Texas Department of Aging and Disability Services
Case Manager Community Care for Aged and Disabled Handbook
Effective: January 2, 2013
Eligibility for Services
3100 Eligibility Determination Procedures
3110 Eligibility for CCAD Services
§48.2901(a). To receive Community Care for Aged and Disabled (CCAD), a client must meet income, resource, age, and need criteria.
§48.2910(b). Clients who live in nursing homes are not eligible to receive CCAD services.
An applicant or individual who lives in Texas may qualify to receive most CCAD services regardless of citizenship or the duration of residency. However, individuals may not receive Community Attendant Services or waiver services without verification of citizenship and identity.
Provider agencies must accept DADS' decision about which individuals are eligible. For eligibility requirements for specific CCAD services, see Section 4000, Specific CCAD Services.
Note: Refer to Appendix XV , Services Available from Other State Agencies, for information about services that may benefit the applicant/individual.
3111 Age Limits
§48.2906 Age Limits
- A person must be 18 years of age or older, or an emancipated minor, to receive Community Care for the Aged and Disabled (CCAD) services, except:
- a person of any age may receive CCAD Medicaid-funded day activity and health services;
- a person of any age who is not eligible for the Texas Health Steps program may receive CCAD Medicaid-funded community attendant services; and
- a person must be 21 years of age or older to receive CCAD primary home care services, except a current CCAD primary home care services individual who is eligible for Texas Health Steps and who becomes 21 years of age on or before February 29, 2008.
- A person under 21 years of age who is eligible for the Texas Health Steps program may be eligible for personal care services provided through the Texas Health and Human Services Commission.
Although age limits do not apply to Title XIX Day Activity and Health Services (DAHS), licensure prohibits service providers to deliver DAHS services in facilities that are not licensed to serve individuals under age 18. There are currently no facilities licensed in Texas that can serve non-adults.
Effective Sept. 1, 2007, Primary Home Care (PHC) for individuals under the age of 21 is no longer available through the Department of Aging and Disability Services (DADS). Individuals under age 21 requiring attendant services receive benefits from the Health and Human Services Commission (HHSC) Personal Care Services (PCS). PCS provides the same type of assistance individuals formerly received through PHC.
3120 Loss of Eligibility
§48.3903(c). The client is not eligible for CCAD services when
- he dies;
- he is admitted to an institution;
- his physician requests service termination (Medicaid services only); or
- he requests service termination or repeatedly refuses to accept help, except in an involuntary protective services case, or he refuses to comply with his service plan.
The case manager must notify the provider as soon as an individual has died or is entering a nursing home. Terminate services effective the date of death or entry into the nursing home. The provider cannot bill for attempting to deliver services after the effective date of the termination.
3200 Resource Eligibility Criteria
3210 Resource Limits
§48.2922. An individual applicant or client is not eligible for CCAD services if the value of nonexempt resources owned by him exceeds $5,000. A couple is not eligible for CCAD services if the value of nonexempt resources they own exceeds $6,000.
The individual limit applies to individuals who are single, even if they live with relatives. The individual limit also applies to individuals whose spouses live in different households. The couple limit applies to married individuals who live in the same household, even if the spouses are ineligible.
Include in the individual's resources those resources the individual owns even if the resources are managed and controlled by someone else acting on the individual's behalf. Also include funds that are not in the individual's name if those funds clearly belong to the individual and are available for use. Determine ownership based on the individual's statement unless contradictory evidence from another source exists.
3220 Types of Resources
§48.2923. In determining eligibility for CCAD services, the department considers the following to be resources:
- Liquid resources including cash on hand, CDs, checking or savings accounts, money market funds, revocable trust funds, saving certificates, stocks, or bonds. Liquid resources also include the individual's or couple's portion of money in a checking or savings account or a money market fund held jointly with another person.
- Jointly held liquid resources are the resources of the applicant/client if he has unrestricted access to the funds, regardless of the source. The applicant/client may move his portion of jointly held funds in a joint account to a new account. Although the new account may be jointly owned, all funds in the new account are considered to be his.
- Money received as a nonrecurring lump sum payment is not considered a resource until 30 days from the date of receipt. Lump sum payments include, but are not limited to, income tax refunds; earned income tax credits or rebates; one-time bonuses from mineral rights; retroactive lump sum Social Security, SSI, or railroad retirement benefits; lump sum insurance settlements; one time gifts, awards, or prizes; and refunds from rental or utility deposits. The applicant/client is responsible for reporting the receipt of a lump sum payment.
- Nonliquid resources including nonexempt licensed or unlicensed vehicles; buildings and land not designated as homestead that are not producing income, or are producing income less than 6% of the equity value; and any other property not specifically excluded.
Evaluate nonliquid resources according to the equity value. Equity value is the market value of the resource minus any recorded encumbrances.
Money received from the sale of a countable or excluded resource, other than a homestead, is not counted as a resource until the first day of the month following a full month after it was sold. Example: The resource is sold on June 15; proceeds are not counted until Aug. 1.
A revocable annuity is a countable resource. If an individual has an annuity, the case manager must review the contract or agreement terms to determine if the principal is an available resource. Refer the annuity document to the regional attorney if there is a question as to whether or not the annuity is revocable.
Irrevocable annuities are not countable resources for Community Care for Aged and Disabled individuals. However, the purchase of an annuity may affect the individual's eligibility for institutional care or waiver services. If the individual is concerned about the effect the annuity may have on future eligibility for services, refer the individual to the Health and Human Services Commission to consult with a Medicaid for the Elderly and People with Disabilities specialist.
If the individual is a guardian for a person other than his spouse, do not include in his resources any separately identifiable funds belonging to the other person but accessible to the individual as that person's guardian.
A person who has a financial power of attorney for another is acting solely as a fiduciary agent. The fiduciary agent acts in a financial capacity, whether formal or informal, regardless of title (for example, representative payee, guardian or conservator); therefore, assets belonging to the other individual should not be considered as part of the individual's available assets.
Assets held by a fiduciary agent for an individual are considered available to the individual, unless otherwise excludable.
3230 Resource Exclusions
§48.2924. In determining eligibility for CCAD services, the department does not consider the following to be resources. They are considered to be excluded for eligibility purposes. Any item not listed as an exclusion is considered a resource.
- Homestead — Any structure used by the client as a residence, including other buildings and contiguous land. Mobile homes, houseboats, and motor homes are considered structures. Vacant property is not a homestead. Contiguous land means land adjacent to the home, including any land separated only by roads, rivers, and streams. Land is contiguous as long as it is not separated by property owned by another person. The homestead is excluded as a resource regardless of its location, even if the client no longer lives there (unless he has purchased another residence). If he owns two houses, his homestead is the property that he uses as a residence. Only one homestead may be excluded for each client or couple.
If the individual lives in a house, but also has a mobile home, houseboat or motor home on the property, these are all excluded as part of the homestead.
- Personal property — Household goods and personal effects.
- Property essential to employment — Tools and equipment required for employment or self-employment.
- Prepaid burials — Prepaid burial arrangements, burial insurance, and burial plots.
- The cash surrender value of all life insurance.
- Vehicles — One passenger car or other vehicle, such as a van or truck, used for transportation; or one unlicensed vehicle.
- A second vehicle may be excluded if it is:
- specially equipped to enable a person with a disability to drive, or
- essential to the employment or self-employment of the family.
- Any additional vehicles, licensed or unlicensed, are considered resources.
An inoperable junk vehicle can be assigned a value of $100, if the individual's resources are less than:
- $4,900 for a single person, or
- $5,900 for a couple.
The case manager must verify the value of an inoperable vehicle when the individual's resources are within $100 of the CCAD resource limit ($5,000 for a single person or $6,000 for a couple).
- Income-producing property — Property that annually produces net income equal to or greater than 6% of the property's equity value. The equity value is the current market value of the property less any recorded encumbrances. (See Section 3231, Rate of Return on Income-Producing Property.)
- Installment contracts from mortgages, notes, or loans — The value of installment contracts for the sale of land, other property, or repayment of loans, if the contract or agreement is producing income according to the fair market value at the time of the agreement. An installment is a mortgage or similar contract in which the buyer promises to pay a fixed amount over a period of time until the principal of the note is paid. Even though the seller retains legal title, the property is not considered a countable resource as long as the buyer is fulfilling the contractual obligation. The payment is considered income.
- Disaster assistance — Government payments granted for the rebuilding of homes destroyed or damaged in a disaster.
Reverse mortgages are treated as loans. The money received is not considered to be income. However, it is a resource the month after receipt.
- Energy assistance — Payments or allowances for energy assistance made under any federal, state, or local law.
- Supplemental Nutrition Assistance Program (SNAP) allotments — The value of SNAP allotments and USDA-donated foods.
- Inaccessible resources — The cash value of resources that are inaccessible to the client. Examples are irrevocable trust funds, property in probate, and pension funds. Real property that the client or family is making a good faith effort to sell is exempt. The client or family must ask a fair price for the property, according to its current market value. Property is also exempt if it is jointly owned and the other co-owners refuse to sell.
- If jointly owned property is not excluded, the market value of the individual's share of the property is countable. However, if the value will not affect eligibility, enter the full value of undivided property and document that the property is jointly owned.
- An IRA should be treated as a pension fund, and therefore not considered as a resource for eligibility determination.
- Mineral rights — The value of mineral rights.
- Life estates and remainder interests — A life estate is the right an individual has to property during the individual's lifetime. A remainder interest is the right of ownership to the property when the life estate holder dies.
- Replacement value of excluded resources — The replacement value of an excluded resource if it is lost, damaged, or stolen. The cash received from an insurance company for replacing the resource is not considered for three months if the resource is personal property or six months if it is real property. Any cash not spent within the specified period is considered a resource.
- Monthly gross income — All income received monthly. Monthly gross income is counted as income in the month received and excluded as a resource in that month.
- Do not deduct income from resources unless the countable resources exceed $5,000 ($6,000 for a couple).
- If resources exceed the $5,000/$6,000 limit, determine whether the monthly income is actually included in the checking or savings account or cash on hand.
- If cash on hand is money remaining from the current month's income, it may be deducted unless this would duplicate deduction of the same money as a checking or savings account deposit.
- If resources exceed the $5,000/$6,000 limit, deduct the amount of income the individual may have received at the end of the month intended for the next month. Example: Next month's Social Security check arrives early (the last day(s) of the month) and is deposited into the individual's checking or savings account.
- If income is deducted and the individual receives Veterans Affairs (VA) aid-and-attendance or homebound benefits, deduct the full amount of VA payment even though aid-and-attendance is excluded from income.
- Sale of a homestead — Proceeds from the sale of a homestead up to six months after they become available to the seller. The six months gives the client time to acquire another homestead. If he does so, any balance from the original sale must be considered as an available resource. If, before the end of the six-month period, the client declares that he has no intention of acquiring another homestead, the proceeds from the sale must be counted as an available resource.
- Agent Orange Settlement Payments — Payments from the Agent Orange Settlement Fund or any other fund established in settlement of the Agent Orange product liability litigation.
- Radiation exposure compensation — Payments received under the Radiation Exposure Compensation Act (P.L. 101-246).
- Funds from the In-home and Family Support Program or the Transition to Life in the Community Program.
- Earned income tax credit (EITC) refunds from the Internal Revenue Service.
3231 Rate of Return on Income-Producing Property
To determine whether the property is producing enough income to be excluded as a resource:
|1||Determine the current market value, or the amount the property would bring on the open market. The current market value may be based on an estimate by a knowledgeable source such as a realtor or bank official.|
|2||Determine the total amount owed on the property (encumbrances) by viewing a copy of the loan agreement, purchase contract, or contract with the creditor.|
|3||Calculate the equity value by subtracting the encumbrances from the current market value.|
|4||Multiply the equity value by 6% to determine the required gross yearly revenue that must be produced to exempt the property.|
|5||Calculate the net yearly income the property produces from rents, leases, etc. by subtracting from the gross yearly income any expenses such as taxes, insurance, costs of repairs and maintenance, and interest on the property's mortgage. (Expenses for capital improvement and depreciation are not deductible.)|
|6||Compare the required gross yearly revenue calculated in step 4 (yearly income that must be produced) with the net yearly income from step 5 (actual yearly income produced) to determine whether the net income equals or exceeds 6% of the equity value. If the property is not producing income equal to or greater than 6% of the equity value, consider the equity value of the property a resource.|
3300 Income Eligibility
3310 Income and Income Eligibles
§48.2902. To be eligible for CCAD services, the applicant/client must:
- be categorically eligible by receiving Supplemental Security Income, Aid to Families with Dependent Children, Supplemental Nutrition Assistance Program, Medicaid, Specified Low-Income Medicare Beneficiary (SLMB) or Qualified Medicare Beneficiary (QMB) benefits; or
- be income eligible. The applicant/client's and spouse's countable income must be equal to or less than the income limit set by the department. For an individual, this amount is the same as the special income limit set for institutional care (medical assistance only) by the Texas Legislature. For a couple, the income limit is twice the special income limit.
Categorical Eligibility for Title XIX Services
Recipients with full Medicaid eligibility have already been determined financially eligible for Title XIX services. These individuals are referred to as being categorically eligible.
See Section 7110, TIERS Inquiries, to determine which programs give an individual financial eligibility for Community Care for Aged and Disabled (CCAD) Title XIX programs.
If a CCAD individual receiving Supplemental Security Income (SSI) has excess income or resources, the case manager must share this information with the Social Security Administration (SSA). The individual will continue to be eligible for CCAD based on SSI status until SSI is denied.
Categorical Eligibility for Title XX Services
Recipients of some non-Medicaid programs are financially eligible for Title XX benefits based on existing program eligibility. These individuals are referred to as having categorical eligibility for Title XX services. See Section 7110.
Financial Eligibility Determination for Title XX Services
CCAD case managers determine financial eligibility for applicants for Title XX programs unless financial eligibility has already been determined based on existing program eligibility. These individuals are referred to as income eligibles.
For details on the income eligible determination process, see:
- Section 3320, Determination of Countable Income;
- Section 3330, Budgeting Countable Income; and
- Section 3340, Computation of Gross Income.
Financial Eligibility for Community Attendant Services (CAS) and Non-SSI Waiver Recipients
Financial eligibility for CAS and non-SSI waiver services is determined exclusively by Medicaid for the Elderly and People with Disabilities (MEPD) specialists. Department of Aging and Disability Services staff must never deny CAS or 1915(c) Medicaid waiver cases based on income. This applies even if the applicant's assets appear to substantially exceed the eligibility limits.
The Health and Human Services Commission (HHSC) is designated as the single state Medicaid agency in the Code of Federal Regulations (CFR). Chapter 42 CFR 431.10(c) maintains that the state plan must specify the agency that determines eligibility and that there are only three choices:
- the Medicaid agency (HHSC);
- the single state agency for Temporary Assistance for Needy Families (TANF) (HHSC); or
- the federal agency administering SSI (SSA).
In Texas State Plan, Section 2.2, HHSC is designated as the state agency that determines eligibility.
Effect of Living Arrangement on Financial Eligibility
If both a husband and wife apply for services and only the wife receives SSI, TANF, Medical Assistance Only or other programs shown in Section 7110 as granting categorical eligibility for CCAD services, compare the total income of both spouses with the couple’s income limit to determine the husband's eligibility.
If a married individual does not live with his spouse, use the individual income limit. Do not consider the income of the spouse unless that income (or part of it) is given to the individual. Income diverted from a spouse in a nursing home to the individual at home is included in the individual's income calculation. If an individual must be denied because of income diverted from a spouse in a nursing home, tell the individual that the amount of income diverted may be reduced or discontinued. Ask the individual to speak to his MEPD specialist, and tell the individual he may reapply for CCAD if the situation changes.
Use the CCAD monthly income limits as reflected in Appendix XI, Monthly Income/Resource Limits.
If a CAS, Primary Home Care or Title XIX Day Activity and Health Services individual wants to receive another CCAD service in addition to the original Title XIX program, the case manager may certify the individual as categorically eligible for Title XX services based on the current Medicaid eligibility certification.
3320 Determination of Countable Income
§48.2903. Determination of Countable Income. Countable income is determined by totaling gross income from all the following sources, less all applicable exclusions and exemptions. Applicable exclusions/exemptions are specified in §§48.2904 and 48.2905 of this title (relating to Income from Excludable Sources and Income from Exempt Sources.)
- Total gross earnings — This includes money, wages, commissions, tips, piece-rate payments, cash bonuses, or salary received for work performed as an employee. This also encompasses pay for members of the armed forces (including allotments from any armed forces pay received by a member of the family group from a person not living in the household).
- Self-employment income (including farm income) — For earned income to be considered self-employment, either the individual or spouse must be actively involved or materially participating in producing the income.
- Social security and railroad retirement benefits.
- Dividends — This consists of dividends from stocks or membership in associations, and periodic receipts from estates of trust funds. These payments are averaged over a 12-month period.
- Rental income — This includes payments to the individual from the rent of housing, store, or other property, as well as from boarders or lodgers.
- Net income derived from oil, gas, or mineral rights — This can include both lease and royalty payments. These payments are averaged over a 12-month period.
(Reminder: Refer to 3330 to determine if this income can be excluded as infrequent and irregular or as a lump sum payment.)
- Income from mortgages or contracts.
- Public assistance or welfare payments — Temporary Assistance to Needy Families, Supplemental Security Income, and general assistance (cash payments from a county or city) are included.
- Veterans' pensions and compensation checks — This may include money paid periodically by the Veterans Administration to disabled members of the armed forces or to survivors of deceased veterans, subsistence allowances paid to veterans for education and on-the-job training, and refunds paid to ex-servicemen as GI insurance premiums.
- Educational loans, grants, fellowships, and scholarships.
- Unemployment compensation — Unemployment compensation may be received from government employment insurance agencies or private companies during periods of unemployment, and includes any strike benefits received from union funds.
- Workers compensation and disability payments — This includes compensation received periodically from private or public insurance companies for injuries incurred at work.
- Regular monthly cash support payments from friends or relatives.
- Pensions, annuities, and irrevocable trust funds — Payments may be paid to a retired person or his survivors by a former employer or by a union, either directly or through an insurance company. Periodic payments from annuities, insurance, irrevocable trust fund payments, and civil service pensions are included.
- Income from the client's share of a life estate.
3330 Budgeting Countable Income
The sources of income that may be included in the income eligibility budget fall into one of three categories: countable, excludable and exempt. Countable income is addressed in Section 3320, Determination of Countable Income. Treatment of the excludable and exempt income varies, as illustrated below.
3330.1 Excludable Income
§48.2904. Income from Excludable Sources. Income may be fully or partially countable, or may be excluded from the current eligibility budget. Excludable income will continue to be monitored by the caseworker at each financial review to determine how eligibility is affected. Excludable sources of income include:
- deductions from earned income, including social security payments, Medicare premium payments, bonds, pensions, and union dues;
- the first $65 of a client's (or couple's) net earned income, plus 1/2 of the remainder;
- loans, grants, scholarships, and fellowship funds obtained and used under conditions that preclude their use for current living costs. Any portion used to pay any other expense (room, board, books, etc.) cannot be excluded;
- Veterans Administration aid-and-attendance benefits, homebound elderly benefits, and payments to certain eligible veterans for purchase of medications;
- infrequent or irregular income (income received less frequently than once a month) that averages $20 per month or less;
- 1/3 of the total amount of child support payments for an eligible child; and
- allowable exclusions from self-employment income, as indicated on the following chart.
Expense Excludability Money paid to or for employees not living in the home Excludable Money paid to or for employees living in the home Excludable Federal, state, or local income taxes Excludable Sales tax Excludable Property tax Excludable Rental of business property Excludable Utilities for business property Excludable Stock/inventory, raw materials Excludable Supplies Excludable Fuel expenses for the business Excludable Insurance premiums Excludable Linen service Excludable Interest for business loans or property Excludable Lodging when traveling (when not counted as shelter) Excludable Own meals when traveling for business Excludable Net loss for same determination period Excludable Additional expenses related to self-employment (advertising, co-op, license fees, journals, etc.) Excludable Additional farming-related expenses (feed, seed, plants, seedlings, farm supplies, breeding fees, fertilizer and lime, crop insurance, crop storage, fees for livestock testing, etc.)
Excludable for self-employment farming
Excludable for unearned income farming only if part of the lease agreement
Depreciation related to self-employment Excludable Cost of doing business in the home (separately identifiable from home expenses), including utilities. For rooms designated for business purposes in a single residence, expenses are compared to the total number of rooms in the house. Bathrooms are not counted as rooms; basements and attics are counted only if they have been converted into living spaces. Excludable Purchase and cleaning of uniforms Not excludable Capital asset purchases Not excludable Capital asset improvements Not excludable Payment on principal of loan for income producing property Not excludable Travel to/from place of business Not excludable Net loss from previous determination period Not excludable Depreciation related to unearned income (e.g., rental income) Not excludable
Mandatory deductions from unearned income may also be excluded from the eligibility budget. Documentation in the case record must clearly state that the deduction is mandatory and whether/when the mandatory deductions will end.
For earned income to be considered self-employment, either the individual or spouse must be actively involved or materially participating in producing the income. A business owner is determined to be materially participating if he meets any one of the following criteria:
- The owner engages in periodic advice and consultation with the tenant, inspection of the production activities, and furnishing of machinery, equipment, livestock, and production expenses.
- The owner makes management decisions that affect the success of the enterprise.
- The owner performs a specified amount of physical labor to produce the commodities raised.
- The owner does not meet the full requirements above, but his involvement in crop production is nevertheless significant.
A blind or disabled student under 22 years of age who regularly attends school, college, a university or a course of vocational or technical training can have limited earnings that are not counted toward the income eligibility budget. (This exclusion does not apply to unearned income.)
The maximum amount of the income exclusion applicable to a student in 2009 is $1,640 per month but not more than $6,600 for the year. The exclusion amount varies from year to year and is determined annually by the Social Security Administration (SSA). Exclusion amounts for subsequent years can be determined online at www.ssa.gov/OACT/COLA/studentEIE.html.
Section 2002 of the American Recovery and Reinvestment Act of 2009 (ARRA) authorizes additional unemployment compensation benefits of $25 per week for individuals receiving unemployment benefits. The additional $25 unemployment compensation benefits received as a result of ARRA are not countable income for either eligibility or co-payment purposes. As the additional unemployment compensation may be included either with the regular payment or as an additional payment, a contact with the Texas Workforce Commission may be needed to determine if any of the payments are part of the ARRA additional compensation.
3330.2 Exempt Income
There are numerous exemptions on countable income. These exemptions can be found in Appendix XXX, Income and Resource Exemptions for Determining Financial Eligibility.
§48.2905. Income from Exempt Sources. Exempt income is not included in the income eligibility calculation. Once identified and documented, caseworkers will not be required to monitor exempt income at subsequent financial redetermination. Sources of exempt income include:
- interest income.
- cash received from the sale of a resource. This cash is a resource, not income.
- income of minor children who are supported by or dependent upon the client.
- refunds from the Internal Revenue Service for earned income tax credit.
- reimbursement from an insurance company for health insurance claims.
- any cash from a non-governmental medical or social services organization if the cash is:
- for medical or social services already received by the individual and approved by the organization, and which does not exceed the value of those services; or
- a payment restricted to the future purchase of a medical or social service.
- proceeds of either a commercial loan or an informal loan, for which repayment is required with or without interest. The proceeds (amount borrowed) are not counted as income in the month in which they are received, but are considered to be a resource in the following month(s). To claim exemption of the proceeds of a loan, a client must prove that he acknowledges an obligation to repay and that some plan for repayment exists. If these conditions can be verified, no written contract is required.
- the amount of the cost-of-living increase in any pension or benefit, received on or after January 1, 1985, that would cause the client to be ineligible for continued services. This exclusion applies only to community care clients who are already receiving services or case management and would become ineligible because of the increase. It does not apply to applicants.
- in-kind income, such as food, clothing, shelter, rent subsidies.
- one-time or lump-sum payments from any source.
- funds from the In-Home Family Support Program or the Transition to Life in the Community Program.
For a complete list of income exemptions, see Appendix XXX.
The term "lump sum," as listed in (10) above, can be defined as income that is not expected to recur with a predictable pattern of frequency.
Income received less than three times per year that does not meet the $20 monthly average requirement, as listed in (5) above, should be treated as a lump sum payment. If the lump sum could affect eligibility, the case should be monitored 30 days following receipt to ensure that resource eligibility is not affected.
3340 Computation of Gross Income
If an individual receives gross income more often than monthly, compute the income as follows.
- Weekly income — multiply by 4.33
- Bi-weekly income — divide by 2 and multiply by 4.33
- Twice monthly income — multiply by 2.
3341 Income Averaging
Calculate the income average of all income that may be received monthly, but is usually received less often. The case manager also may need to calculate the 12-month average income for monies received for seasonal employment, such as agricultural or construction work.
If an individual ends regular employment to accept seasonal employment but later returns to the regular job, calculate the income average from the combined sources over the 12-month period.
3400 Verification Procedures
3410 Verification of Public Assistance Status
Within 24 months of the last financial review, verify the correct categorical financial status of current Temporary Assistance for Needy Families (TANF), Supplemental Security Income (SSI), Qualified Medicare Beneficiary (QMB), Specified Low-Income Medicare Beneficiary (SLMB), Qualifying Individuals (QI), Supplemental Nutrition Assistance Program, Medicaid Buy-In or Medicaid individuals and certify eligibility on this basis. Documentation on Form 2064, Eligibility Worksheet, or a printed copy of a DADS computer inquiry placed in the individual's case folder will satisfy verification requirements for an individual receiving service(s) based on categorical financial status.
Refer to Section 7110, TIERS Inquiries, for a full listing of programs that provide categorical eligibility for Community Care for Aged and Disabled programs.
3420 Verification of Income and Resources
Program Standard: The case manager must accurately establish the countable amount of income and resources to determine the income-eligible applicant's financial eligibility.
Determine the amount of countable assets for persons applying as income eligibles. Within 24 months of the last financial review, financial eligibility must also be redetermined for these individuals. An individual's declaration of income/resources for all programs is acceptable (excluding waiver services) unless:
- there is reason to doubt the reliability of the applicant's statement. The case manager has the option of requesting verification whenever any doubt exists.
- the applicant's declared resource amount is within $100 of the resource eligibility limit.
- the applicant's declared income amount is within $10 of the income eligibility limit.
- the applicant appears unsure about the amount of income or resources available. The case manager may accept a certain level of uncertainty. Example: The individual may state that he receives "about $350 per month." Since this is well below the income eligibility cap, the applicant's statement may be accepted even though the individual is not absolutely sure about the amount. However, if the applicant responded with "somewhere around $1,500," it would be necessary to verify the amount of income, given the uncertainty and the proximity to the eligibility limit.
If an individual meets the criteria in Section 3430, Eligibility Before Verification, refer the individual for services before verifying income and resources, and complete the verification within 30 days of the application.
Applicants are responsible for providing all information needed to establish eligibility. Ask the applicant or responsible party to provide the needed information to verify income and resources.
When information is requested from the applicant or responsible party, give a specific due date and explain the result of not providing the requested information. During a review, make the due date two weeks before the day the current certification period ends. This will allow a few more days to give the individual a second chance before terminating services effective the last day of certification. Follow up at least one time before denying the applicant for failure to cooperate.
During a financial review, if an individual reports closing a bank account or no longer having an account that was included in the last review, and adding the last known balance would bring the individual to within $100 of the resource eligibility limit, verify with the bank that the account has been closed.
If the information can be obtained by making a telephone call or mailing a verification form, attempt to obtain the information before denying the application. If the case manager cannot obtain the information and the applicant does not provide the information, deny the application. If the case manager cannot obtain information needed for a financial recertification and the individual does not provide the information, send Form 2065-A, Notification of Community Care Services, at least 12 days before termination becomes effective.
The case manager may, without verifying the income or resources, deny an application because the individual reports excess income or resources. Explain the reason for the denial to the individual or responsible party. Explain in the comments section of Form 2064, Eligibility Worksheet, that the denial was due to the individual's declaration of excess income or resources.
See Appendix XII, Examples of Methods to Verify Income and Resources, for examples of methods to verify income and resources. The case manager may use a verification source not listed in Appendix XII if it is determined the source is both knowledgeable and objective. A person is considered knowledgeable if that person routinely assesses values on that type of resource in the area where the resource is located. A person may not be considered objective if that person has a vested interest in the individual's eligibility.
Documentation on Form 2064 should contain enough information to determine what, when, where and how the applicant's/individual's income/resources were verified, so that they can be traced to the original source. For categorically eligible applicants and individuals (Temporary Assistance for Needy Families (TANF), Medical Assistance Only (MAO), Supplemental Security Income (SSI), Qualified Medicare Beneficiary (QMB), Specified Low-Income Medicare Beneficiary (SLMB), Qualifying Individual (QI) and the Supplemental Nutrition Assistance Program), the case record must:
- show that categorical status was verified, or
- include a printed copy that shows the applicant's categorical status.
Form 2064 must show that verifications were received before the date eligibility rules were processed.
3421 Financial Documentation Requirements
This chart is designed to assist in determining what is required for financial eligibility documentation.
|If the individual's:||and||then:|
|income is not within $10 of the eligibility limit
resources are not within $100 of the eligibility limit
|information gathered by the case manager matches information on the application form,||no verification is required. Enter the monthly dollar amount in SASW and select the client statement option. No other documentation is required.|
|income is not within $10 of the eligibility limit
resources are not within $100 of the eligibility limit
|information gathered by the case manager does not match information on the application form,||no verification is required. Enter the monthly dollar amount in SASW and select the client statement option. No other documentation is required.|
|income is within $10 of the eligibility limit
resources are not within $100 of the eligibility limit
|information gathered by the case manager matches information on the application form,||view verification containing all information listed in Column 3 of Appendix XII. Enter the monthly dollar amount and select the appropriate documentation source in SASW/TIERS. No further documentation is required.
If the case manager is not able to view adequate documentation, verification of income and resources is required.
|income is within $10 of the eligibility limit
resources are not within $100 of the eligibility limit
|information gathered by the case manager does not match information on the application form,||view verification containing all information listed in Column 3 of Appendix II. Enter the monthly dollar amount and select the appropriate documentation source in SASW/TIERS. Explain the discrepancy in documentation.|
|income is within $10 of the eligibility limit
resources are within $100 of the eligibility limit
|N/A||verification of income and resources is required.|
3422 Exceptions to Verification Requirements
Within 24 months of the initial financial determination, income-eligible individuals must complete a new Form H1200, Application for Assistance – Your Texas Benefits,/H1200-EZ, Application for Assistance — Aged and Disabled. Subsequent financial redeterminations will not require completion of Form H1200/H1200-EZ, unless the case manager has reason to believe the individual's financial eligibility may be in question.
Even though a new Form H1200/H1200-EZ is not needed, the case manager still must contact the individual and confirm that significant changes in income and resources have not occurred.
If there is a new source of income at a financial review or a new resource, then re-verify all of the individual's resources. If adding the individual's new assets to existing income/resources brings the total income within proximity of financial eligibility limits, re-verify all of the individual's resources.
Following these guidelines, at a review the case manager may need to verify both income and resources, income but not resources, resources but not income, or neither income nor resources.
If an individual loses categorical eligibility (for example, stops receiving Temporary Assistance for Needy Families or the Supplemental Nutrition Assistance Program) between reviews, that individual may be able to continue receiving services without a financial review until the next financial review is due (see Section 3441, Loss of Categorical Status). In such a case, the case manager must verify both income and resources at the next financial review.
3430 Eligibility Before Verification
§48.3901(g). A Medicaid-certified applicant for CCAD-purchased services who requires a verbal referral is eligible to receive CCAD-purchased services when his eligibility for Medicaid is verified. A non-Medicaid certified applicant who meets the requirements for a verbal referral is eligible to receive CCAD purchased services while income and resources are verified. [See Section 1130, Definitions, and Section 2631, Negotiated Referrals.]
- To be eligible, this applicant must:
- be a new applicant for CCAD services;
- appear to be eligible based on the declaration of income and resources on his application for services or to have possession of a current medical care identification card; and
- meet the age and need criteria for the CCAD service he requires.
- The eligibility period for non-Medicaid applicants begins on the date of application.
- To continue receiving services, a non-Medicaid applicant must provide within 30 days of the application date the information needed to verify the applicant's income and resource amounts.
If, pending financial eligibility verification, the non-Medicaid applicant appears eligible for immediate service initiation, use the following procedures, as appropriate.
- Refer the applicant to the provider according to Section 2631.
- On Form 2101, Authorization for Community Care Services, enter the earliest date negotiated with the provider as the date services begin.
- If the applicant is determined ineligible within the 30-day verification period, or if the applicant does not provide the information needed to verify income and resource amounts by the 30th day, send Form 2065-A, Notification of Community Care Services, to the individual to terminate services 12 days after the Form 2065-A date. (Refer to Appendix IX, Notification/Effective Date of Decision.)
3440 Changes in Financial Circumstances
§48.3901(f). The client must report promptly any changes in income, resources, or family size; loss of assistance grant or Medicaid benefits; or other changes in functional ability or circumstances that affect eligibility. The client is subject to fraud prosecution if he willfully fails to report changes and continues to receive services for which he is not eligible.
Individuals must report promptly any changes in income or resources. Note in the case record, but do not verify, reports of changes in income or resources that do not affect eligibility. Newly acquired resources that may affect eligibility, such as an inheritance involving property, are disregarded for 30 days from the date received. After 30 days, determine the amount of resources and terminate the individual's eligibility if the amount exceeds the resource limit.
3441 Loss of Categorical Status or Financial Eligibility
In situations in which a Community Care for Aged and Disabled (CCAD) individual temporarily loses categorical or financial eligibility, the case manager must contact the individual and/or the appropriate agency to determine the reason for the denial and determine if reinstatement is likely.
If the individual loses Medicaid eligibility because his Supplemental Security Income (SSI) is being denied, the case manager must contact the individual and/or the Social Security Administration (SSA) to determine the reason for the denial and if the individual may be reinstated without a break in coverage.
Case managers may receive a copy of a denial notice or the monthly Loss of Eligibility Report for eligibility determined through the Health and Human Services Commission for the following programs:
- Community Attendant Services (CAS)
- Medicaid Buy-In (MBI)
- Medicaid through Temporary Assistance for Needy Families (TANF)
- Categorical eligibility through the Supplemental Nutrition Assistance Program (SNAP)
- Qualified Medicare Beneficiary (QMB)
- Specified Low-Income Medicare Beneficiary (SLMB)
- Qualifying Individual (QI)
- Medicaid through Type Program (TP) 03 (Pickle), TP 18 (Disabled Adult Children), TP 19 (SSI Denied Children) or TP 22 (Widow/Widower).
Upon learning of the denial, the case manager must check the Texas Integrated Eligibility Redesign System (TIERS) to verify the denial and the reason. The case manager must contact the individual to discuss the situation and, if feasible, assist the individual with completing the actions necessary for reinstatement of eligibility. If the individual has been denied on failure to furnish information, the case manager must contact the individual as soon as possible to advise him of the loss of service and the necessity of providing the information required by Medicaid for the Elderly and People with Disabilities (MEPD) or TANF. The case manager may also contact the MEPD or TANF specialist involved, ask about the individual's current income and resource amounts, and whether reinstatement will be occurring.
3441.1 Procedures Pending Reinstatement
If the case manager is advised by SSA, MEPD or TANF that the individual will be reinstated within a month or is working on reinstatement, the case manager explores transferring the individual to Family Care (FC), if enrollment is possible in the region.
If the individual has not responded to requests for information and continues to fail to furnish information to the appropriate agency by the agency's deadline, he is not eligible to transfer to FC and the case is denied.
During times of extreme budget limitations on a regional or statewide basis, no individual may bypass the FC interest list. In absence of these budget limitations, the following procedures may be used.
If the individual or case manager reports income and resources within eligibility limits (and no other information exists to contradict this report), the individual may continue to receive Title XX (block grant) services or be transferred from Primary Home Care (PHC) to FC without being placed on an interest list. Note the individual's changed status and record the self-declared income and resources in the case record. Update the Service Authorization System (SAS) to show the individual as income eligible. It is not necessary to obtain Form H1200, Application for Assistance – Your Texas Benefits, or Form H1200-EZ, Application for Assistance – Aged and Disabled, from the individual or to verify income and resource amounts until the next financial review is due.
When applicable, submit Form 2101, Authorization for Community Care Services, to transfer an individual from PHC to FC. Use the day after the last date of Medicaid coverage as the "from" date. (If the Medicaid denial is unknown until after the last day of Medicaid coverage, use the earliest date FC can begin as the "from" date.) In the event that the individual has been receiving a block grant service and will continue to receive the same service, the same authorization may be continued.
If transferring to FC is not an option due to regional constraints, the case manager may suspend services for 30 calendar days until a determination is made regarding the reinstatement of services. Within two business days of determining suspension is appropriate, the case manager sends the individual Form 2065-A, Notification of Community Care Services, checking the Notification of Ineligibility or Termination of Benefits, the date services end, and noting services are suspended pending reinstatement of Medicaid or financial eligibility (as applicable). The case manager also sends the provider Form 2067, Case Information, suspending services effective the date of Medicaid denial.
During this 30-day period, the case manager continues any regularly scheduled monitoring or review contacts and notes on Form 2314, Satisfaction and Service Monitoring, that services are temporarily suspended. The case manager must set a special review for the 30th day and check on that date if eligibility has been re-established. At any time during the 30-day period the case manager learns that eligibility is re-established, the case manager must call the provider the same day and negotiate the earliest date for services to resume. Within two business days, the case manager follows up the telephone call with Form 2067 to the provider, noting reinstatement of services with the negotiated date. The case manager documents the reinstatement of eligibility in the case record and sends the individual Form 2065-A with a statement that services have been reinstated.
If, on the 30th day eligibility has not been re-established, the case manager sends the individual Form 2065-A denying services. The date of denial will be based on the:
- Medicaid eligibility end date as indicated in TIERS; or
- denial date on Form H4808, Notice of Change in Applied Income/Notice of Denial of Medical Assistance, from MEPD.
Form 2101 must be sent to the provider on the same date, noting services are denied effective the date of the financial denial.
3441.2 Reinstatement Procedures After Denial
If financial or categorical eligibility is re-established within 60 days of the denial date and the individual reapplies for services, the case manager may use the information currently on file to determine eligibility. Completing new forms will not be required, except for a new Form 2110, Community Care Intake, and Form 2101, Authorization for Community Care Services. The case manager must note in the Comments section of Form 2110 that reinstatement procedures are being used within 60 days of the denial date and may use the following forms currently on file:
- Form 2059, Summary of Client's Need for Service
- Form 2060, Needs Assessment Questionnaire and Task/Hour Guide
- Form 2307, Rights and Responsibilities
- Form 1584, Consumer Participation Choice
The case manager must contact the individual and review the functional assessment, including Form 2060 and Form 2059, to determine if there have been any changes in the individual's physical condition or needs. Form 2060 may be updated, or if already updated, a new Form 2060 must be completed. If Form 2060 is over one year old, if there have been changes in the individual's condition or needs or if the individual has difficulty communicating by telephone, the case manager must make a home visit to review/revise the assessment. Initial eligibility time frames will apply.
The case manager must send an initial referral packet and initial Form 2101 referral to the selected provider. For Primary Home Care and Community Attendant Services, the provider must complete all pre-initiation activities, including obtaining a new Form 3052, Practitioner's Statement of Medical Need.