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Client Eligibility
4.1 General Medicaid Eligibility 4-3
4.1.1 Retroactive Eligibility 4-3
4.1.2 Expedited Eligibility (Applies to Medicaid-eligible Pregnant Women
Throughout the State) 4-4
4.1.3 Medicaid Buy-In Program for Employed Individuals with Disabilities 4-4
4.1.4 Foster Care 4-4
4.1.5 Eligibility Verification 4-4
4.2 Medicaid Identification and Verification 4-4
4.3 Restricted Medicaid Coverage 4-5
4.3.1 Emergency Only 4-5
4.3.2 Client Limited Program 4-6
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 and 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 Hospital Services 4-7
4.3.2.7 Limited Status Claims Payment 4-8
4.3.3 Hospice Program 4-8
4.3.3.1 Hospice Medicaid Identification 4-8
4.3.3.2 Physician Oversight Services 4-8
4.3.4 Presumptive Eligibility (PE) 4-8
4.3.4.1 PE Medicaid Identification 4-8
4.3.4.3 Qualified Provider Enrollment 4-9
4.4 CHIP Perinatal Program 4-9
4.4.1 Program Benefits 4-9
4.4.2 Claims 4-10
4.4.3 Client Eligibility Verification 4-10
4.4.4 Submission of Birth Information to Texas Vital Statistics Unit 4-11
4.5 Medically Needy Program (MNP) 4-11
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) 4-13
4.7 Medicaid for Breast and Cervical Cancer (MBCC) 4-13
4.8 Medicare and Medicaid Dual Eligibility 4-14
4.8.1 QMB/MQMB Identification 4-14
4.8.2 Medicare Part B Crossovers 4-14
4.8.3 Clients Without QMB/MQMB Status 4-14
4.8.4 Medicare Part C 4-14
4.9 Contract with Outside Parties 4-14
4.10 Third-Party Resources (TPR) 4-15
4.10.1 Medicaid Identification (Form H3087) 4-15
4.10.2 Workers' Compensation 4-16
4.10.3 Adoption Cases 4-16
4.10.4 THSteps TPR Requirements 4-16
4.10.5 Third-Party Insurance 4-16
4.10.6 Accident-Related Claims 4-16
4.10.6.1 Accident Resources, Refunds 4-16
4.10.7 Third-Party Liability - Tort 4-17
4.10.7.1 Providers Filing Liens for Third Party Reimbursement 4-17
4.10.7.2 Submission of Informational Claims 4-18
4.10.7.3 Informational Claim Converting to Claims for Payment 4-18
4.11 Health Insurance Premium Payment (HIPP) Program 4-18
4.12 Long-Term Care Providers 4-19
4.13 Medicaid Managed Care 4-19
4.14 State Mental Retardation Facilities (State Schools) 4-19
4.15 Medicaid Identification Form H3087 4-19
4.15.1 Medicaid Eligibility Verification (Form H1027-A) 4-31
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