4.1 General Medicaid EligibilityProviders are responsible for requesting and verifying current Medicaid eligibility information about the client by asking the client to produce the Medicaid Identification form issued for the month that services are being rendered. Clients should share eligibility information with providers. If clients have lost their identification or forgotten to bring it to appointments, providers may verify their eligibility through the Automated Inquiry System (AIS), TMHP Electronic Data Interchange (EDI) Gateway, or by accessing the TMHP website and treat the clients the same as though they had presented a Medicaid Identification (Form H3087) or Medicaid Verification Letter (H1027). Medicaid clients in Cameron, Hidalgo, and Travis counties are now issued a Medicaid Access Card-a plastic smart card that automates client check-in and eligibility verification. In these counties, clients use their Medicaid Access Card in place of the Medicaid Identification Form (Form H3087) to identify themselves as eligible for Medicaid. If a Medicaid client with one of these cards sees a provider for service in an area that is not using the new process, providers can still verify the client's Medicaid eligibility either by using existing processes or by calling the TMHP Contact Center at 1-800-925-9126. A person may be eligible for medical assistance through Medicaid if the following conditions are met:
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• Most children in the state of Texas foster care program are automatically eligible for Medicaid. To ensure that these children have access to the necessary health-care services for which they are eligible, providers can accept the Medicaid Eligibility Verification Form H1027 as evidence of Medicaid eligibility. Although this form may not have a Medicaid number, it is an official state document that establishes Medicaid eligibility. Providers should honor Form H1027 as proof of Medicaid eligibility and must bill the Texas Medicaid Program as soon as a Medicaid ID number is assigned. Medicaid ID numbers will be assigned approximately one month from the initial presentation of the Medicaid Eligibility Verification Form H1027. The form includes a Department of Family and Protective Services (DFPS) client number that provides additional means of identification and tracking for children in foster care. Refer to: "Medicaid Identification, Verification" . Retroactive Eligibility Medicaid coverage may be assigned retroactively for a client. For claims for an individual who has been approved for Medicaid coverage but has not been assigned a Medicaid client number, the 95-day filing deadline does not begin until the date the notification of eligibility is received from HHSC and added to the TMHP eligibility file. The date the client's eligibility is added to the TMHP eligibility file is the add date. To ensure the 95-day filing deadline is met, providers must verify eligibility and add date information by calling AIS or using TMHP EDI's electronic eligibility verification. Reminder: The add date is the date the client's eligibility was added to the TMHP eligibility file. When authorization is required for a Medicaid service, authorization requests for clients with retroactive eligibility must be submitted after the client's eligibility has been added to TMHP's eligibility file. For accurate claims processing, an authorization request must be submitted to TMHP before a claim submission. Providers have 95 days from the add date to obtain authorization for services that have already been performed. PCCM providers must obtain prior authorization requests within 95 days of the add date and before claims submission. If a person is not eligible for medical services under the Texas Medicaid Program on the date of service, reimbursement for all care and services provided must be resolved between the provider and the client receiving the services. Providers are not required to accept Medicaid for services provided during the retroactive eligibility period and may continue to bill the client for those services. This guideline does not apply to nursing facilities certified by the Department of Aging and Disability Services (DADS). If it is the provider's practice not to accept Medicaid for services during the retroactive eligibility period, the provider must use the policy consistently for all clients who request retroactive eligibility. Providers must inform the client about the policy before rendering services. If providers accept Medicaid assignment for the services and want to submit a claim for Medicaid-covered services for clients who receive retroactive eligibility, providers must refund payments received from the client before billing Medicaid for the services. Note: The Medicaid Managed Care programs do not generally have retroactive eligibility. Clients who are not eligible for Medicaid but meet certain income guidelines may receive family planning services through other family planning funding sources. Clients not eligible for Medicaid are referred to a family planning provider. Refer to: Department of State Health Services (DSHS) website, www.dshs.state.tx.us/famplan/, for information about family planning and the locations of family planning clinics receiving Title V, X, or XX funding from DSHS. The provider should also check the date on the Form H3087 under Medicaid Date to see if the client has retroactive coverage for previous bills. Clients with retroactive coverage are only issued one Medicaid Identification showing the retroactive period. The Texas Medicaid Program considers all services between the Medicaid Date and the Valid Through Date for reimbursement. Providers can determine whether a client has retroactive coverage for previous bills by verifying eligibility on www.tmhp.com, transmitting an electronic eligibility request, or calling AIS or the TMHP Contact Center. Refer to: "Medicaid Identification Form H3087" . Expedited Eligibility (Applies to Medicaid-eligible Pregnant Women Throughout the State) HHSC processes Medicaid applications for pregnant women within 15 business days of receipt. Once certified, a Medicaid Identification (Form H3087) will be issued to verify eligibility and to facilitate provider reimbursement. Medicaid Buy-In Program for Employed Individuals with Disabilities The Medicaid Buy-In (MBI) Program allows employed individuals with disabilities to receive Medicaid services by paying a monthly premium. Some MBI participants, based on income requirements, may be determined to have a $0 premium amount and therefore are not required to make a premium payment. Individuals with earnings of up to 250 percent of the federal poverty level (FPL) may be eligible to participate in the program. Applications for the program are accepted through HHSC's regular Medicaid application process. Participants will have a Medicaid identification card that indicates the Medicaid services for which they are eligible. MBI participants in urban service areas will be served through traditional Medicaid (fee-for-service) and MBI participants in Primary Care Case Management (PCCM) counties will be served through PCCM. |
The applicant must be eligible for medical assistance at the time the service is provided. It is not mandatory that the process of determining eligibility be completed at the time service is provided; the client can receive retroactive eligibility. Services or supplies cannot be paid under the Texas Medicaid Program if they are provided to a client before the effective date of eligibility for Medicaid or after the effective date of denial of eligibility. Having an application in process for Medicaid eligibility does not guarantee the applicant will be eligible.
