Tex. HHSC Medicaid Hospice Provider Manual § 3100

Revision 06-2; Effective December 12, 2006

The purpose of this subsection is to provide hospice staff with a basic understanding of Medicaid eligibility determinations for general discussions with families, nursing facility (NF) staff, hospital staff and other service providers. However, Health and Human Services Commission (HHSC) Medicaid eligibility (ME) staff are the experts in this area. Consult ME staff and keep them informed on all issues related to the eligibility of an applicant or recipient.

The Social Security Administration (SSA) through Supplemental Security Income (SSI) or HHSC determines if an individual is eligible for Medicaid. Hospice is only one program that can be paid by Medicaid. Some Medicaid recipients are not eligible for nursing facility (NF) services or for the home and community-based waiver services, because of transferred assets (that is, recipient deletes name from joint bank account, transfers home to a relative, etc.). Not all Medicaid recipients are eligible for all Medicaid services. Each individual Medicaid service has certain criteria that must be met in order to qualify.

The ME determination process for non-SSI eligible individuals begins when an application is submitted to HHSC ME. The process involves an investigation of the applicant's financial status, proof of citizenship, and ends with a decision of approval or denial. If an institutionalized applicant or one who seeks home and community-based waiver services is determined eligible, the ME staff determines the amount of income he must apply toward the cost of his care (copay). Denial of Medicaid eligibility may be appealed through a request to the HHSC ME staff.

Determining Medicaid eligibility may be a complex and lengthy process that varies with each applicant. ME staff must complete the process within 45 days, except in unusual situations. Payment does not begin until HHSC establishes a record of eligibility in its central computer.

HHSC staff use Form 1230, Notification of Eligibility - Regular Medicaid Benefits, to inform the recipient and the hospice provider of the individual's eligibility for Medicaid benefits and the initial amount of copay, if applicable. HHSC Form H4808, Notice of Change in Applied Income/Notice of Denial of Medical Assistance, is used for subsequent denials and copay adjustments. The hospice provider receives these and any other appropriate eligibility forms directly from HHSC ME staff.

When an individual is a full vendor SSI Medicaid recipient and receives Medicaid hospice services in an NF or ICF/MR-RC, the hospice provider is responsible for notifying SSA. SSA must have this information so the SSI payment to the recipient can be reduced to $30 a month, which is the federal benefit rate (FBR) for an institutionalized individual.

ME staff determine financial eligibility for medical assistance only (MAO). Eligibility determination is a complex procedure— do not attempt to advise applicants, recipients or their families. Direct any questions about a recipient's eligibility for Medicaid benefits to the ME staff at HHSC. The following information is intended to be a guide for referral of individuals to ME staff.

HHSC issues Form H3087, Medicaid Identification, to eligible Medicaid recipients each month. This card ensures that the recipient, whose name appears on it, is eligible for services for the specific dates indicated on the card. Individuals may be eligible if they meet certain income and resource requirements. Aged or disabled individuals with very low or no income should apply to SSA for SSI benefits to obtain Medicaid coverage.

Ask to see and review the hospice individual's Medicaid Identification before the Medicaid hospice election and at the first of each month thereafter to verify the individual's Medicaid eligibility.

HHSC considers payments for services the responsibility of the individual receiving the service if:

the services received are not a benefit covered by Medicaid,

the applicant is not eligible for medical services under the Medicaid program, or

the applicant has been denied eligibility before the date of service.