M—910  General Policy

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

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

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

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

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

M—920  Verification Requirements

Accept self-declaration of adequate health coverage.

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

M—930  Documentation Requirements

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