Texas Health and Human Services Commission
Texas Works Handbook
Revision: 15-4
Effective: October 1, 2015

Part A — Section 800

Medicaid Eligibility

A—810  General Policy

Revision 15-4; Effective October 1, 2015

Medical Programs

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

Some former individuals on TP 08, TP 43, TP 44, and TP 48 remain eligible for Transitional Medicaid after their eligibility is denied. See the chart that follows for more information.

Reason for Denial Type Program Who Is Covered?
Spousal support TP 20 (A-850, Spousal Support Post Medicaid Coverage) The household
New or increased earnings TP 07 (A-842, TP 07 Transitional Medicaid) The household

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, advisors should 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 – Earnings Transitional (TP 07)
  • MA – Parents and Caretaker Relatives (TP 08)
  • 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)
  • MA – Former Foster Care Children (FFCC) (TA 82)

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 15-4; Effective October 1, 2015

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. Advisors 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. Advisors must document this contact in Case Comments.

  • The MED for the parent or caretaker relative 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 parent or caretaker relative 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 parent or caretaker relative complies.
  • The MED cannot precede the month at least one eligible dependent child is certified for Medicaid.

If the only child that makes a parent or caretaker relative eligible for TP 08 dies before certification, advisors must process an application for Medicaid for a deceased individual. Advisors must provide coverage for the child through the date of death and for the parent or caretaker relative through the remainder of that month.

TP 40

Medicaid for a pregnant woman does not begin before the first day of the month her 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, advisors may use one of the verification sources in A-870 to obtain the pregnancy start date and anticipated date of delivery.

Advisors must 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, the application is denied. Advisors 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: Pregnancy verification is not required 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. The advisor must 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, the advisor must provide advance notice of adverse action and deny her coverage.

TP 45

Before providing initial TP 45 coverage for a newborn child, the advisor must verify that 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, the advisor must 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 members.

Note: The Clearinghouse may discover a discrepancy while processing a spend down Eligibility Determination Group (EDG). Processing is put on hold and the 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, or Form H3038-P, CHIP Perinatal – 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 15-4; Effective October 1, 2015

Medical Programs

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

A—821.1  Fee-for-Service

Revision 15-4; Effective October 1, 2015

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 the claims administrator for reimbursement of Medicaid-covered services.

A—821.2  Managed Care

Revision 15-4; Effective October 1, 2015

Medical Programs except TP 56, TA 31, TP 32, TP 33, TP 34, TP 35 and TP 36

Medicaid managed care is health care provided through a network of doctors, hospitals, or other health care providers. The state pays a managed care organization (MCO) a capitated rate for each member enrolled, rather than paying for each unit of service. The providers submit claims directly to the MCO for reimbursement of Medicaid-covered services.

Medicaid managed care programs include:

  • STAR (State of Texas Access Reform). STAR provides acute care services (like doctor visits, hospital visits, and prescriptions), and each member is enrolled in an MCO and assigned a main doctor to coordinate care. Individuals who are dually eligible are excluded from this program. It is a statewide program.
  • STAR Health. STAR Health provides comprehensive, coordinated health care services for children in foster care and kinship care. Each member is enrolled in a single MCO, Superior HealthPlan, and is assigned a main doctor to coordinate care. Individuals who are dually eligible are excluded from this program. It is a statewide program.
  • STAR+PLUS. STAR+PLUS provides acute care and long-term services and supports (LTSS). A key feature of this program is service coordination, or specialized care management. Each member is enrolled in an MCO, and Medicaid-only members are assigned a main doctor. STAR+PLUS serves Medicaid-only and dually eligible individuals, including most nursing facility residents. It is a statewide program.
  • Children's Medicaid Dental Services. Children's Medicaid Dental Services provides primary and preventive dental services in managed care. Each member is enrolled in a dental maintenance organization (DMO) and has a main dental home. Most children, birth through age 20, who receive Medicaid are eligible for dental services.

Medicaid managed care 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.

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. Exceptions (not comprehensive):

  • STAR exceptions: Dual eligibles; children enrolled in the DSHS Children with Special Health Care Needs (CSHCN) Program; unaccompanied refugee minors (URM); children in foster care; children residing in institutions; Medically-needy program participants; children in foster care/kinship care.
  • STAR Health exceptions: Dual eligibles; youth adjudicated in Texas Juvenile Justice Department (TJJD) facilities; youth from other states placed in Texas, or Texas youth placed in other states; youth residing in Medicaid-paid facilities.
  • STAR+PLUS exceptions: Individuals age 20 or younger who reside in a nursing facility.
  • Children's Medicaid Dental Services exceptions: Individuals age 20 or younger who reside in an institution; individuals in STAR Health; adults age 21 and older.

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 or a main doctor by the deadline provided in the enrollment packet, MAXIMUS assigns a plan and a main doctor and mails the individual the information.

Special populations are exempt from mandatory enrollment in Medicaid managed care and may choose to participate voluntarily. The special populations include:

  • members of federally recognized Indian tribes (all managed care programs); and
  • individuals age 20 or younger who receive Supplemental Security Income (SSI) or SSI-related benefits and who do not reside in a nursing facility (STAR+PLUS).

At all Medicaid applications and redeterminations, advisors identify and designate individuals appropriately. If the advisor does not have this information, the advisor does not designate an individual as meeting one of the special populations. The application is not pended nor is an eligibility determination delayed for this information.

TIERS refers 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 MAXIMUS 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, the advisor refers 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 15-4; Effective October 1, 2015

Medical Programs

Advisors must 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.

Step

Action

1

If the losing state denied the recipient's Medicaid the last day of the month the recipient moved from the state or later, then go to Step 2.

If the losing state denied the recipient's Medicaid the day the recipient moved from the state, then assign an MED = date the applicant became a Texas resident.

2

Did any member of the certified group incur Medicaid-reimbursable bills after they moved to Texas?

If yes, then verify the effective date of denial in the losing state. Go to Step 3.

If no, then verify the effective date of denial in the losing state. Assign an MED = first day of the month after the month the losing state denied the recipient's Medicaid.

3

Will the losing state pay for the bills incurred in Texas after the day the person became a Texas resident?

If yes, then assign an MED = first day of the month after the month the losing state denied the recipient's Medicaid.

If no, then assign an MED = date the applicant became a Texas resident.


Note: If the applicant is unable to provide a contact person in the losing state, the advisor must contact the appropriate state Medicaid director's office. See C-1111, State Medicaid Agencies, 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 the claims administrator at 1-800-925-9126.

A—823  Lock-In Status

Revision 15-4; Effective October 1, 2015

Medical Programs

HHSC identifies fee-for-service and managed care 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 main doctor 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 YourTexasBenefits.com, 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, the advisor may 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. 

Advisors 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 15-4; Effective October 1, 2015

Medical Programs

Advisors must 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 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 pages. If inquiry is unavailable, advisors must 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 pages:

  • 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. Advisors 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, advisors 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. Advisors select the Individual – Managed Care page to view the individual's plan to which the individual is enrolled.

Advisors must issue Form H1027-A for everyone on the case in the same managed care plan by printing the appropriate managed care program name (e.g., STAR, STAR Health, STAR+PLUS) 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.

Form H1027-A is not used if the most recent medical period:

  • is closed, or
  • shows institutional coverage.

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

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

The advisor must issue Form H1027-A if the person has a completed Form H1266, Short-term Medicaid Notice: Approved, showing the date the person is approved for coverage.

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

State Paid Medicaid

TA 62

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 percent state-funded.

A—825  Medicaid Termination

Revision 15-4; Effective October 1, 2015

TP 08

TIERS automatically denies the EDG effective the end of the month if a packet is not received, as explained in B-120, Redeterminations.

Related Policy
Denial at Redetermination, A-2342

TA 31, TP 32, TP 33, TP 34, TP 35 and TP 36

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, the coverage is denied effective the last day of the second month following the month the pregnancy terminated.

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

TP 43, TP 44 and TP 48

A child is continuously eligible for six months of the 12-month certification period. If a household fails to report required information at application that would have caused a child to be ineligible for Medicaid, the EDG is denied and the advisor must 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, the Medicaid EDG is not denied. 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. Advisors must address the income discrepancy when the child’s six months of continuous eligibility ends and the child is in a period of non-continuous eligibility.

Note: Independent children residing in state hospitals are continuously eligible for the first six months of the 12-month certification period, 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 continuous eligibility period, the advisor must process the address change, following the policy described in B-631, Actions on Changes, for TP 43, TP 44 and TP 48, and continue coverage. If a child is released from the facility during the six-month non-continuous eligibility period, the advisor must process the change, and the change may affect eligibility. Under Modified Adjusted Gross Income (MAGI) household composition rules, explained in A-240, Medical Programs, an individual joining or leaving a household may or may not affect eligibility depending on that person’s tax status, tax relationships, and family relationships.

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 12-month 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 12th 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.

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 MAGI is equal to or below the corresponding Federal Poverty Income Limits (FPIL). If the MAGI 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 the end of the continuous eligibility period, the system will determine if the child is eligible for the Children’s Health Insurance Program (CHIP) or ineligible for all Medical Programs.

If the child ages out during the non-continuous eligibility period, the system will determine if the child is eligible for CHIP or ineligible for all Medical Programs.

Exception: Children aging out of TP 44 are eligible through the month of their 19th birthday regardless of whether they age out during a continuous or non-continuous eligibility period.

If a child is ineligible for the next type of assistance or turns age 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.

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

TP 45

A child's eligibility terminates the month of the child's first birthday. The child on TP 45 is denied 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 15-4; Effective October 1, 2015

Medical Programs except TP 40

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.

TP 40

Medicaid for a pregnant woman does not begin before the first day of the month her pregnancy began, as explained in A-820, Regular Medicaid Coverage.

A—831.1  How to Apply for Three Months Prior Coverage

Revision 15-4; Effective October 1, 2015

Medical Programs except TP 45

A person applies for three months prior Medicaid coverage by completing Form H1113, Application for Prior Medicaid Coverage. Advisors must give this form to applicants who indicate on an 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, Form H1113 is not required 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 15-4; Effective October 1, 2015

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.

Advisors 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 15-4; Effective October 1, 2015

Medical Programs

Advisors must reopen Medical Programs 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.

Advisors 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: Advisors must 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 15-4; Effective October 1, 2015

Medical Programs

Staff must determine eligibility for each month in which there are unpaid medical bills using the income and verification rules explained in A-1300, Income

The needs and income of people who would have been considered in the client’s MAGI household composition for each month the client’s MAGI household composition has unpaid medical bills are included.

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

Revision 15-4; Effective October 1, 2015

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 modified adjusted gross income for the prior month is … then …
TP 08, less than or equal to the FPIL amount for TP 08 and there is no gap in coverage, certify the application for the prior month.
TP 08, less than or equal to the FPIL amount for TP 08 and:
  • there is a gap in coverage, or
  • the individual is not currently eligible,
certify the application for the prior month(s).
TP 08, more than the FPIL amount for TP 08, do not certify the application for the prior month in this type program. Check eligibility for another type program.
TP 40, TP 43, TP 44, or TP 48, less than or equal to the FPIL amount for that program, certify the application for the prior month.
TP 40, TP 43, TP 44, or TP 48, 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.
TP 45, not applicable, these applicants are always eligible back to the date of birth.
TP 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 yes, then certify the children or pregnant woman.

If no, then deny the application for prior coverage.
TA 31, TP 33, TP 34, TP 35, or TP 36, less than or equal to the FPIL amount for that program, certify the applicant for the prior month only for the dates of the emergency medical condition verified on Form H3038, Emergency Medical Services Certification, or Form H3038-P, CHIP Perinatal – Emergency Medical Services Certification.
TP 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 yes, then certify the child or pregnant woman.

If no, then deny the application for prior coverage.

Note: Applicants are considered for eligibility in Medicaid for Former Foster Care Children (TA 82) and Medicaid for Transitioning Foster Care Youth (TP 70) before TP 08.

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 15-4; Effective October 1, 2015

TP 08 and TA 31

If the applicant claiming incapacity meets the other eligibility requirements for prior Medicaid coverage, the advisor must document information according to A-1080, Disability Verification.

A—832  Continuous Medicaid Coverage

Revision 15-4; Effective October 1, 2015

TP 40

Advisors provide continuous Medicaid coverage without an application 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; and

    Note: 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.
  • received Medicaid within 11 months prior to the application month.

Note: Advisors 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:

  • SSI or 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 certified on TP 08 who is not eligible for TP 07 or TP 20.
  • a caretaker or child certified on TP 07 or TP 20.
  • a child certified on TP 44.

TP 43, TP 44 and TP 48

A child under age 19 receives a 12-month certification period. The child is continuously eligible for Medicaid for six months or through the month of the child’s 19th birthday, whichever is earlier. The second six months of coverage is non-continuous, and changes may impact the child’s eligibility.

Exceptions:

  • During the continuous eligibility period, if a household reports that a sibling has moved into the household and requests Medicaid for the sibling, the sibling is added to the current case. TIERS aligns the end of the new Medicaid-eligible child’s certification period with the end of the existing child’s certification period.
  • 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 15-4; Effective October 1, 2015

TP 45

Advisors must provide retroactive TP 45 coverage for newborn children without requiring an 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 154; Effective October 1, 2015

Medical Programs

If a newborn or child is abandoned at the hospital, 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).

If applicable, for abandoned children, the income calculation will also be determined based on the policy for Medical Programs explained in A-1300, Income.

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 15-4; Effective October 1, 2015

TP 07

Some TP 08 household members may be eligible for transitional Medicaid, TP 07.

An eligibility determination for TP 07 is based on whether a parent or caretaker relative is certified for TP 08, Parents and Caretaker Relatives Medicaid, in Texas for three of the six months before the first month of ineligibility. If a parent or caretaker relative certified for TP 08 coverage is eligible for transitional Medicaid, his or her children will be eligible as well. Each individual will be certified on an individual transitional Medicaid EDG for the duration of the certification period.

Example: The household composition consists of mother, father, and two mutual children. The mother and father each are certified on an individual TP 08 EDG in Texas for three of the six months before the month of ineligibility and each child on an individual Children's Medicaid EDG. The father has an increase in income that makes him ineligible for TP 08. The father is then certified on an individual TP 07 EDG. The mother and the two children will be certified on individual TP 07 EDGs, each with the same certification period as the father.

When a TP 07 EDG has been created, other eligible household members receive a new TP 07 EDG. See A-846.1, Parents and Caretaker Relatives 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 if the member was ineligible for TP 08 because the individual committed fraud during any of the six months before the TP 07 EDG was opened. The fraud must be determined by a court or through a hearing. If the TP 07 EDG was opened before the fraud determination was known:

  • the household member is disqualified using advance adverse action notice procedures, and
  • transitional child care staff must be notified that the member should not have received transitional benefits because of Medicaid fraud.

TP 08 households denied for any reason (such as failure to keep an appointment) may request TP 07 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 any time after denial. These individuals and their household members may also request TP 07 if they become employed.

The number of months of transitional coverage is 12 months.

A—841.1  Multiple Changes That Cause TP 08 Ineligibility

Revision 15-4; Effective October 1, 2015

TP 08

If two or more changes (when one is new or increased earned income) cause the income to increase from less than the FPIL for TP 08 to more than the FPIL for TP 08 for the same month, and the household has not been notified that members are eligible for TP 07, advisors follow the steps below:

Step Action
1

If all other case factors remain the same, is the household income increased to above the FPIL for TP 08 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 the FPIL for TP 08 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 FPIL for TP 08 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  after the household is notified of transitional Medicaid eligibility, even when both changes affect the same month.

Exceptions: The EDG is denied 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 15-4; Effective October 1, 2015

TP 08

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

  • that their TP 08 and their children on associated TP 43, TP 44 and TP 48 EDGs are denied;
  • the date their TP 07 benefits will end; and
  • about the transitional Medicaid eligibility and reporting requirements. Note: If the individual is in the office, the advisor may explain the reporting requirements.

A—841.3  Eligibility Criteria During Transitional Medicaid Coverage

Revision 15-4; Effective October 1, 2015

TP 07

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.

Note: For transitional Medicaid, an eligible child is a child who meets all of the following requirements:
  • citizenship,
  • Social Security number (SSN),
  • age,
  • relationship, and
    domicile.
OR A parent or caretaker relative cares for a child who receives:
  • SSI;
  • adoption assistance payments; or
  • federal, state or local foster care payments; or
  • Medicaid (TP 07, 20, 40, 43, 44, 45, or 48.

The noncomplying adult who is certified for TP 07 is denied 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 another-related caretaker failed to cooperate with TPR requirements or was found guilty of a Medicaid intentional program violation, the advisor must:

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

The advisor must not:

  • count unearned income of household members when determining continued eligibility for households certified for transitional Medicaid; or
  • 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.

A—842  TP 07 Transitional Medicaid

Revision 15-4; Effective October 1, 2015

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 parent, certified caretaker relative, 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 15-4; Effective October 1, 2015

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 certified parent or caretaker relative on TP 08 to be over the FPIL for TP 08.

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 15-4; Effective October 1, 2015

TP 08

Advisors must determine whether 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.

Advisors must count any month when at least one household member was eligible for and received benefits. Advisors must include any month that someone in the household received TP 08.

Advisors must 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

Advisors must determine whether 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.

Advisors must count any month when at least one household member was eligible for and received Medicaid through:

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

Advisors must 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 15-4; Effective October 1, 2015

TP 07

Recipients terminated from TP 07 must be retested for eligibility for any other Medical Programs, as explained in A-2342.1, Retesting Eligibility.

A—843  Reserved

Revision 15-4; Effective October 1, 2015

A—844 Transitional Medicaid Reporting Requirements for TP 07

Revision 15-4; Effective October 1, 2015

TP 07

Individuals receiving TP 07 coverage are required to report the following changes during the 4th, 7th and 10th months of the transitional period:

  • Changes in the household members' gross monthly earnings, and
  • Changes in the household composition.

Form H1146, Medicaid Report, is computer-generated and is sent to the household at cutoff in the 3rd, 6th and 9th 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.

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

Advisors must not require verification for the transitional Medicaid EDG. Exception: Advisors must require appropriate verifications to determine whether a new household member is eligible to be added to the EDG. See A-846.1, Parents and Caretaker Relatives 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 15-4; Effective October 1, 2015

TP 07

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

If the household returns 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 43, TP 44, TP 45, TP 48, 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, Parents and Caretaker Relatives 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 parent or caretaker relative in at least one of the three report months, and there is no good cause for the lack of earnings; or
  • the average monthly gross earnings of the household members* exceeds the applicable income limit for the household size,

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

Note: If the medical coverage is shortened because the parent or 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, 185% FPIL Test, for budgeting policies.


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

Revision 15-4; Effective October 1, 2015

TP 07

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

If the household returns Form H1146 and Form H1146 indicates … then …
the household no longer meets the household composition requirements in A-841.3, Eligibility Criteria During Transitional Medicaid Coverage, deny the EDG and send Form TF0001, Notice of Case Action.
  • there are no earnings by the parent or caretaker relative in at least one of the three report months, and there is no good cause for the lack of earnings; or
  • the average monthly gross earnings of the household members* exceeds the applicable income limit for the household size,
  • deny the EDG using the 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 received information (earnings) 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 parent or 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.)
the household continues to be eligible, take no action.
a child who is not receiving TP 43, TP 44, TP 45, TP 48, 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, Parents and Caretaker Relatives Enter or Already Live in the Home.

* See A-844.3, 185% FPIL Test, 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 15-4; Effective October 1, 2015

TP 07

Advisors use the following policies and procedures to determine whether the household's earnings are at or below the 185 percent FPIL when processing Medicaid reports.

Advisors must include all members of the individual’s MAGI household composition when determining the MAGI income.

Exceptions:

  • Advisors must not count the earnings of a child who is exempt according to A-1341, Income Limits and Eligibility Tests.
  • See A-240, Medical Programs, and A-1341 for exceptions to household composition and countable income.
  • 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, the person is not included 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 15-4; Effective October 1, 2015

TP 07

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 15-4; Effective October 1, 2015

TP 07

Certain households whose transitional Medicaid EDGs are denied before the end of their original eligibility period may have transitional Medicaid coverage reinstated. Advisors must 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 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 is 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 transitional Medicaid must have remained continuously eligible for transitional Medicaid during the months the TP 07 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 15-4; Effective October 1, 2015

TP 07

Advisors must count the months of absence from transitional Medicaid as if the family had actually received transitional Medicaid.

Advisors 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, advisors must:

  • 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:

  • Advisors must not open a new application. If a new application was created, it is denied as filed in error.
  • When processing the reinstatement, any members who are no longer in the household are removed.
  • Advisors send Form TF0001, Notice of Case Action, to notify the household of their continued eligibility.

Advisors must obtain information on household composition and earnings for the months the household did not receive TP 07 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 Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (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.

Advisors determine whether the individual was continuously eligible for TP 07 Medicaid using:

  • A-844.1, Advisor Action on the Fourth Month Medicaid Report, for the fourth-month Medicaid Report;
  • A-844.2, Advisor Action on the Seventh and Tenth Month Medicaid Reports, for the seventh- and tenth-month Medicaid Reports; and
  • A-844.4, Good Cause Determinations, 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  Parents and Caretaker Relatives Enter or Already Live in the Home

Revision 15-4; Effective October 1, 2015

TP 07

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

Advisors must add the member to the case and open a new TP 07 EDG for the individual, 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 has a disability and is unable to care for the children.

A—846.2  Child Enters or Already Lives in the Home

Revision 15-4; Effective October 1, 2015

TP 07

Advisors follow the procedures in the chart below:

  • when the TP 07 household reports that a child who is not receiving TP 07, TP 43, TP 44, TP 45, or TP 48 is in the home;
  • when denying a TP 08 EDG and opening a TP 07 EDG; and
  • upon review of another Medical Program EDG for a child who lives with a TP 07 recipient.

An other-related child's separate Medical Program EDG continues unless the caretaker needs Transitional Child Care services for the child.

If a child who is not receiving TP 43, TP 44, TP 45, TP 48, 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/Medical Program or SNAP recipient.

Do not consider the following criteria:

  • deprivation, 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 Medical Programs policy explained in A-1341, Income Limits and Eligibility Tests.

If the child is eligible, then send Form TF0001, Notice of Case Action, to the household to inform the household of the child's eligibility.

If the child is not eligible or the household does not provide the information/verification, then:

  • send Form TF0001 to the household;
  • inform the household that:
    • their TP 07 EDG will continue; but
    • the child cannot be added to the case, stating the reason the child cannot be added; and
  • take no action on the case.

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

  • determine and document three months prior eligibility according to Medical Programs policies and procedures in A-830, Medicaid Coverage for the Months Prior to the Month of Application; and
  • assign the child an MED beginning the first prior month the child met all TP 07 eligibility requirements.

The child's MED cannot precede the:

  • first month the household was eligible for TP 07 (advisors must 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
  • date the child entered the household.

A—846.3  Household Member Leaves the Home

Revision 15-4; Effective October 1, 2015

TP 07

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
  • deny the child’s TP 07 EDG.
household no longer meets the household composition requirements in A-841.3,
  • send Form TF0001 to the household, and
  • deny the TP 07 EDGs that no longer are eligible.

Advisors follow normal procedures to remove a parent or caretaker relative when the household reports the person is no longer in the home.

A—846.4  Minor Parents Certified as Children

Revision 15-4; Effective October 1, 2015

TP 07

See A-240, Medical Programs, for household composition rules.

A—847  Other EDG Actions

Revision 13-2; Effective April 1, 2013


A—847.1  Changes Affecting Transitional Medicaid EDGs

Revision 15-4; Effective October 1, 2015

TP 07

Advisors must not take action on the TP 07, except for the following changes:

  • A child is born, moves in, or is already living with the certified group. Add the member to the case and open a TP 07 EDG for the individual following procedures in A-846.2, Child Enters or Already Lives in the Home.
  • A parent or caretaker relative moves in or otherwise becomes eligible. Add the member to the case and open a TP 07 EDG for the individual following procedures in A-846.1, Parents and Caretaker Relatives Enter or Already Live in the Home.
  • A member included in an individual’s household composition leaves the household. Remove the member from the case following procedures in A-846.3, Household Member Leaves the Home.
  • A household member is no longer eligible. Remove the member from the case. For example:
    • A child no longer meets the Medical Programs age criteria.
    • A child moves out of state.

A—847.2  Reapplication for TP 08

Revision 15-4; Effective October 1, 2015

TP 07

A household receiving TP 07 may reapply for TP 08 by submitting an application. If the household is eligible, TIERS will:

  • deny the TP 07;
  • certify the parent/caretaker relative on a TP 08 EDG and the child on the appropriate Children’s Medicaid EDG; and
  • send Form TF0001, Notice of Case Action, to the household.

Related Policy
Minor Parents Certified as Children, A-846.4

A—850  TP 20 Spousal Support Post Medicaid Coverage

Revision 15-4; Effective October 1, 2015

TP 08

Individuals denied TP 08 because of new or increased spousal support may be eligible for TP 20. Determination of TP 20 eligibility will be based on a parent or caretaker relative certified for TP 08. Household members are eligible for TP 20 for four months following the last month of TP 08 eligibility if:

  • the modified adjusted gross income before spousal support receipt was at or below the income limit for TP 08;
  • the denial is because new or increased spousal support income is added to the budget and the individual’s MAGI household 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.
If the household is eligible, an individual transitional Medicaid EDG will be created for each parent or caretaker relative and one for each child.

A—851  Eligibility Criteria During Post Medicaid

Revision 15-4; Effective October 1, 2015

TP 20

Certified members remain eligible for Medicaid if the household continues to:

  • live in Texas, and
  • receive spousal support.

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 is denied.

A—852  Automated Process

Revision 15-4; Effective October 1, 2015

TP 08

If the Office of the Attorney General (OAG) receives a new or increased spousal support collection that is greater than the TP 08 income limits, TIERS determines whether the TP 08 EDG should be denied and a TP 20 opened, or whether the TP 08 EDG should be denied. If either is appropriate, TIERS notifies the individual on Form TF0001, Notice of Case Action.

A—853  Denial of TP 20

Revision 15-4; Effective October 1, 2015

TP 20

Recipients terminated from TP 20 must be retested for eligibility for any other Medical Programs, as explained in A-2342.1, Retesting Eligibility.

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  Parents and Caretaker Relatives Enter or Already Live in the Home

Revision 15-4; Effective October 1, 2015

TP 20

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

Advisors must add the member to the case and open a new TP 20 EDG for the individual if the person is a caretaker relative 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); or
  • is a returning absent parent/second parent in the home.

A—855.2  Child Enters or Already Lives in the Home

Revision 15-4; Effective October 1, 2015

TP 20

Advisors follow the procedures in the chart below:

  • when the TP 20 household reports that a child who is not receiving TP 20 or TP 43, TP 44, TP 45, or TP 48  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.

Advisors must continue an other-related child's separate Medical Program EDG.

If a child who is not receiving TP 43, TP 44, TP 45, TP 48 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/Medical Program or SNAP recipient.

Do not consider the following criteria:

  • deprivation, and
  • income.

If the child is eligible, then:

  • send Form TF0001, Notice of Case Action, informing the household of the child's eligibility for TP 20; and
  • add the child to the case and open a new TP 20 EDG for the child.

If the child is not eligible or the household does not provide the information/verification, then:

  • send Form TF0001 to the household;
  • inform the household:
    • their TP 20 EDG will continue; but
    • the child cannot be added to the case, stating the reason the child cannot be added; and
  • take no action on the case.

A—855.3  Minor Parents Certified as Children

Revision 15-4; Effective October 1, 2015

TP 20

See A-240, Medical Programs, for household composition rules.

A—856  Reapplication for TP 08

Revision 15-4; Effective October 1, 2015

TP 20

A household receiving post Medicaid may reapply for TP 08. If the household is eligible, the advisor must:

  • deny the TP 20 EDG;
  • create the applicable Medical Program EDG; and
  • send Form TF0001, Notice of Case Action, to the household.

A—860  Third-Party Resources (TPR)

Revision 15-4; Effective October 1, 2015

Medical Programs

A TPR is a source of payment for medical expenses other than the recipient or Medicaid. TPR 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;
  • 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, the advisor must instruct the individual to tell medical providers about the health insurance. The provider then bills the insurance company rather than 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 denied.

The denied legal parent is included in the household composition.

A—861  Third-Party Resources (TPR) and Accidents

Revision 15-4; Effective October 1, 2015

Medical Programs

The advisor must 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 Third-Party Resources (TPR) Unit

Revision 15-4; Effective October 1, 2015

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, the advisor must 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
Austin, Texas 78708-5200

Advisors must 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 the name and address of the 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 Third-Party Resources (TPR) Unit Noncooperation Notices

Revision 15-4; Effective October 1, 2015

Medical Programs

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

A—861.3  Third-Party Resources (TPR) Reimbursements

Revision 15-4; Effective October 1, 2015


A—861.3.1  Client-Initiated Reimbursements

Revision 15-4; Effective October 1, 2015

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 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. Advisors must 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 Third-Party Resources (TPR) Unit

Revision 15-4; Effective October 1, 2015

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. The advisor must include any available information about the accident and the payment in the report.

The TPR Unit investigates the claim and reports back. The advisor uses the guidelines in A-861.4, Responding to Third-Party Resources (TPR) Unit Recovery Requests, upon receipt of a memo from the TPR Unit confirming the non-reimbursement.

A—861.4  Responding to Third-Party Resources (TPR) Unit Recovery Requests

Revision 15-4; Effective October 1, 2015

Medical Programs

Advisors use the following chart in responding to TPR Unit recovery requests.

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 that the individual:

  • provide verification of the amount of the private insurance payment, and
  • contact the advisor about reimbursing HHSC.

If the individual does not respond, then go to Step 2.
If the individual does respond, then 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 the 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, Resources, and A-1300, Income, for policy on how to count the payments.

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

If the individual makes full payment, then 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 Third-Party Resources (TPR) Unit

Revision 15-4; Effective October 1, 2015

Medical Programs

After certification, Medicaid recipients must remit to the TPR Unit any cash medical support payments received for a certified child. The advisor gives the individual sufficient copies of Form H1710, Payment Identification, and TPR self-addressed envelopes, if payments are being made or might be made. The advisor instructs 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" and to 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, the advisor must:

  • 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, advisors must follow policy in B-700, Claims, and process a claim for the month(s) of unreported income, if required.

Related Policy
TANF, A-1124
Medical Support Payments, A-1326.2.3

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

Revision 15-4; Effective October 1, 2015

Medical Programs

The application asks applicants and individuals whether any household members have health insurance. Form H1028, Employment Verification, asks employers to verify if health insurance is available, and whether the employee is enrolled. When an individual reports a new job or a change in employers, the advisor determines whether 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 15-4; Effective October 1, 2015

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.

Advisors must report individuals potentially eligible for HIPP on Form H1039, Medicaid Insurance Input. HHSC refers Form H1039 with HIPP information to its 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 whether 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 at 1-800-252-8263.
  • staff must contact the TPR Unit at 1-800-846-7307.

A—870  Verification Requirements

Revision 15-4; Effective October 1, 2015

Medical Programs

Advisors must:

  • Verify spousal 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 the 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, the advisor must deny the EDG and create a TP 07 EDG if the individual meets the eligibility requirements in A-842, TP 07 Transitional Medicaid.
  • When a household requests continuation of Medicaid for children aging out of TP 44, 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, The Work Number.

Emergency Medicaid

Advisors must verify the emergency medical condition by using Form H3038, Emergency Medical Services Certification, or Form H3038-P, CHIP Perinatal – Emergency Medical Services Certification. These forms 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

Advisors must 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 the 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 the form is completed by another medical professional, the advisor must 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-State Program (SP), TP 07, TP 08 and TP 20, B-480
Questionable Information, C-920
Providing Verification, C-930

A—880  Documentation Requirements

Revision 15-4; Effective October 1, 2015

Medical Programs

Advisors must 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, The Work Number.
  • 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 spousal 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, the advisor must document according to policy in A-825, Medicaid Termination, whether 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, the advisor must 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

Advisors must document the method of pregnancy verification and anticipated delivery date.

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