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Client Eligibility
4.1 General Medicaid Eligibility 4-3
4.1.1 Eligibility Verification 4-4
4.2 Medicaid Identification, Verification 4-4
4.3 Restricted Medicaid Coverage 4-5
4.3.1 Emergency Only 4-5
4.3.2 Client Limited Program 4-5
4.3.2.1 Limited Medicaid Identification 4-6
4.3.2.2 Exceptions to Limited Status 4-6
4.3.2.3 Selection of Designated Provider, Pharmacy 4-7
4.3.2.4 Duration of Limited Status 4-7
4.3.2.5 Referral to Other Providers 4-7
4.3.2.6 Emergency Care 4-7
4.3.2.7 Hospital Services 4-7
4.3.3 QMB, MQMB 4-8
4.3.4 Hospice Program 4-8
4.3.4.1 Medical Services Not Related to the Terminal Illness 4-8
4.3.4.2 Medical Services when Client is Discharged from Hospice 4-9
4.3.4.3 Lab and X-Ray 4-9
4.3.4.4 Physician Oversight Services 4-9
4.3.5 Presumptive Eligibility (PE) 4-9
4.3.5.2 Qualified Provider Enrollment 4-9
4.3.5.4 Medicaid Identification (Form H3087) 4-10
4.4 CHIP Perinatal Program 4-10
4.4.1 Program Benefits 4-10
4.4.2 Claims 4-10
4.4.3 Client Eligibility Verification 4-10
4.5 Medically Needy Program (MNP) 4-10
4.5.1 Spend Down Processing 4-11
4.5.2 Closing an MNP Case 4-12
4.5.3 Medically Needy Program for CSHCN Services Program Clients 4-12
4.6 Women's Health Program (WHP) 4-12
4.7 Breast and Cervical Cancer Program 4-13
4.8 Medicare/Medicaid Clients 4-13
4.8.1 QMB/MQMB Clients 4-13
4.8.2 Medicare Part B Crossovers 4-13
4.8.3 Clients Without QMB/MQMB Status 4-14
4.9 Contract with Outside Parties 4-14
4.10 Third Party Resources (TPR) 4-14
4.10.1 Workers' Compensation 4-14
4.10.2 Adoption Cases 4-15
4.10.3 Medicaid Identification (Form H3087) 4-15
4.10.4 THSteps Requirements 4-15
4.10.5 Other Insurance Reimbursement 4-15
4.10.6 Refunds to TMHP Resulting from Other Insurance Payments and Conditions Surrounding Provider Billing of Third Party Insurers 4-15
4.10.7 Accident-Related Claims 4-16
4.10.8 Accident Resources, Refunds 4-16
4.10.8.1 Providers Filing Liens for Third Party Reimbursement 4-17
4.10.8.2 Submission of Informational Claims 4-17
4.10.8.3 Informational Claim Conversion to Claim for Payment 4-17
4.10.9 Long Term Care Providers 4-18
4.11 NorthSTAR (Behavioral Health Program in Dallas Service Area Only) 4-18
4.12 Medicaid Identification Form H3087 4-19
4.12.1 Medicaid Eligibility Verification (Form H1027-A) 4-26
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