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

Part W — Section 900

Health Care Eligibility

W—910  General Policy

Revision 13-1; Effective January 1, 2013

A woman is continuously eligible for 12 months beginning the first day of the month all eligibility criteria are met. There is no three months prior eligibility for the Texas Women's Health Program (TWHP).

Note: This does not include three months prior only Medicaid or Medical Assistance - Medically Needy with Spend Down programs. Three months prior Medicaid eligibility is not applicable to the TWHP. An applicant can apply for and receive three months prior benefits under a Medicaid program.

The medical effective date cannot precede the:

  • effective date of the program (Jan. 1, 2007), or
  • month of the woman's 18th birthday.

This is a fee-for-service program. Fee for service allows access to any health care provider and self-referral to specialists. The provider submits claims directly to the Texas Medicaid and Healthcare Partnership (TMHP) for reimbursement of covered services.

If a household failed to report required information at the time of the application that causes the woman to be ineligible for TWHP, deny the case and send a fraud referral to the Office of Inspector General.

Eligibility determination groups (EDGs) with end dates do not require an action to close when the individual does not return Form H1867-R, Texas Women's Health Program Renewal Application, or Form H1831, Adjunctive Eligibility Letter. These EDGs will close the last day in the 12th month of the certification period.

Note: Women are eligible to receive TWHP during their Pay for Performance forfeit month(s).

Related Policy
Eligibility Begin Dates, W-1920

W—911  Current Medicaid, Medicare (Part A or B) and Children's Health Insurance Program (CHIP) Recipients

Revision 13-1; Effective January 1, 2013

A woman is not eligible to receive TWHP benefits if currently receiving Medicaid, Medicare (Part A or B) or CHIP. If an application is received for a woman who is actively receiving Medicaid, Medicare (Part A or B) or CHIP, deny the application using the following disposition denial reason:

  • English — You are ineligible to receive Texas Women's Health Program services as you are currently receiving assistance under Medicare, Medicaid or CHIP.
  • Spanish — Usted no llena los requisitos para recibir los servicios del Programa de Salud de la Mujer de Texas ya que actualmente recibe ayuda de Medicare, Medicaid o CHIP.

Staff must verify via State On-line Query (SOLQ) and CHIP inquiry that an applicant is not currently enrolled in Medicare (Part A or B) or CHIP. The Texas Integrated Redesign System (TIERS) verifies if the applicant is receiving Medicaid benefits at application, renewal and during the TWHP 12-month continuous eligibility. Staff must complete CHIP inquiry prior to certifying an 18-year-old applicant to verify she has not been enrolled in CHIP since applying for TWHP.

If applications are received for … and the … the advisors must … TIERS will … Note:
both TWHP and Medicaid before either are processed, TWHP application is certified first, continue working on the Medicaid application. If the Medicaid EDG is certified, automatically deny the TWHP EDG. If eligible, the medical effective date (MED) for the Medicaid application will follow current MED policy. If the applicant is not certified for Medicaid, she will continue to receive ongoing TWHP benefits.
Medicaid application is certified first, deny the TWHP application. Use the appropriate denial code and provide the individual with a TF001W, Notice of Case Action. issue an error if the worker attempts to certify a TWHP EDG and the individual is actively receiving Medicaid benefits. -

Note: This does not include three months prior only Medicaid or Medical Assistance - Medically Needy with Spend Down programs. Three months prior Medicaid eligibility is not applicable to the TWHP. An applicant can apply for and receive three months prior benefits under Medicaid. The three months prior check boxes will be disabled when Health Care-TWHP is selected.

Related Policy
Eligibility Begin Dates, W-1920

W—912  Sterile Women

Revision 13-1; Effective January 1, 2013

Women who are sterile are ineligible to receive TWHP benefits. If the question, "Are you sterile, infertile or unable to get pregnant due to medical reasons?" is marked Yes, deny the application using the following denial reason and add the statement below to the comment section of Form TF001W, Notice of Case Action.

  • English — On your application, you told us you are unable to get pregnant due to medical reasons. Women who are unable to get pregnant due to medical reasons cannot receive Texas Women's Health Program benefits.
  • Spanish — En la solicitud usted nos dijo que no puede quedar embarazada por razones médicas. Las mujeres que no pueden quedar embarazadas por razones médicas no pueden recibir beneficios del Programa de Salud de la Mujer de Texas.

A sterile woman is a woman of childbearing age (18 - 44 years old) who has had sterilization surgery, is infertile or has another condition that results in infertility.

If the question is not answered, pend the Eligibility Determination Group. Allow the applicant normal processing time frames to provide an answer. Advisors must manually pend for verification. Verification is self-declared. Deny the application for failure to provide verification if the applicant/individual does not provide verification.

If during the individual's 12-months continuous coverage period she reports having sterilization surgery, record the change and take action on the information at the next renewal.

W—913  Pregnant Women

Revision 13-1; Effective January 1, 2013

Women who are pregnant are ineligible to receive TWHP benefits. If the question, "Are you pregnant?" is marked Yes on Form H1867, Texas Women's Health Program Application, Form H1867-S (Spanish), Form H1867-R, Texas Women's Health Program Renewal Application, or Form H1831, Adjunctive Eligibility Letter, deny the application/renewal using the following denial reason code and add the statement below to the comment section of Form TF001W, Notice of Case Action.

  • English — On your application, you told us you are pregnant. Women who are pregnant cannot receive Texas Women's Health Program benefits. To find out if you can receive Medicaid for pregnant women, please complete, sign and return the attached application.
  • Spanish — En la solicitud, usted nos dijo que está embarazada. Las mujeres embarazadas no pueden recibir beneficios del Programa de Salud de la Mujer de Texas. Para saber si puede recibir Medicaid para mujeres embarazadas, por favor, llene, firme y envíe la solicitud adjunta.

Include the Form H1010, Texas Works Application for Assistance - Your Texas Benefits, along with Form TF001W, Notice of Case Action, and a self-addressed stamped envelope addressed to the Document Processing Center when denying an application due to pregnancy.

If the question is not answered, pend the Eligibility Determination Group. Allow the applicant normal processing time frames to provide an answer. Advisors must manually pend for verification. Verification is self-declared. Deny the application for failure to provide verification if the applicant/recipient does not provide verification.

Do not deny the recipient if a report of pregnancy is received during the 12-months continuous coverage. Record the change and take action on the information at the next renewal.

Note: For TWHP recipients who apply for Medical Assistance for Pregnant Women, TIERS will deny the Eligibility Determination Group once the recipient is certified to receive benefits for her pregnancy.

W—914  Third-Party Resource (TPR)

Revision 13-1; Effective January 1, 2013

A woman is ineligible to receive TWHP benefits if she has creditable health coverage (TPR). The applicant/recipient has creditable health coverage if her private health insurance covers family planning services.

An applicant/recipient's private health insurance is considered to cover family planning services if it provides both:

  • family planning-related physician office visits and procedures, and
  • contraceptive drugs and devices.

In making this determination, only consider whether the private health insurance provides coverage and not give consideration to other issues such as high deductibles or dollar limits on drug coverage.

Form H1867, Texas Women's Health Program Application, Form H1867-S (Spanish) and Form H1867-R, Texas Women's Health Program Renewal Application, ask the applicant the following questions:

  1. Do you have health insurance that covers family planning services? Yes No
  2. If yes, will filing a claim on your health insurance cause physical, emotional or other harm to you from your spouse, parents or other person? Yes No
  3. If yes, you must provide an explanation below of your situation.

A TWHP applicant with creditable health coverage is eligible to receive benefits only if identifying and providing information to assist in pursuing third parties is against her best interest.

Staff must pend the applicant if she does not answer questions 1 and/or 2. Allow the applicant normal processing time frames to provide an answer. Verification is self-declared by the applicant. If the applicant does not self-declare the answer to question 1 and/or 2 by the deadline, deny the application for failure to provide.

If the applicant states Yes to question 1 and question 2 but leaves question 3 blank, do not pend the applicant for an answer; continue determining eligibility.

If the applicant states Yes to question 1 and No to question 2, deny the application using the following denial reason code and add the statement below to the comment section of Form TF001W, Notice of Case Action.

  • English — On your application you told us you are covered by other health insurance. Women who are covered by other health insurance cannot receive Texas Women's Health Program benefits.
  • Spanish — En la solicitud, usted nos dijo que tiene cobertura de otro seguro médico. Las mujeres con cobertura de otro seguro médico no pueden recibir beneficios del Programa de Salud de la Mujer de Texas.

If during the recipient's 12-months continuous coverage she reports having creditable health insurance, record the change and take action on the TPR information at the next renewal.

W—920  Verification Requirements

Revision 07-0; Effective July 1, 2007

Accept self-declaration of pregnancy, sterility and TPR.

W—930  Documentation Requirements

Revision 07-0; Effective July 1, 2007

For TPR, staff must document in case comments:

  • the availability of TPR for family planning services;
  • if filing a claim would cause physical, emotional or other harm to the individual; and
  • why, if provided.