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Section 4: 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 Newborn Eligibility 4-4
4.1.5 Foster Care 4-5
4.2 Eligibility Verification 4-5
4.2.1 Advantages of Electronic Eligibility Transactions 4-6
4.3 Medicaid Identification and Verification 4-6
4.4 Restricted Medicaid Coverage 4-8
4.4.1 Emergency Only 4-8
4.4.2 Client Limited Program 4-8
4.4.2.1 Limited Medicaid Identification 4-9
4.4.2.2 Exceptions to Limited Status 4-9
4.4.2.3 Selection of Designated Provider and Pharmacy 4-10
4.4.2.4 Duration of Limited Status 4-11
4.4.2.5 Referral to Other Providers 4-11
4.4.2.6 Hospital Services 4-11
4.4.2.7 Limited Status Claims Payment 4-12
4.4.3 Hospice Program 4-12
4.4.3.1 Hospice Medicaid Identification 4-12
4.4.3.2 Physician Oversight Services 4-12
4.4.3.3 Medicaid Services Unrelated to the Terminal Illness 4-13
4.4.4 Presumptive Eligibility (PE) 4-13
4.4.4.1 PE Medicaid Identification 4-13
4.4.4.3 Qualified Provider Enrollment 4-13
4.5 CHIP Perinatal Program 4-14
4.5.1 Program Benefits 4-15
4.5.2 Claims 4-15
4.5.3 Client Eligibility Verification 4-15
4.5.4 Submission of Birth Information to Texas Vital Statistics Unit 4-16
4.6 Medically Needy Program (MNP) 4-17
4.6.1 Spend Down Processing 4-17
4.6.2 Closing an MNP Case 4-19
4.7 Women's Health Program (WHP) 4-19
4.8 Medicaid for Breast and Cervical Cancer (MBCC) 4-20
4.9 Medicare and Medicaid Dual Eligibility 4-20
4.9.1 QMB/MQMB Identification 4-21
4.9.2 Medicare Part B Crossovers 4-21
4.9.3 Clients Without QMB/MQMB Status 4-21
4.9.4 Medicare Part C 4-21
4.10 Contract with Outside Parties 4-22
4.11 Third Party Resources (TPR) 4-22
4.11.1 Medicaid Identification (Form H3087) 4-23
4.11.2 Workers' Compensation 4-24
4.11.3 Adoption Cases 4-24
4.11.4 THSteps TPR Requirements 4-24
4.11.5 Accident Related Claims 4-24
4.11.5.1 Accident Resources, Refunds 4-25
4.11.6 Third Party Liability - Tort 4-26
4.11.6.1 Providers Filing Liens for Third Party Reimbursement 4-26
4.11.6.2 Informational Claims 4-27
4.11.6.3 Submission of Informational Claims 4-27
4.11.6.4 Informational Claim Converting to Claims for Payment 4-28
4.12 Health Insurance Premium Payment (HIPP) Program 4-28
4.13 Long-Term Care Providers 4-29
4.14 Medicaid Managed Care 4-29
4.15 State Mental Retardation Facilities (State Supported Living Centers) 4-29
4.16 Forms 4-29
4.1 Medicaid Identification Form H3087 4-30
4.2 Informational Claims Submission Form 4-47
4.3 Other Insurance Form 4-48
4.4 Authorization for Use and Release of Health Information (2 pages) 4-49
4.5 Tort Response Form 4-53
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