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December 2016 Texas Medicaid Provider Procedures Manual

Section 4: Client Eligibility

Section 4: Client Eligibility
Table of Contents
4.1 General Medicaid Eligibility 4
4.1.1 Your Texas Benefits Medicaid Card 4
4.1.2 Retroactive Eligibility 5
4.1.3 Expedited Eligibility (Applies to Medicaid-eligible Pregnant Women Throughout the State) 5
4.1.4 Medicaid Buy-In Program for Employed Individuals with Disabilities 5
4.1.5 Newborn Eligibility 6
4.1.6 Potential Supplemental Security Income (SSI)/Medicaid Eligibility for Premature Infants 6
4.1.7 Foster Care 7
4.1.8 Former Foster Care 7
4.1.9 Medicaid Managed Care Eligibility 7
4.2 Eligibility Verification 7
4.2.1 Advantages of Electronic Eligibility Transactions 8
4.2.2 Contract with Outside Parties 8
4.3 * Medicaid Identification and Verification 9
4.4 Restricted Medicaid Coverage 10
4.4.1 Emergency Only 10
4.4.2 Client Lock-in Program 10
4.4.2.1 Lock-in Medicaid Identification 11
4.4.2.2 Exceptions to Lock-in Status 11
4.4.2.3 Selection of Designated Provider and Pharmacy 12
4.4.2.4 Pharmacy services 13
4.4.2.5 Duration of Lock-in Status 13
4.4.2.6 Referral to Other Providers 14
4.4.2.7 Hospital Services 14
4.4.2.8 Lock-in Status Claims Payment 14
4.4.3 Hospice Program 14
4.4.3.1 Hospice Medicaid Identification 15
4.4.3.2 Physician Oversight Services 15
4.4.3.3 Medicaid Services Unrelated to the Terminal Illness 15
4.4.4 Presumptive Eligibility 16
4.4.4.1 PE Medicaid Identification 16
4.4.4.2 Services 16
4.4.4.3 Qualified Provider Enrollment 16
4.4.4.4 Process 17
4.5 CHIP Perinatal Program 17
4.5.1 Program Benefits 17
4.5.2 Claims 18
4.5.3 Client Eligibility Verification 18
4.5.3.1 Confirming Receipt of Form H3038 or H3038P 19
4.5.3.2 Eligibility Verification for Clients Without a Medicaid ID 19
4.5.3.3 Mother’s eligibility 20
4.5.3.4 Newborn’s eligibility 20
4.5.4 Submission of Birth Information to Texas Vital Statistics Unit 20
4.6 Medically Needy Program (MNP) 20
4.6.1 Spend Down Processing 21
4.6.2 Closing an MNP Case 22
4.7 Medicaid Buy-in for Children (MBIC) Program 23
4.8 Texas Medicaid Wellness Program 23
4.9 Healthy Texas Women (HTW) Program 24
4.10 Medicaid for Breast and Cervical Cancer (MBCC) 24
4.10.1 Initial MBCC Program Enrollment 24
4.10.2 MBCC Program Eligibility 25
4.10.3 Continued MBCC Program Eligibility 25
4.11 Medicare and Medicaid Dual Eligibility 26
4.11.1 QMB/MQMB Identification 27
4.11.2 Medicare Part B Crossovers 27
4.11.3 Clients Without QMB or MQMB Status 27
4.11.4 Medicare Part C 27
4.12 Health Insurance Premium Payment (HIPP) Program 28
4.13 Long-Term Care Providers 28
4.14 State Supported Living Centers 28
4.15 Forms 29
 

Texas Medicaid & Healthcare Partnership
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