Tex. HHSC Medicaid Hospice Provider Manual § 3200

Revision 06-2; Effective December 12, 2006

Applicants for medical assistance may be eligible for Medicaid coverage as early as the first day of the third month before the month of application for assistance. Eligibility depends on the applicant's unpaid or reimbursable bills for Medicaid-covered medical services provided during the three-month period. The applicant also must meet all other eligibility criteria during that period. A bona fide agent may apply for coverage on behalf of a deceased individual. Applications for prior coverage must be filed with HHSC.

For certified SSI applicants, Medicaid coverage is automatically added for the month before the first SSI payment. Medicaid coverage also is available for the two preceding months, if all eligibility requirements were met and the applicant had unpaid, reimbursable medical bills. An application must be filed with HHSC for prior-month eligibility determination.

For denied SSI applicants with unpaid, reimbursable medical bills, the retroactive period is the three months before the SSI application month. An application must be filed with HHSC for prior-month eligibility determination.

HHSC encourages providers to maintain open communication with individuals, NF staff and family members so the hospice provider will be immediately aware if and when an individual may be eligible for Medicaid. When an individual applies for Medicaid, Medicaid eligibility may be established both prospectively, and for the three months prior to the application, if the individual met all Medicaid eligibility criteria during the prior three months. If an individual becomes eligible for Medicaid for the three months prior to application, the NF is required to refund any payments received for NF care to the individual. The NF bills HHSC for those three months and will be paid the NF rate for those three months. Once ME has been established, the individual can elect Medicaid hospice. If the individual is dually eligible, they must elect both the Medicaid and Medicare hospice programs. For more information regarding dual eligibility, see Item 3640, Dually Eligible Recipients. For the prospective period of Medicaid eligibility, the room and board payment for the NF must pass through the hospice, since the individual has elected out of the Medicaid NF program. This does not negate the provider's responsibility when an individual is dually eligible. For information regarding room and board, see Item 4540, Room and Board. For information regarding per diem rates, see Item 6310, Hospice-Nursing Facility Per Diem Rate.