  • No. Go to Step 3.
3 Is the family ineligible when you consider all changes in Step 1 and Step 2? Yes. The family is eligible for TP 07 or TP 37 if the members meet the other eligibility requirements.

If two or more changes (when one is new or increased earned income) cause the income to increase from less than the TANF recognizable needs to more than the TANF income limits for the same month, and the household has not been notified that members are eligible for TP 07, follow the steps below:

Step Action
1 If all other case factors remain the same, is the household income increased to above TANF recognizable needs because of new or increased earnings?
  • Yes. The family is eligible for TP 07 if members meet the other eligibility requirements.
  • No. Go to Step 2.
2 Is the income increased to above TANF recognizable needs as a result of a change other than new or increased earnings?
  • Yes. The family is not eligible for TP 07. Go to Step 3.
  • No. Go to Step 4.
3 Does the family meet the income limits for the Medical Program EDGs for which they are certified?
  • Yes. Continue current Medical Program coverage.
  • No. Deny the Medical Program EDG(s) for which the individual is no longer income eligible.
4 Is the income increased to above the TANF recognizable needs when all changes are considered? Yes. The family is eligible for TP 07 if the members meet the other eligibility requirements.

Changes reported in a timely manner do not stop the denial of the TP 08 EDG and creation of the TP 07 or TP 37 EDG after the household is notified of transitional Medicaid eligibility, even when both changes affect the same month.

Exceptions: Deny the EDG if the household

  • moves out of Texas,
  • no longer meets the household composition requirement as specified in A-841.3, Eligibility Criteria During Transitional Medicaid Coverage, or
  • reports a change that makes the household ineligible before the first month of transitional Medicaid eligibility.

A—841.2  Notice to Clients

Revision 13-2; Effective April 1, 2013

TP 08

When TIERS denies a TP 08 EDG and creates a TP 07 or TP 37 EDG, TIERS generates TF0001, Notice of Case Action, to notify the household:

  • their TP 08 is denied;
  • the date their TP 07 or TP 37 benefits will end; and
  • about the transitional Medicaid eligibility and reporting requirements. Note: If the individual is in the office, explain the reporting requirements.

Note: If a household is certified for TANF, but not TP 08, TIERS denies the TANF EDG and notifies the household of its potential eligibility for TP 08.

A—841.3  Eligibility Criteria During Transitional Medicaid Coverage

Revision 13-2; Effective April 1, 2013

TP 07 and TP 37

Certified members remain eligible for transitional Medicaid if the

  • household continues to live in Texas, and
  • EDG meets one of the following household composition requirements.

The transitional EDG includes an eligible child.

Notes:

  • For transitional Medicaid, an eligible child is a child who meets all of the following requirements:
    • citizenship,
    • SSN,
    • age,
    • relationship, and
    • domicile.
  • To remain on or be added to the transitional Medicaid EDG, a child does not have to be
    • deprived,
    • part of the original TP 08 EDG, or
    • previously eligible for TP 08.
OR

A caretaker/second parent cares for a child who

  • receives
    • SSI;
    • adoption assistance payments; or
    • federal, state or local foster care payments; or
    • Medicaid (TP 07, 20, 37, 40, 43, 44, 45, 47 or 48 ; or
  • is certified for TP 08 or other Medical Program because the child is
    • a dependent child;
    • an other-related child (B-481); or
    • a minor parent who was certified as a child on the caretaker's EDG and is now certified as a TP 08 caretaker (A-846.4); or
    • a stepchild or unwed parent's child (with the legal parent) from a previous incapacity or TP 08 case (B-483).

Disqualify the noncomplying adult who is certified for TP 07 or TP 37, when the advisor receives notice that the legal parent failed to cooperate with third-party resource (TPR) requirements or has been found guilty of a Medicaid intentional program violation.

If an other-related caretaker failed to cooperate with TPR requirements, or was found guilty of a Medicaid intentional program violation,

  • change the status to payee, or
  • deny the transitional Medicaid EDG if the other-related caretaker is the only person on the EDG.

Do not

  • count resources or unearned income of household members when determining continued eligibility for households certified for transitional Medicaid, and
  • deny a transitional Medicaid EDG because of new or increased income of a household member, unless reported in the seventh or tenth month Medicaid Status Report.

Individuals must also submit Medicaid status reports in the fourth, seventh, and tenth months of coverage if reporting a

  • loss of employment,
  • change in income or child care expenses, or
  • change in household composition.

A—841.4  Transitional Child Care Eligibility

Revision 13-2; Effective April 1, 2013

TP 07 and TP 37

Household members are potentially eligible to receive transitional child care for the same 12-month period for which the members are certified for transitional Medicaid on TPs 07 or 37.

Refer the individual to the local child care contractor. To meet transitional child care eligibility requirements, the individual must be working and household must include a dependent child who receives TP 08 or TP 07/37.

A—842  TP 07 Transitional Medicaid

Revision 13-2; Effective April 1, 2013

TP 08

TP 08 certified members are eligible for TP 07 if

  • at least one of the group members was eligible for and received TP 08 in Texas for three of the six months before the first month of ineligibility, and
  • the denial is because
    • a certified caretaker, certified second parent, or disqualified legal parent began receiving or had an increase in gross earned income; or
    • of the earnings of a new or returning absent parent who is added to the certified group because the household meets incapacity or deprivation criteria.

A—842.1  Determining the First Month of TP 07 Medicaid

Revision 13-4; Effective October 1, 2013

TP 08

The first TP 07 month is the month the change is effective (when reported and acted on timely) when new or increased earnings cause a TP 08 household to fail the Recognizable Needs test (25%).

Determine the first month of TP 07 eligibility using the following chart:

Step Action
1

The first month of TP 07 is the first month after adverse action expires when the change is reported, verified, and processed timely (or should have expired if the change was not reported, verified, or processed timely).

Note: The first month can be no later than the first month of overpayment as described in B-752.1.2, Errors After Certification, but may be earlier based on the date the notice of adverse action expires (as described in A-2343.1, How to Take Adverse Action if Advance Notice is Required).

2

Was at least one household member eligible for and did that member receive TP 08 in Texas for at least three of the six months prior to the month identified in Step 1? (See A-842.2, Determining the Three of Six Months Eligibility Requirement.)

If yes, continue to Step 3.

If no, deny the EDG.

3 Designate the month from Step 1 as the first month of TP 07 eligibility.

Individuals who appeal the advisor's decision to deny the TP 08 EDG often receive TP 08 while the appeal is pending. If the hearing officer sustains the advisor's decision, the months the client received continued benefits during the appeal process are counted as TP 07 months.

A—842.2  Determining the Three of Six Months Eligibility Requirement

Revision 13-2; Effective April 1, 2013

TP 08

Determine if at least one household member was eligible for and received TP 08 in Texas for three of the six months before the first month of ineligibility.

COUNT any month when at least one household member was eligible for and received benefits. Include any month that someone in the household:

  • received TP 08; or
  • is in the second month of noncooperation with PRA requirements, even if the month is a full-family sanction month.

DO NOT COUNT any month benefits were

  • issued but the household was not eligible,
  • not issued,
  • received in another state,
  • Prior Medicaid coverage, or
  • Medicaid only for the application month due to certification in a later month.

TP 08 with Other Household Members on a Medical Program

Determine if at least one TP 08 household member was eligible for and received Medicaid in Texas for three of the six months before the first month the income increase is effective.

COUNT any month when at least one household member was eligible for and received Medicaid through

  • TP 08, TP 20, TP 37, TP 40, TP 43, TP 44, TP 45, TP 47, TP 48, or TP 56 and spend down was met;
  • SSI, including SSI Medicaid only;
  • federal, state, or local foster care; or
  • adoption assistance.

DO NOT COUNT any months Medicaid benefits were

  • certified but the household member was not eligible,
  • received in another state, or
  • prior Medicaid benefits.

A—842.3  Automatic Denial of TP 07

Revision 13-2; Effective April 1, 2013

TP 07

At cutoff in the last month of TP 07 coverage, TIERS denies the EDG and notifies the individual of Medicaid denial on Form TF0001, Notice of Case Action.

A—843  TP 37 Transitional Medicaid

Revision 13-2; Effective April 1, 2013

TP 08

Certified members are eligible for TP 37 if

  • at least one TP 08 group member was eligible for and received TP 08 in Texas for three of the six months before the first month of ineligibility, and
  • the denial is because of loss of the 90% earned income deduction.

TP 37 begins the month after a certified or disqualified member receives the deduction for the maximum number of months.

A—843.1  Automated Process for TP 37

Revision 13-2; Effective April 1, 2013

TP 08

A household member is eligible for the 90% earned income deduction for four months in a fixed 12-month period. TIERS removes the deduction at cutoff in the third month. If this results in TP 08 ineligibility, TIERS

  • denies the TP 08 EDG;
  • opens a TP 37 EDG effective the fifth month; and
  • notifies the household of
    • TP 08 denial,
    • TP 37 eligibility, and
    • the transitional Medicaid reporting requirements.

A—843.2  Automatic Denial of TP 37

Revision 13-2; Effective April 1, 2013

TP 37

At cutoff in the next to last month of Medicaid coverage, TIERS denies the EDG and notifies the members that Medicaid coverage is ending on Form TF0001, Notice of Case Action.

A—844  Transitional Medicaid Reporting Requirements for TP 07 and TP 37

Revision 13-2; Effective April 1, 2013

TP 07 and TP 37

TP 08 households receiving 12 months of TP 07 or TP 37 are required to report certain changes during the fourth, seventh, and tenth months of the transitional period.

Form H1146, Medicaid Report, is computer-generated and is sent to the household at cutoff in the third, sixth, and ninth months. Form H1146:

  • informs the household of the availability of continuing transitional coverage,
  • provides information about the change reporting requirements, and
  • provides a way to report the required information.

Use Form H1146-M, Medicaid Report (Manual), to replace TIERS-generated forms that the household reports are lost or destroyed.

During any of the reporting periods, the household is required to report changes in:

  • the household members' gross monthly earnings,
  • child care expenses necessary for the employment of the caretaker relative, and
  • household composition.

Do not require verification for the transitional Medicaid EDG. Exception: Require appropriate verifications to determine if a new household member is eligible to be added to the EDG. See A-846.1, Caretakers and Parents Enter or Already Live in the Home, and A-846.2, Child Enters or Already Lives in the Home.

Note: If the household does not return Form H1146, no action is required.

A—844.1  Advisor Action on the Fourth Month Medicaid Report

Revision 13-2; Effective April 1, 2013

TP 07 and TP 37

Use the following procedures to process Form H1146, Medicaid Report, if the household returns the fourth month Medicaid Report. Ensure that action is taken on the household members' other EDGs/cases if the information reported affects those benefits.

If the household returns a Form H1146 and Form H1146 indicates ... then ...
the household still meets the household composition requirements in A-841.3, Eligibility Criteria During Transitional Medicaid Coverage, take no action on the transitional Medicaid case.
a child who is NOT receiving TP 08 or transitional Medicaid is in the home, see A-846.2, Child Enters or Already Lives in the Home.
a child left the home, see A-846.3, Household Member Leaves the Home.
a returning absent parent or stepparent, see A-846.1, Caretakers and Parents Enter or Already Live in the Home.
the household no longer meets the household composition requirements in A-841.3,
  • deny the EDG, and
  • send Form TF0001, Notice of Case Action.
  • there are no earnings by the caretaker relative in at least one of the three report months, and there is no good cause for the lack of earnings,
  • the average monthly gross earnings of the household members* (minus the average monthly child care expenses necessary for the employment of the caretaker relative) exceeds the 185% federal poverty income limits chart figure for the household size,

    Note: Do not limit the amount of child care expenses nor limit them to certified TP 08 children only, as is done with TP 08 dependent care deduction.

shorten the transitional Medicaid coverage to end after the sixth month.

Note: If the medical coverage is shortened because the caretaker relative did not have earnings for a complete month, inform the household that they can show good cause. They must show good cause within 13 days. (See A-844.4, Good Cause Determinations.)


*See A-844.3 for budgeting policies.


A—844.2  Advisor Action on the Seventh and Tenth Month Medicaid Reports

Revision 13-2; Effective April 1, 2013

TP 07 and TP 37

Use the following procedures to process Form H1146, Medicaid Report, for the seventh and tenth months. Ensure that action is taken on the household members' other EDGS/cases if the information reported affects those benefits.

If the household returns a Form H1146 and Form H1146 indicates ... then ...
the household no longer meets the household composition requirements in A-841.3, Deny the EDG due to no eligible children and send Form TF0001, Notice of Case Action, to the household.
  • there are no earnings by the caretaker relative in at least one of the three report months, and there is no good cause for the lack of earnings,
  • the average monthly gross earnings of the household members* (minus the average monthly child care expenses necessary for the employment of the caretaker relative) exceeds the FPIL chart figure for the household size,

    Note: Do not limit the amount of child care expenses nor limit them to certified TP 08 children only, as is done with TP 08 dependent care deduction.

  • deny the EDG using appropriate denial reason,
  • open a new EDG for the appropriate medical program if applicable, and
  • send Form TF0001 to the household.

If the EDG is denied and the household is not eligible for another type of medical program, send Form H1010, Texas Works Application for Assistance – Your Texas Benefits, along with Form TF0001.

HHSC must act on information (earnings) received that makes the household ineligible for transitional Medicaid even if the information is received outside of the reporting period (i.e., changes); however, eligibility can only be terminated at the end of the seventh or tenth month.

Note: If the denial is because the caretaker relative did not have earnings for a complete month, inform the household that they can show good cause. They must show good cause within 13 days. (See A-844.4.)

the household continues to be eligible, take no action.
a child who is not receiving TP 08, or transitional Medicaid is in the home, see A-846.2.
a child left the home, see A-846.3.
a returning absent parent or stepparent, see A-846.1.

*See A-844.3 for budgeting policies.

Note: A denial notice (Form TF0001) will be sent to the household at the end of their 12 months of transitional Medicaid.

A—844.3  185% FPIL Test

Revision 13-2; Effective April 1, 2013

TP 07 and TP 37

Use the following policies and procedures to determine if the household's earnings are at or below the 185% Federal Poverty Income Limit (FPIL) when processing Medicaid reports.

Include the following certified and noncertified household members in the household size and count their gross earnings:

  • persons listed on the TP 07 or TP 37 EDG;
  • minor children (including unmarried minor parent caretakers);
  • parents of unmarried minor parents;
  • spouses; and
  • other-related children in the care of a person who is included in the household size.

Exceptions:

  • Do not count the earnings of a child who is exempt according to A-1323.1, Children's Earned Income.
  • Do not include in the household size or count the earnings of a
    • child who receives SSI; adoption assistance payments; or federal, state, or local foster care payments; or
    • minor child if the household fails to provide the necessary information and verifications to add the minor child to its transitional Medicaid EDG and the child does not receive other Medical Programs coverage.
  • When a person is disqualified because of failure to cooperate with child/medical support or TPR requirements, or is found guilty of a Medicaid intentional program violation, do not include the person in the household size.
If the person who fails to cooperate is ... then ...
a certified legal parent, count the person’s earnings.
an "other relative" caretaker who is the parent or stepparent of a child on the case, count the person’s earnings.
an "other relative" caretaker who is not a parent or stepparent to a child on the case, do not count the person’s earnings.

A—844.4  Good Cause Determinations

Revision 13-2; Effective April 1, 2013

TP 07 and TP 37

Good cause for the caretaker relative not having earnings in one or more of the report months includes

  • involuntary loss of employment,
  • illness,
  • actively looking for work but unable to find a job, and
  • other reasons beyond the household's control.

A—845  Reinstatement of Denied Transitional Coverage

Revision 13-2; Effective April 1, 2013

TP 07 and TP 37

Certain households whose transitional Medicaid EDGs are denied before the end of their original eligibility period may have transitional Medicaid coverage reinstated. Reinstate eligible household members for the remainder of their original transitional Medicaid period if

  • the original transitional Medicaid end date has not expired;
  • the TP 07 or TP 37 EDG was denied. For example, members
    • were recertified for TP 08; or
    • moved out of Texas.
  • the household does not want to apply for TP 08; or are not eligible for TP 08 (at application, review, or change); and
  • there is a dependent child in the household certified for Medicaid.

Note: Individuals requesting reinstatement of TP 07 or TP 37 transitional Medicaid must have remained continuously eligible for transitional Medicaid during the months the TP 07 or TP 37 EDG was denied. Exception: A household that moved out of Texas must meet all of the eligibility criteria except residence.

A—845.1  Advisor Action on Reinstatements

Revision 13-2; Effective April 1, 2013

TP 07 and TP 37

Count the months of absence from transitional Medicaid as if the family had actually received transitional Medicaid.

Use the following table to determine the MED:

If the member ... then enter the day ...
remained in Texas during the transitional Medicaid denial period and did not receive other Medicaid coverage, following the denial date.
moved out of the state, the member returned to Texas and was no longer eligible for Medicaid in another state (See A-822, Medicaid Coverage for New State Residents).
was certified for TP 08 or another Medical Program, following the denial date on the other TP 08 or other Medicaid EDG.

To reinstate denied transitional Medicaid:

  • Determine which mode to use. If the case status is denied and there is:
    • no active EDG, use Reopen mode.
    • an active EDG, use Complete Action mode.
  • On the Program Summary page, select Reactivation from the Program Action drop-down menu.
  • On the Program Details page, enter the Reactivation Date and select the appropriate Reactivation Reason.
  • From the Program – Individuals Summary display, select the person(s) requesting aid.
  • Change Aid Requested to Yes. Note: The Date Requested is defaulted to the previous date for individuals who were on the EDG when it was terminated.
  • Continue through Data Collection.
  • In Disposition, choose Administrative TMA Reinstatement as the reason for eligibility.

Notes:

  • Do not open a new application. If a new application was created, deny it as filed in error.
  • When processing the reinstatement remove any members who are no longer in the household.
  • Send Form TF0001, Notice of Case Action, to notify the household of their continued eligibility.

Obtain information on household composition, earnings, and child care expenses for the months the household did not receive TP 07 or TP 37 and is required to report on Form H1146, Medicaid Report.

If the household missed the ... then obtain information on months ...
fourth month Medicaid report, one, two, and three.
seventh month Medicaid report, four, five, and six.
tenth month Medicaid report, seven, eight and nine.
If the household was ... then ...
certified for SNAP, TANF, or any of the Medical Programs, use case information, requesting additional information from the household only if necessary.
not certified, obtain the necessary information.

Determine if the individual was continuously eligible for TP 07 or TP 37 Medicaid using

  • A-844.1 for the fourth-month Medicaid Report;
  • A-844.2 for the seventh- and tenth-month Medicaid Reports; and
  • A-844.4 to determine good cause for no earnings.

A—846  Special Household Composition Policies for Transitional Medicaid

Revision 13-2; Effective April 1, 2013

A—846.1  Caretakers and Parents Enter or Already Live in the Home

Revision 13-2; Effective April 1, 2013

TP 07 and TP 37

Follow procedures below if the household requests TP 07 or TP 37 benefits for a caretaker, returning absent parent, stepparent, or second parent in the home.

Add the member to the EDG or change an ineligible member to eligible if the person is a caretaker or second parent who

  • was disqualified on the TP 08 or transitional EDG but has complied with the eligibility requirement for which he was disqualified (for example: TPR);
  • is a returning absent parent/second parent in the home; or
  • is a stepparent caretaker because the legal parent is disabled and unable to care for the children.

A—846.2  Child Enters or Already Lives in the Home

Revision 13-2; Effective April 1, 2013

TP 07 and TP 37

Follow the procedures in the chart below

  • when the TP 07 or TP 37 household reports that a child who is not receiving TP 08, TP 07 or TP 37 is in the home;
  • when denying a TP 08 EDG and opening a TP 07 or TP 37 EDG;
  • upon review of another Medical Program EDG for a child who lives with a TP 07 or TP 37 recipient.

Allow a child who receives Medicaid on another Medical Program to remain certified on the other program or be added to the family's transitional TP 07 or TP 37 EDG, whichever is in the household's best interest.

Continue an other-related child's separate Medical Program EDG unless the caretaker needs Transitional Child Care services for the child, or the child becomes ineligible on a separate EDG.

If a child who is NOT receiving TP 08 or transitional Medicaid ... then ...
is a newborn, moves in, or already lives in the home, Obtain the appropriate information/verifications and determine if the child meets all of the following requirements:
  • citizenship,
  • SSN,
  • age,
  • relationship, and
  • domicile.

Use information/verifications from other case records when the child is currently or has been a TANF/MP or SNAP recipient.

Do not consider the following criteria:

  • deprivation,
  • resources, and
  • income.

Note: Obtain information regarding a child's earned income when processing the seventh and tenth month Medicaid reports if the child's earnings are counted following TANF policy in A-1323.1, Children's Earned Income.

- if the ... then ...
- child is eligible,
  • send Form TF0001, Notice of Case Action, to the household, to inform the household of the child's eligibility.
-
  • child is not eligible, or
  • household does not provide the information/verification,
  • send Form TF0001 to the household;
  • inform the household that
    • their TP 07 or TP 37 EDG will continue; but
    • the child cannot be added to the EDG, stating the reason the child cannot be added; and
  • take no action on the EDG.

If a child who is added to the EDG has unpaid medical bills for any of the three months prior to the month the request is received to add the child,

  • determine and document three months prior eligibility according to TP 08 policies and procedures in A-830, and
  • assign the child a MED beginning the first prior month the child met all TP 07 or 37 eligibility requirements.

The child's MED cannot precede the

  • first month the household was eligible for TP 07 or 37. Determine a child's eligibility for another Medical Program if the individual applies for prior coverage that precedes the first month the household is eligible for TP 07 or 37.
  • date the child entered the household.

A—846.3  Household Member Leaves the Home

Revision 13-2; Effective April 1, 2013

TP 07 and TP 37

Follow the procedures in the chart below when the transitional Medicaid household reports that a child leaves the household.

If a child leaves the household and the ... then ...
  • child was part of the transitional certified group, and
  • household continues to meet the household composition requirements in A-841.3, Eligibility Criteria During Transitional Medicaid Coverage,
  • send Form TF0001, Notice of Case Action, to the household informing the household that the child will no longer receive Medicaid, and
  • remove the child from the EDG.
household no longer meets the household composition requirements in A-841.3,
  • send Form TF0001 to the household, and
  • deny the EDG.

Follow normal procedures to remove a caretaker or second parent when the household reports the person is no longer in the home.

A—846.4  Minor Parents Certified as Children

Revision 13-2; Effective April 1, 2013

TP 07 and TP 37

A minor parent receiving transitional Medicaid as a child may apply for TP 08 as a caretaker for the minor parent’s child(ren) by submitting Form H1010, Texas Works Application for Assistance – Your Texas Benefits. If eligible,

  • remove the minor parent's household members from the TP 07 or 37 EDG;
  • send Form TF0001, Notice of Case Action, to notify the remaining TP 07 or 37 member(s) that they will continue receiving transitional Medicaid coverage;
  • open a new TP 08 EDG for the minor parent's household; and
  • send Form TF0001 to the TP 08 household.

A—847  Other EDG Actions

Revision 13-2; Effective April 1, 2013

A—847.1  Changes Affecting Transitional Medicaid EDGs

Revision 13-2; Effective April 1, 2013

TP 07 and TP 37

Do not take action on the TP 07 or TP 37 EDG except for the following changes:

  • A child is born, moves in, or is already living with the certified group. Add the member to the EDG following procedures in A-846.2, Child Enters or Already Lives in the Home.
  • A caretaker or second parent moves in or otherwise becomes eligible. Add the member to the EDG following procedures in A-846.1, Caretakers and Parents Enter or Already Live in the Home.
  • A certified group member leaves the household. Remove the member from the EDG following procedures in A-846.3, Household Member Leaves the Home.
  • A household member is no longer eligible. Remove the member from the EDG. For example:
    • A member begins receiving SSI benefits.
    • A child no longer meets the Medical Programs age criteria.

A—847.2  Reapplication for TP 08

Revision 13-2; Effective April 1, 2013

TP 07 and TP 37

A household receiving TP 07 or TP 37 may reapply for TP 08 by submitting Form H1010, Texas Works Application for Assistance – Your Texas Benefits. If eligible, TIERS will:

  • deny the TP 07 or TP 37 EDG;
  • certify the household on a TP 08 EDG; and
  • send Form TF0001, Notice of Case Action, to the household.

Related Policy
How to Recombine Household Members, B-482.2
Minor Parents Certified as Children, A-846.4

A—850  TP 20 Child Support Post Medicaid Coverage

Revision 13-2; Effective April 1, 2013

TP 08

TP 20 continues Medicaid for households denied TP 08 because of child support income. Household members are eligible for TP 20 post Medicaid for four months following the last month of TP 08 eligibility if:

  • the adjusted gross income before child support receipt was below TANF limits,
  • the denial is because new or increased child support income is added to the budget and the family's adjusted gross income now exceeds the income limit for the household's size, and
  • at least one TP 08 household member was eligible for and received Medicaid in Texas for three of the six months before the first month of ineligibility.

A—851  Eligibility Criteria During Post Medicaid

Revision 13-2; Effective April 1, 2013

TP 20

Certified members remain eligible for Medicaid if the household continues to

  • live in Texas, and
  • receive child support.

Disqualify the legal parent, who is certified for TP 20 when the advisor receives notice that the legal parent failed to cooperate with child/medical support or TPR requirements, or has been found guilty of a Medicaid intentional program violation.

Resources do not count in TP 20. Do not deny the EDG because of resources of any household member.

A—852  Automated Process

Revision 13-2; Effective April 1, 2013

TP 08

If the Office of the Attorney General (OAG) receives a new or increased child support collection that is greater than the TANF income limits, TIERS determines if the EDG should be denied and a TP 20 be opened or if the EDG should be denied. If either is appropriate, TIERS notifies the individual on TF0001, Notice of Case Action.

See C-830, Child Support Systems, for additional information on automated processing.

A—853  Denial of TP 20

Revision 13-2; Effective April 1, 2013

TP 20

When the four months post Medicaid ends, TIERS

  • denies the TP 20 EDG; and
  • notifies the individual on Form TF0001, Notice of Case Action, that Medicaid coverage is ending.

A—854  Reinstatement of Denied TP 20 Coverage

Revision 13-2; Effective April 1, 2013

TP 20

Certain households whose TP 20 EDGs are denied before the end of their eligibility period has expired may have post Medicaid coverage reinstated. Reinstate eligible household members for the remainder of the original TP 20 Medicaid period if:

  • their original post Medicaid end date has not expired;
  • their TP 20 EDG was denied because the members moved out of Texas; and
  • they:
    • do not wish to apply for other medical coverage; or
    • are not eligible for other medical coverage.

Follow procedures in A-845, Reinstatement of Denied Transitional Coverage, to reinstate TP 20 coverage.

A—855  Special Household Composition Policies for Post Medicaid

Revision 13-2; Effective April 1, 2013

A—855.1  Caretakers and Parents Enter or Already Live in the Home

Revision 13-2; Effective April 1, 2013

TP 20

Follow procedures below if the household requests TP 20 benefits for a caretaker, returning absent parent, stepparent, or second parent in the home.

Add the member to the EDG or change an ineligible member to eligible if the person is a caretaker or second parent who

  • was disqualified on the TP 08 or transitional EDG but has complied with the eligibility requirement for which the member was disqualified (for example: child/medical support, TPR);
  • is a returning absent parent/second parent in the home; or
  • is a stepparent caretaker because the legal parent is disabled and unable to care for the children.

A—855.2  Child Enters or Already Lives in the Home

Revision 13-2; Effective April 1, 2013

TP 20

Follow the procedures in the chart below

  • when the TP 20 household reports that a child who is not receiving TP 08 or TP 20 is in the home,
  • when denying a TP 08 EDG and creating a TP 20 EDG, or
  • upon review of another Medical Program case for a child who lives with a TP 20 recipient.

Allow a child who receives Medicaid on another Medical Program to remain certified on the other program or be added to the family's TP 20 EDG, whichever is in the household's best interest.

Continue an other-related child's separate Medical Program EDG unless the child becomes ineligible on a separate EDG.

If a child who is NOT receiving TP 08 or TP 20 ... then ...
is a newborn, moves in, or already lives in the home, obtain the appropriate information/verifications and determine if the child meets all of the following requirements:
  • citizenship,
  • SSN,
  • age,
  • relationship, and
  • domicile.

Use information/verifications from other case records when the child is currently or has been a TANF/MP or SNAP recipient.

Do not consider the following criteria:

  • deprivation,
  • resources, and
  • income.
- if the ... then ...
- child is eligible,
  • send Form TF0001, Notice of Case Action, informing the household of the child's eligibility for TP 20; and
  • add the child to the TP 20 EDG.
-
  • child is not eligible, or
  • household does not provide the information/verification,
  • send Form TF0001 to the household;
  • inform the household:
    • their TP 20 EDG will continue; but
    • the child cannot be added to the EDG, stating the reason the child cannot be added; and
  • take no action on the EDG.

A—855.3  Minor Parents Certified as Children

Revision 13-2; Effective April 1, 2013

TP 20

A minor parent receiving post Medicaid as a child may apply for TP 08 as a caretaker for the minor parent’s child(ren) by submitting Form H1010, Texas Works Application for Assistance – Your Texas Benefits. If eligible,

  • remove the minor parent's household members from the TP 20 EDG;
  • send Form TF0001 to notify the remaining TP 20 member(s) that they will continue receiving post Medicaid coverage;
  • open a new TP 08 EDG for the minor parent's household; and
  • send Form TF0001 to the minor parent’s household.

A—856  Reapplication for TP 08

Revision 13-2; Effective April 1, 2013

TP 20

A household receiving post Medicaid may reapply for TP 08 by submitting Form H1010. If eligible,

  • deny the TP 20 EDG,
  • create a TP 08 EDG, and
  • send Form TF0001 to the household.

Related Policy
How to Recombine Household Members, B-482.2

A—860  Third-Party Resources (TPR)

Revision 13-2; Effective April 1, 2013

Medical Programs

A third-party resource is a source of payment for medical expenses other than the recipient or Medicaid. They include payments from private and public health insurance and from other liable third parties that can be applied toward the recipient's medical expenses. Title XIX (Medicaid) funds are to be used for the payment of medical services only after all available third-party resources have been used, except for medical services from the following:

  • Texas Department of Assistive and Rehabilitative Services;
  • Texas Commission for the Blind;
  • Texas Kidney Health Care Program;
  • Muscular Dystrophy Association;
  • Children with Special Health Care Needs (CSHCN);
  • Texas Band of Kickapoo Equity Health Program;
  • Maternal and Child Health (Title V);
  • State Legislative Impact Assistance Grant (SLIAG);
  • Crime Victims Compensation Program; and
  • adoption agencies or adoptive parents with medical obligations to the recipient.

Income maintenance insurance policies not related to actual medical expenses are not third-party resources unless the policy is assignable to a hospital or other medical provider.

When an applicant has health insurance, instruct the individual to tell medical providers about the health insurance. The provider then bills the insurance company instead of or before billing Medicaid.

Individuals must cooperate

  • in identifying and pursuing any third party who may be liable for medical support payments, including absent parents who pay cash medical support;
  • in reimbursing HHSC for medical expenses paid by Medicaid from
    • court settlements; and
    • liability, casualty, or health insurance payments; and
  • with HHSC and its Health Insurance Premium Payment (HIPP) contractor by
    • providing information about available health insurance coverage;
    • enrolling in their employer's health insurance program; and
    • providing proof of their premium payments.

Individuals who refuse to cooperate without good cause are disqualified.

For TP 08, use disqualified legal parent budgeting procedures for legal parents disqualified for noncompliance.

For other Medical Programs, include the disqualified legal parent in the budget group.

A—861  TPR and Accidents

Revision 13-2; Effective April 1, 2013

Medical Programs

Instruct individuals to report any accident-related injuries requiring medical care or accident-related unsettled legal claims within 60 days.

A—861.1  Reporting the Accident to the TPR Unit

Revision 13-2; Effective April 1, 2013

Medical Programs

If a recipient reports an injury requiring medical treatment for which liability/casualty insurance (the individual's own or someone else's) may provide payment, determine the details of the accident and any legal action involved, and forward the information by memorandum to

HHSC/OIG/TPR Unit
MC 1354
P.O. Box 85200
AustinTexas  78708-5200

Include in the report

  • individual-identifying information;
  • the date and nature of the accident and resulting injuries;
  • information regarding the liable or potentially liable third party, including the liability insurance policy number and name and address of insurance adjuster, if available;
  • dates, types, and sources of medical services related to the injury; and
  • the status or plans for any legal action, including the name and address of any attorney involved, if available.

A—861.2  Responding to TPR Unit Noncooperation Notices

Revision 13-2; Effective April 1, 2013

Medical Programs

When the TPR Unit becomes aware of a possible accident through information included on a Medicaid claim form, they contact the individual to obtain information about the accident.

A—861.3  TPR Reimbursements

Revision 13-2; Effective April 1, 2013

A—861.3.1  Client-Initiated Reimbursements

Revision 13-2; Effective April 1, 2013

Medical Programs

When a recipient reimburses HHSC for medical expenses from a court settlement or from a liability, casualty, or health insurance payment, the reimbursement should be by personal check, cashier's check, or money order payable to the Texas Department of Health and Human Services.

Advisor action:

  1. Give the individual a Form H4100, Money Receipt.
  2. Send the reimbursement and a copy of Form H4100 to ARTS at P.O. Box 149044, Austin, Texas 78714.
  3. Enter the type(s) and date(s) of the medical service(s) in the "For" section of the form.
  4. If unsure what medical services were involved, complete a memorandum giving as much information as is known concerning the reimbursement.
  5. Attach a copy of any information identifying the nature of the payment, such as a statement from the insurance company, to Form H4100.

The actual claim paid by Medicaid is verified in state office and the individual is reimbursed if the payment made is in excess of the Medicaid payment. The advisor is notified of the reimbursement. Consider the reimbursement as possible TANF and/or TP 08 income.

Related Policy
Lump Sum Payments, A-1331
Reimbursements, A-1332

A—861.3.2  Reporting Non-Reimbursement to the TPR Unit

Revision 13-2; Effective April 1, 2013

Medical Programs

When an advisor becomes aware that a recipient received a reimbursement for medical expenses paid by Medicaid and failed to reimburse HHSC, the advisor reports the non-reimbursement to the TPR Unit. Include any available information about the accident and the payment in the report.

The TPR Unit investigates the claim and reports back. Use the guidelines in A-861.4, Responding to TPR Unit Recovery Requests, upon receipt of a memo from the TPR Unit confirming the non-reimbursement.

A—861.4  Responding to TPR Unit Recovery Requests

Revision 13-2; Effective April 1, 2013

Medical Programs

When the TPR Unit becomes aware that an individual received a private insurance payment and has not made any payments to the Medicaid provider, the TPR Unit sends a memo to the regional director. The memo includes the amount of

  • Medicaid paid; and
  • the private insurance payment, if known.

The advisor must use the following procedures after receiving the memo.

Step Action
1

Send Form H1020, Request for Information or Action, to the caretaker, requesting the individual:

  • provide verification of the amount of the private insurance payment, and
  • contact the advisor about reimbursing HHSC.
- If the individual ... then ...
- does not respond, go to Step 2.
- does respond, go to Step 3.
2

Send Form TF0001, Notice of Case Action, to initiate action to disqualify the legal parent from the certified and/or budget group. Process a referral for intentional program violation if the Medicaid payment was $100 or more. To report waste, abuse or fraud to OIG/TPR Unit, use the online reporting form https://oig.hhsc.state.tx.us/wafrep/ or call toll-free 1-800-436-6184.

3

Collect the lesser of the

  • Medicaid payment, or
  • private insurance payment.

Note: If the private insurance payment is greater than the Medicaid payment, count the difference as lump-sum payments for TANF, SNAP and Medical Programs. Refer to A-1200 and A-1300 for policy on how to count the payments.

- If the individual ... then ...
- does not make a full payment, go back to Step 2.
- makes full payment, go to Step 4.
4

When the individual makes a payment,

  • ensure the payment is made by personal check, cashier's check or money order payable to the Texas Department of Health and Human Services;
  • give the individual Form H4100, Money Receipt. Annotate the form with "TPR/TMHP Insurance Recovery;" and
  • send a copy of Form H4100 with the payment to Fiscal Division, State Office, E-411.

A—861.5  Remitting Cash Medical Support Payments to the TPR Unit

Revision 13-2; Effective April 1, 2013

Medical Programs

After certification, Medicaid recipients must remit to the TPR Unit any cash medical support payments received for a certified child. Give the individual sufficient copies of Form H1710, Payment Identification, and TPR self-addressed envelopes, if payments are being made or might be made. Instruct the individual upon receipt of a cash medical support payment from an absent parent after certification of the requirement to:

  • write on the check or money order, "Deposit Only - State Treasury." Do not endorse the check or money order;
  • include Form H1710 with the check or money order; and
  • send it to the HHSC/OIG/TPR Unit, MC 1354, P.O. Box 85200, Austin, TX 78708-5200.

If the individual turns in cash medical support payments to the local office,

  • forward the payment(s) to the HHSC/OIG/TPR Unit, and
  • give the individual a copy of Form H4100, Money Receipt.

Upon becoming aware that an individual did not remit a cash medical support payment, follow policy in B-700 and process a claim for the month(s) of unreported income, if required.

Related Policy
Remitting Child Support Payments to the State, A-1124
Medical Support Payments, A-1326.2.3

A—862  Third-Party Resource (TPR) Reporting System

Revision 14-3; Effective July 1, 2014

Medical Programs

Form H1010, Texas Works Application for Assistance — Your Texas Benefits, and Form H1205, Texas Streamlined Application, ask applicants and individuals if any household members have health insurance. Form H1028, Employment Verification, asks employers to verify if health insurance is available and if the employee is enrolled. When an individual reports a new job or a change in employers, determine if there is any new or potential private health insurance coverage for certified household members during the eligibility interview or application processing.

If information from the individual, the employer or other source indicates ... then report ...
Medicaid-eligible household members have private health insurance coverage,

information about the private health insurance in the Third Party Resources logical unit of work of the case the individual is a member of in TIERS.

health insurance coverage is available for Medicaid-eligible household members but the members are not enrolled in the health insurance plan,

information about the available health insurance in the Third Party Resources logical unit of work of the case the individual is a member of in TIERS.

The TPR unit will use the information to initiate an inquiry about HIPP program eligibility.

To contact the TPR unit about TPR questions or problems:

  • advisors may call 1-800-846-7307.
  • clients may call the Client Medicaid Hotline at 1-800-252-8263.

A—863  Health Insurance Premium Payment (HIPP) Program

Revision 13-2; Effective April 1, 2013

Medical Programs

The HIPP program is administered by the TPR Unit, HHSC. This program

  • pays the costs of premiums, co-insurance, and deductibles; and
  • reimburses the policy holder for private health insurance payroll deductions for Medicaid-eligible persons when HHSC determines it is cost-effective for households who
    • have health insurance but need help with paying the premium; or
    • are not enrolled in group medical coverage that is available to them.

Report individuals potentially eligible for HIPP on Form H1039, Medicaid Insurance Input. HHSC refers Form H1039 with HIPP information to their HIPP contractor. If the contractor determines it is cost-effective to pay the insurance premiums, the contractor sends a letter to the employee and requests that the employee provide verification (usually a paycheck stub) of the premium payments. The HIPP contractor mails a reimbursement check to the employee within two weeks after receiving the verification. For information about the HIPP program, individuals can call 1-800-440-0493.

When the HIPP contractor begins reimbursing an employee, the contractor sends a notice to the advisor. The notice includes:

  • one of the family's Medical Program (MP) EDG numbers, and
  • all family members listed on the referenced EDG, including noncertified family members.

The advisor must determine if the member who received the premium reimbursement was allowed a medical deduction in a SNAP case that should no longer be allowed. No action is needed on the TANF or MP cases.

The HIPP contractor does not send another notice to the advisor until the reimbursement

  • stops, or
  • amount changes.

Individuals cannot appeal decisions made by the HIPP contractor. To obtain assistance in resolving problems or issues with the HIPP contractor,

  • individuals must contact the Medicaid Hotline: 1-800-252-8263.
  • staff must contact the TPR Unit: 1-800-846-7307.

A—870  Verification Requirements

Revision 13-4; Effective October 1, 2013

Medical Programs

  • Verify child support to establish eligibility for TP 20.
  • Verify unpaid medical bills for three months prior coverage. Exception: Refer to A-831.2, Eligibility for Three Months Prior Coverage, for TP 40 prior coverage.
  • Verify income for each of the three months prior to coverage. Exception: For Children's Medicaid, do not request more income verification for prior Medicaid coverage than what is required for ongoing eligibility. See A-1371, Verification Sources, for Children's Medicaid.
  • Verify that an application was filed when reopening an application for prior month coverage according to A-831.2.1, Reopening Three Months Prior Applications.
  • Verify if applying child is receiving Medicaid or CHIP.
  • Verify eligibility for TP 07 by verifying gross earnings and the date the individual received the earnings. Exception: If verification is not readily available, accept the individual's statement unless questionable. If the household provides earnings information sufficient to determine eligibility for TP 07 but does not provide verification of the earnings, deny the EDG and create a TP 07 EDG if they meet the eligibility requirements in A-842, TP 07 Transitional Medicaid.
  • When a household requests continuation of Medicaid for children aging out of TP 44 and TP 47, verify if the child
    • is hospitalized on the child's 19th birthday,
    • remains hospitalized through the end of the six-month eligibility period, and
    • meets all other criteria according to policy in A-825, Medicaid Termination.
  • Verify TPR and report to the TPR Unit any household member who:
    • has private medical insurance, or
    • is not enrolled in group medical coverage that is available to him.

This verification may be found in TALX. See C-825.11, Income Verification System (TALX).

Emergency Medicaid

Verify the emergency medical condition by using Form H3038, Emergency Medical Services Certification, or Form H3038-P, CHIP Perinatal – Emergency Medical Services Certification. These are the only acceptable sources that can be used to verify an emergency medical condition. A licensed practitioner must complete and sign Form H3038 or Form H3038-P.

Note: An original or a faxed copy of Form H3038 or Form H3038-P may be accepted to verify the emergency medical condition.

TP 40

Verify pregnancy by using:

  • Form H3037, Report of Pregnancy;
  • another document containing the same information as Form H3037; or
  • applicant's (pregnant woman's, case name's or AR's) verbal or written statement of pregnancy, including start month, number of children expected and anticipated date of delivery.

The verification must be provided by an acceptable source such as:

  • a physician;
  • a hospital;
  • a family planning agency;
  • a social service agency; or
  • the applicant.

A physician, nurse, advanced nurse practitioner or other medical professional must sign Form H3037 or another document for it to be considered verification from a medical source. If it is completed by another medical professional, ensure that information about the supervising physician is provided.

Related Policy
Pregnancy, A-144.5
Regular Medicaid Coverage, A-820
Verification Requirements, A-1370
A Household with Members on TANF/TANF-SP and Medical Assistance Only, B-480
Questionable Information, C-920
Providing Verification, C-930

A—880  Documentation Requirements

Revision 13-4; Effective October 1, 2013

Medical Programs

Document:

  • verification of income and unpaid medical bills for the three months prior coverage.
  • medical insurance other than Medicaid. This information may be found in TALX. See C-825.11, Income Verification System (TALX).
  • method of income computation.
  • eligibility for transitional and post Medicaid, including the action taken when the EDG includes:
    • an other-related child;
    • an unwed TP 08 parent's child from a previous relationship; or
    • a stepchild.
  • reason for assigning less than the maximum post or transitional Medicaid coverage.
  • denial of TP 20 because child support payments stopped.
  • reason for action on a Medicaid EDG.
  • gross earnings and the dates the individual received the earnings.
  • cost of health insurance premium for the child(ren) before certifying for CHIP.
  • name and phone number of state hospital employee.

If the household requests continuation of Medicaid for children aging out of TP 44 and TP 47, document according to policy in A-825, Medicaid Termination, if the child:

  • is hospitalized on the child's 19th birthday;
  • remains hospitalized through the end of the six-month eligibility period; and
  • meets all other criteria according to A-825.

If providing prior coverage for more than three months, document according to policy in A-831.2.1, Reopening Three Months Prior Applications, that:

  • there was an application on file to cover any of the prior months; and
  • the file date on the application was used to cover these months.

TP 40

Document the method of pregnancy verification and anticipated delivery date.

Related Policy
Documentation Requirements, A-950
Documentation, C-940
The Texas Works Documentation Guide