Texas Health and Human Services Commission
Medicaid for the Elderly and People with Disabilities Handbook
Effective: March 1, 2013
Medical Effective Date, Prior Months' Eligibility and Case Actions
N-8100 Medical Effective Date
The medical effective date (MED) for Medicaid Buy-In for Children (MBIC) cannot be before Jan. 1, 2011. This includes any prior months' eligibility for MBIC. If an application is received in which the prior months occur before January 2011, determine eligibility for other MEPD programs in those prior months. Do not automatically disregard the prior months because an MBIC application is received and the prior months occur before January 2011.
N-8200 Prior Months' Eligibility
Eligibility for three prior months to the application month is available for this program. Prior months' eligibility for MBIC cannot be granted before Jan. 1, 2011.
If a premium is required, eligibility for prior months is not granted until premiums have been paid.
See Appendix XLVIV, Medicaid Buy-In for Children Forms Chart. Form TF0001-MBIC, Prior Months Eligibility Notice, serves as both the eligibility notice and denial notice. If the premiums are not received by the due date, the prior months are not granted and are denied. Do not send a separate denial notice for failure to pay premium for prior months.
N-8300 Case Actions
N-8310 Verification Checklist and Pending Reasons
- Send proof that you signed up for your job's health insurance.
- Send proof that shows you get health insurance through your job.
- Send proof that the child applying for Medicaid Buy-In for Children can't be on your job's health insurance plan.
- Send proof that your health insurance company changed.
- Let us know the next date you can enroll <child's name> in your job's health insurance plan.
- Send proof that your job pays at least half the premium of your health insurance.
N-8320 Change Action Reasons
The following new change action reasons have been created for this program. These reasons will be pre-populated by TIERS on Form TF0001-MBIC, Change in Monthly Premium Amount or Cost-Share Limit.
- You reached your cost-share limit for this benefit period.
- You did not reach your cost-share limit for this benefit period.
- Your family is making more money (income).
- Your family is making less money (income).
- The number of people in your family changed.
- You have health insurance through your job
- You don't have health insurance through your job.
- The Health Insurance Premium Payment program (HIPP) is paying for your private health insurance.
- The Health Insurance Premium Payment program (HIPP) isn't paying for your private health insurance.
N-8330 Denial Reasons
In addition to existing MEPD denial codes, new denial reasons have been created for this program. These reasons and references will be pre-populated by TIERS on:
- Form TF0001-MBIC, Case Action Termination;
- Form TF0001-MBIC, Case Action Denial; and
- Form TF0001-MBIC, Prior Months Eligibility.
Section N-8331 below outlines the reasons and references.
N-8331 Denial Reasons and Reference Chart
|It is too late to ask for benefits for these months.||1 TAC §361.115(g)|
|<Child's name> is married.||1 TAC §361.107|
|You didn't send proof that shows you get health insurance through your job.||1 TAC §361.113|
|You didn't send proof that shows when your job's health insurance benefits began.||1 TAC §361.113|
|You didn't send proof that shows your child can't be on your job's health insurance plan.||1 TAC §361.113|
|You didn't send proof that shows you signed up for your job's health insurance.||1 TAC §361.113|
|Your payment couldn't be processed.||1 TAC §361.115(a)|
|<Child's name> is age 19 or older.||1 TAC §361.107|
Redeterminations for MBIC follow regular Medicaid for the Elderly and People with Disabilities (MEPD) policy for redeterminations.
Streamlining methods and passive reviews are not allowed for an MBIC redetermination.
If a case has an MBIC eligibility determination group (EDG) and another ME EDG, the persons in the case will get both a Form H1200-MBIC and another Form H1200 for the redeterminations.
A TIERS MBIC redetermination packet will include:
HHSC is responsible for all appeals, including those concerning premiums and cost sharing. If premium and/or cost-sharing information is needed for an appeal, refer to the MBIC business process document.
If an individual is dissatisfied with HHSC's decision concerning his eligibility for medical assistance, he has the right to appeal through the appeal process established by HHSC. In certain circumstances, the individual is entitled to receive continued benefits or services until a hearing decision is issued. Whether an individual is entitled to continued assistance is based on requirements set forth in appropriate state or federal law or regulation of the affected program. See the Fair and Fraud Hearings Handbook.