Texas Health and Human Services Commission
Texas Works Handbook
Revision: 13-4
Effective: October 1, 2013

Part X — Section 900

Medicaid Eligibility

X—910  Screening and Active Treatment

Revision 12-3; Effective July 1, 2012

To qualify for Medicaid for Breast and Cervical Cancer (MBCC)-Presumptive or MBCC, applicants must have been screened and found to need active treatment for either breast or cervical cancer.

Related Policy
Screening, X-911

At each periodic review, MBCC recipients must provide verification that they continue to receive treatment for breast or cervical cancer.

Related Policy
Active Treatment, X-912

X—911  Screening

Revision 12-3; Effective July 1, 2012

A woman must be screened for breast and cervical cancer under the Centers for Disease Control and Preventionís (CDCís) National Breast and Cervical Cancer Early Detection Program (NBCCEDP). The Breast and Cervical Cancer Services (BCCS) contractor or provider, through the Department of State Health Services (DSHS), is responsible for providing HHSC with verification that a woman has been screened and diagnosed using the NBCCEDP criteria.

A woman is considered screened under the NBCCEDP if:

  • CDC Title XV funds paid for all or part of the cost of her screening services, or
  • Her particular clinical service has not been paid for by CDC NBCCEDP Title XV funds, but the:
    • service provided by a provider and/or an entity funded at least in part by CDC Title XV funds,
    • service was within the scope of a grant, sub-grant or contract under that state program, and
    • state CDC Title XV grantee has elected to include such screening activities provided by the provider as screening activities pursuant to CDC Title XV.

The 80th Texas Legislature passed Senate Bill 10, the Medicaid Reform Act, which authorized any health care provider to refer eligible women in need of treatment for breast or cervical cancer to Medicaid. Beginning Sept. 1, 2007, any woman diagnosed with breast or cervical cancer may receive MBCC if they meet all eligibility requirements. The diagnosing provider refers the woman to a BCCS contractor who assists the woman in applying for MBCC.

If a Form H1034, Medicaid for Breast and Cervical Cancer, is received and the woman does not have a qualifying medical diagnosis, deny the application due to the woman not having a diagnosis for breast or cervical cancer.

X—912  Active Treatment

Revision 13-3; Effective July 1, 2013

At reapplication and at each redetermination, the MBCC applicant or recipient must provide Form H1551, Treatment Verification Form, completed by her treating health professional verifying that she needs active treatment services for breast or cervical cancer. Active cancer treatment includes services related to the individual's condition as documented in her plan of care, such as:

  • surgery,
  • chemotherapy,
  • radiation,
  • reconstructive surgery, and
  • medication (ongoing hormonal treatment).

These services also may include diagnostic services that are necessary to determine the extent and proper course of treatment and active disease surveillance for triple negative receptor breast cancer.

Women who are determined to require only routine health screening services for a breast or cervical condition (for example, annual clinical breast examinations, mammograms and pap tests as recommended by the American Cancer Society and the U.S. Preventative Services Task Force) are not considered to need treatment and are not eligible for MBCC. A woman may reapply for MBCC if she is later diagnosed with a new breast or cervical cancer, pre-cancerous condition or a metastatic or recurrent breast or cervical cancer.

If the woman’s treating health professional indicates on Form H1551 that she is not actively receiving treatment, deny the MBCC EDG due to the woman not actively receiving treatment.

X—920  Medicaid Coverage

Revision 12-3; Effective July 1, 2012

Women who are eligible for MBCC-Presumptive or MBCC receive full regular Medicaid benefits.

Before certifying a woman for MBCC-Presumptive or MBCC, Centralized Benefit Services (CBS), staff must complete inquiry into the Texas Integrated Eligibility Redesign System (TIERS) and the Childrenís Health Insurance Program (CHIP) inquiry system to verify whether the applicant is currently receiving Medicaid or CHIP benefits. Deny the application if the woman is receiving other Medicaid coverage. Exceptions: Do not deny the application if it is determined that the other Medicaid coverage is ending or being denied.

Related Policy
Other Medical Assistance, X-932

X—921  Medical Effective Date (MED)

Revision 12-3; Effective July 1, 2012

Medicaid eligibility begins the date an applicant meets all eligibility criteria. The MED cannot precede the day after the diagnosis date.

For MBCC-Presumptive, the MED is the date the BCCS contractor determines the woman is presumptively eligible for MBCC, but no earlier than the date after the woman was diagnosed with breast or cervical cancer. If the woman provides information needed for MBCC eligibility, provide MBCC coverage for dates that precede the MBCC-Presumptive MED.

Related Policy
Prior Coverage, X-922

X—922  Prior Coverage

Revision 12-3; Effective July 1, 2012

A woman may be eligible for up to three months of prior coverage under MBCC if all other eligibility requirements are met. MBCC only covers unpaid medical bills for services received after the individual's breast and cervical cancer diagnosis date. If a woman indicates on Form H1034, Medicaid for Breast and Cervical Cancer, that she has unpaid medical bills that occurred during the three months before she applied for MBCC, assign an MED of the day after her diagnosis date. Do not require the woman to provide proof of the unpaid medical bills or a completed Form 1113, Application for Prior Medicaid.

For medical expenses incurred before or on her date of diagnosis, the client must apply for prior Medicaid coverage at an HHSC eligibility office using Form H1010, Texas Works Application for Assistance ó Your Texas Benefits. Refer the client to an HHSC eligibility office for the appropriate application or have the client call 2-1-1 to locate the nearest HHSC eligibility office.

Example One: The applicant was diagnosed on Aug. 15 and applied for MBCC on Nov. 21 indicating that she has unpaid medical bills for August, September, October and November. Assign an MED of Aug. 16.

Example Two: The applicant was diagnosed on July 7 and applied for MBCC on July 21 indicating that she has unpaid medical bills for May and June. The individual is not eligible for prior coverage under MBCC since the unpaid medical bills were before her diagnosis date. Assign an MED of July 8.

Example Three: The applicant was diagnosed on Jan.31 and applied for MBCC on June 4 indicating she has unpaid bills for February. The woman is not eligible for prior coverage since her unpaid medical bills occurred prior to the three-month period before she applied for MBCC.

Note: If the applicant had creditable coverage before applying for MBCC and indicates she has unpaid medical bills for the months she was covered by insurance, the client is not eligible for prior coverage under MBCC. The client must complete Form H1010 for prior Medicaid coverage and provide it to the local eligibility office to determine if she meets all eligibility requirements for prior Medicaid. See A-831, Three Months Prior Coverage.

X—923  Medicaid Termination

Revision 10-2; Effective April 1, 2010

MBCC eligibility ends when the recipient first meets any of the following conditions. The recipient:

  • becomes 65,
  • obtains creditable coverage,
  • is no longer receiving active treatment for breast or cervical cancer,
  • no longer resides in Texas, or
  • dies.

X—930  Creditable Coverage

Revision 12-3; Effective July 1, 2012

X—931  General Overview

Revision 13-1; Effective January 1, 2013

A woman is ineligible to receive MBCC if she has creditable coverage. Deny an MBCC application if her plan covers breast or cervical cancer treatment.

Creditable coverage is defined as:

  • group health insurance,
  • health insurance coverage,
  • Medicare (Part A or B),
  • Medicaid,
  • Children's Health Insurance Program (CHIP),
  • armed forces insurance, or
  • a state health risk pool.

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 creditable coverage. Note: The Texas Womenís Health Program is not considered creditable coverage.

Consider a woman as having creditable coverage even if it has limits on benefits, such as limited drug coverage or limits on the number of outpatient visits, or high deductibles. A woman is considered to no longer have creditable coverage if she:

  • is in a period of exclusion (such as pre-existing condition exclusions or a health maintenance organization [HMO] affiliation period) for treatment of breast or cervical cancer; or
  • exhausts her lifetime limit on all benefits under the plan or coverage or her yearly benefits for breast or cervical cancer treatment. When the new plan year begins, determine if the woman has creditable coverage.

Note: Set a special review if it is known that the exclusion period of the creditable coverage will expire (pre-existing period has expired) or the womanís yearly benefits for breast or cervical cancer treatment will be reinstated before the next periodic review. See X-1930, Setting Special Reviews.

There is no requirement for a waiting period of prior un-insurance before a woman screened under BCCS can become eligible for Medicaid.

As long as the termination of the creditable coverage occurs before disposition, a woman is eligible to receive benefits under the MBCC program.

A woman is required to report when she has obtained creditable coverage.

If an MBCC applicant indicates she has health insurance but does not know whether it provides coverage for breast or cervical cancer, certify the woman for MBCC-Presumptive. Contact the insurance provider to verify whether the policy provides coverage for breast or cervical cancer.

X—932  Other Medical Assistance

Revision 12-3; Effective July 1, 2012

An MBCC applicant is not eligible to receive benefits if she is currently receiving Medicaid, Medicare Part A or B, or coverage through CHIP. If an application is received for a woman who receives Medicaid, Medicare (Part A or B) or CHIP, or if a Medicaid or CHIP application is certified before the MBCC application, deny the MBCC application.

Staff must verify via TIERS, the State Online Query (SOLQ) or the Wire Third-Party Query (WTPY) system and the CHIP inquiry system that an applicant is not currently enrolled in Medicaid, Medicare Part A/B, CHIP or the Womenís Health Program (WHP) before disposition. If a woman is eligible for MBCC and is currently receiving WHP, the WHP case must be denied.

X—932.1  Currently Receiving MBCC and Applies for Other Benefits

Revision 13-3; Effective July 1, 2013

A woman receiving MBCC-Presumptive or MBCC who is found eligible for another type of Medicaid program is ineligible to continue to receive MBCC-Presumptive or MBCC. The MBCC advisor receives a task to prospectively deny the MBCC-Presumptive/MBCC Eligibility Determination (EDG) so that the advisor processing the application can certify the woman for the other type of Medicaid. The MED for the other Medicaid type begins the first of the month following the MBCC-Presumptive/MBCC EDG denial.

When the other Medicaid type of assistance is denied, the woman may be eligible for MBCC if she continues to be in need of active treatment for breast or cervical cancer and she meets all other eligibility criteria. When the other type of Medicaid is denied (unless the denial is due to death, unable to locate or a move out of state) and the woman is under age 65, TIERS generates a reapplication packet containing:

  • Form H1833, Cover Letter - Other Medicaid Ending;
  • Form H2340, Medicaid for Breast and Cervical Cancer Renewal;
  • Form H1551, Treatment Verification Form;
  • a self-addressed envelope; and
  • Form H0025, Voter Registration Application.

The woman must return the completed Form H2340 and Form H1551 for her eligibility for MBCC to be reconsidered.

X—940  New State Residents

Revision 13-4; Effective October 1, 2013

If a woman is screened in another state through the CDC’s National Breast and Cervical Cancer Early Detection Program (NBCCEDP) and moves to Texas, she may be eligible for MBCC in Texas. If a woman meets the MBCC eligibility criteria in Texas, her screening in another state does not prohibit her from receiving MBCC in Texas.

A new state resident requests MBCC in Texas by contacting 2-1-1. Form H2340-OS, Medicaid for Breast and Cervical Cancer, is mailed to the woman for her to complete and return. 

Upon receipt of Form H2340-OS, CBS determines the woman’s eligibility for MBCC. Staff must verify with the losing state the woman’s screening under NBCCEDP and termination of any Medicaid benefits received in that state, if any, before certification. Use Form H1550, Out of State NBCCEDP Verification, to verify the applicants screening and diagnosis.

Related Policy
New Texas Residents, A-720
Medicaid Coverage for New State Residents, A-822