Revision 11-1; Effective March 1, 2011  

The Social Security Administration (SSA) determines Medicaid eligibility for all persons who apply for SSI cash benefits. When SSA makes a determination on an application for SSI cash benefits (either approved or denied), HHSC is notified by means of the SSA/State Data Exchange System (SDX).

SSA is responsible for redetermination of SSI Medicaid eligibility. See section H-6000, Co-Payment for SSI Cases, for other special handling of SSI eligible individuals.

B-7110 Medicaid Coverage After SSI Termination  

Revision 25-3; Effective Sept. 1, 2025

Medicaid recipients who stop meeting the eligibility requirements for Supplemental Security Income (SSI) benefits may still be eligible for Medicaid under another eligibility group. Explore eligibility for all other medical programs before ending SSI Medicaid.

Modified Administrative Renewal Process

The system initiates a modified administrative redetermination process before ending Medicaid when notified of an SSI denial. The modified redetermination process uses information from the existing case record and electronic data sources (ELDS) to determine if the person is eligible for any other type of Medicaid benefits. The SSI Medicaid Eligibility Determination Group (EDG) is maintained during the redetermination process.

The Texas Integrated Eligibility Redesign System (TIERS) requests ELDS information on the eighth of the month after the loss of SSI eligibility. The system runs eligibility to test for all non-SSI Medicaid programs, including the Medicare Savings Programs (MSPs) on the third of the next month.

The case is auto-disposed, and TIERS generates a TF0001, Notice of Case Action, if enough information is available to verify all eligibility criteria for another type of Medicaid. The person does not need to submit other information, and no staff action is required.

An eligibility packet is automatically generated and must be completed and returned within 30 days if:

• the system is unable to determine ongoing eligibility based on existing information and available ELDS information; or
• the person is only eligible for a lesser Medicaid or MSP.

Note: Eligibility for Medicaid and MSP is determined separately. For example, if eligibility for ME-Waivers is approved but eligibility for MC-QMB is pending, the approved ME-Waivers EDG is disposed. An eligibility packet is generated for the MC-QMB EDG.

If the person might be eligible for an MEPD or MSP program, the packet includes the following forms:

• Form H1233P, Redetermination Notice, populated with the maintained EDG number or numbers
• Form H1200, Application for Assistance – Your Texas Benefits
• Notice H1296, Notice of SSI Medicaid Ending
• Form H1020, Request for Information or Action, if TIERS cascaded to a pending EDG

If the person might be eligible for a Texas Works (TW) Medicaid program or the Children's Health Insurance Program (CHIP), the packet includes the following forms:

• Form H1830P, TW Renewal Packet, populated with the maintained EDG number or numbers
• Form H1010R, Your Texas Works Benefits - Renewal Form
• Notice H1296, Notice of SSI Medicaid Ending
• Form H1020, Request for Information or Action, if TIERS cascaded to a pending EDG

If the person returns an eligibility form before the 31st day, process the case and explore eligibility for all Medicaid programs, including MSP. Maintain SSI and any SSI-associated QMB coverage until processing is complete.

If the person does not return the eligibility form on or before the 30th day, the maintained SSI EDG and any SSI-associated QMB EDGs are automatically terminated, and a Form TF0001 is generated.

Adults Receiving Waiver Services

If the person was receiving waiver services before the loss of SSI eligibility, a new Form H1746-A, MEPD Referral Cover Sheet, is not needed to explore ongoing waiver eligibility. If it is indicated that the person was receiving waiver services, verify ongoing enrollment. Use the chart below to send an email to the appropriate mailbox based on the type of waiver program in the Long-Term Services and Support (LTSS) Summary screen.

The subject line of the email must be: SSI Termination: Client Initials -XXX where XXX is the last 3 digits of the person’s Medicaid ID number. Example: SSI Termination: JG-123

Include the following information in the body of the email:

        • Full name of recipient

        • Full Medicaid ID number

        • Full Social Security number

        • The following statement: This person’s SSI benefits have been terminated. Case history indicates this person was previously receiving [insert name of Waiver program] services. Please confirm current Waiver enrollment status.

Suspend the case pending a response. Document the program response in case comments and take appropriate action to complete the case when a response is received.

Children Receiving Waiver Services

Determine ongoing eligibility for ME-Waiver Medicaid if a Form H1200 is received by the 30th day. If eligible, ME-Waiver Medicaid remains active through the end of the month the child turns 18.

• Applications submitted by the child, or their parent or authorized representative do not need an associated Form H1746-A.
• Applications submitted by program providers, including managed care organizations (MCOs), local intellectual and developmental disability authorities (LIDDAs) and local authorities (LAs), on behalf of a child must include an associated Form H1746-A.

If SSA reinstates SSI benefits while the child is active under ME-Waiver Medicaid, SSI Medicaid is suppressed, and ME-Waiver Medicaid remains active. This avoids future gaps in coverage.

If SSI benefits are active when the child turns 18, ME-Waiver Medicaid ends. The system automatically reinstates SSI Medicaid.

If SSI benefits are not active when the child turns 18, ME-Waiver Medicaid remains active and follows the regular renewal process.

Related Policy

Supplemental Security Income (SSI), A-2100
Disabled Adult Children (DAC), A-2310
Pickle, A-2330
Widow(er)s, A-2340
SSI Applications, B-7100
SSI Cash Benefits Denied Due to Entry into a Medicaid Facility, B-7200
When Deeming Procedures Are Not Used, E-7200

B-7120 Pregnancy and 12-Month Postpartum Coverage After SSI Denial

Revision 24-4; Effective Dec. 1, 2024

Pregnant and postpartum women will automatically transition to Medicaid for Pregnant Women (TP 40) for the remainder of their pregnancy and the 12-month postpartum period if:

• they received Supplemental Security Income (SSI) Medicaid while pregnant; and
• lose ongoing eligibility for SSI.

A new TP 40 EDG is created without an application for pregnancy Medicaid. A full redetermination of eligibility must occur at the end of the TP 40 certification period.

Continuous Medicaid and CHIP coverage is provided through the pregnancy and the 12-month postpartum period regardless of any change in circumstance unless the woman:

• voluntarily withdraws;
• moves out of state;
• dies; or
• is ineligible due to agency error, fraud, abuse or perjury attributed to the person.

Unverified Pregnancy

When a recipient loses SSI eligibility, and pregnancy information is received through an interface, the woman is automatically certified for TP 40 with postponed verification. Form H1020, Request for Information or Action is sent. If verification is provided, the woman is eligible for TP 40 coverage through her pregnancy and postpartum period. If verification is not provided, or shows the woman does not meet eligibility requirements, TP 40 coverage is terminated unless the woman is under 19.

Related Policy

Supplemental Security Income (SSI), A-2100
Disabled Adult Children (DAC), A-2310
Pickle, A-2330
Widow(er)s, A-2340
SSI Applications, B-7100
Extending Postpartum Coverage After MEPD Termination, B-9400
When Deeming Procedures Are Not Used, E-7200

Revision 25-3; Effective Sept. 1, 2025

When a Supplemental Security Income (SSI) recipient enters a Medicaid facility, the Social Security Administration (SSA) ends the SSI cash benefit if their income is more than the reduced federal benefit rate (FBR).

The State Data Exchange (SDX) system tells HHSC when SSI cash benefits end because of income more than the reduced SSI federal benefit rate. When HHSC receives the SDX denial, the system maintains the SSI Medicaid coverage, and any SSI-associated QMB coverage. It then initiates the SSI modified administrative redetermination process.

There is no option to overlap coverage in the system. Certification for MEPD benefits cannot occur until the system ends the SSI EDG.

Determine financial eligibility for MEPD using the special income limit beginning with the first month after SSI denial if the person returns a Form H1200, Application for Assistance – Your Texas Benefits. Verify and document that the recipient has an approved medical necessity or level of care (LOC) and meets all other eligibility requirements. If the recipient was denied medical necessity or level of care but remains in the Medicaid facility, or if the recipient does not remain in a Medicaid facility for 30 consecutive days, explore eligibility for Medicaid under another program and refer the recipient back to SSA for reinstatement of full SSI benefits.

Notes:

• A Medicaid facility can be a nursing facility (NF), Medicare skilled nursing facility (SNF) or an intermediate care facility for individuals with an intellectual disability or related condition (ICF/IID).
• When a recipient is eligible for institutional Medicaid coverage, the medical effective date (MED) of the MEPD program is the day after the last day of SSI Medicaid coverage.
• Refer to Chapter H, Co-Payment, for exceptions to the reduced SSI payment standard.

Related Policy

Medicaid Coverage After SSI Termination, B-7110

Revision 25-4; Effective Dec. 1, 2025

People who applied for SSI, but had their SSI application delayed more than 90 days, may be certified under the appropriate MEPD program pending the SSI eligibility decision.

The person must meet all applicable non-financial and financial MEPD criteria to be eligible including:

• disability; and
• institutionalization for 30 consecutive days.

Consider the age of the person when deciding if a disability determination is necessary.

The state office Disability Determination Unit (DDU) needs a disability determination if the person is younger than 65. DDU cannot make a disability determination decision unless 90 days have passed since the SSI date of application, and SSA's disability decision is still pending. If SSA finds the person is not disabled after DDU has established a disability, DDU must follow SSA’s decision. The staff must deny eligibility. Set a special review for the fifth month to monitor the final SSA decision on disability.

When a MEPD recipient becomes eligible for SSI, SSA reports the SSI eligibility to HHSC by the State Data Exchange (SDX). Upon receipt of the SDX information, the eligibility determination system automatically denies the MEPD benefit and activates the SSI coverage. This is not an adverse action because the person does not lose benefits.

The above policy only applies to situations where the processing of an SSI application was delayed. Verify and document that an SSI application was filed.

Note: If the person is 65 or older, a disability determination is not necessary. Verify that the person has filed an application for SSI.

Related Policy

SSI Applications, B-7100
Special Reviews, B-8430
Supplemental Security Income (SSI) Applicants and Retroactive Coverage, D-2500

Revision 12-3; Effective September 1, 2012

HHSC is responsible for processing Medicaid applications for certain residents of Medicaid facilities (Medicare SNF, NF, ICF/IID and institutions for mental diseases (IMD)). To qualify for medical assistance for institutional care, a person must:

• meet the 30-consecutive-day stay requirement (for verification and documentation requirements, see Appendix XVI, Documentation and Verification Guide);
• meet financial criteria; and
• have an approved level of care or medical necessity determination.

Reference: Section B-6300, Institutional Living Arrangement.

HHSC processes:

• initial applications from persons whose income is equal to or in excess of the reduced SSI federal benefit rate; and
• reapplications for Medicaid from persons who will be or have been denied SSI on the basis of excess income because the SSI federal benefit rate has been reduced after entry into a Medicaid facility.

B-7410 Persons Under Age 22

Revision 09-4; Effective December 1, 2009

State law (Chapter 242, Health and Safety Code) requires that community resource coordination groups (CRCG) be notified when a recipient under age 22 with a developmental disability enters an institutional setting. HHSC must notify the CRCG in the county of residence of the recipient's parent or guardian within three days of the recipient's admission.

The name and telephone number of the appropriate CRCG can be obtained by calling the CRCG state office at 1-866-772-2724. A CRCG list is available on the Internet at: /services/service-coordination/community-resources-...

Documentation of the notification to the CRCG should be filed in the case record.

B-7420 Level of Care/Medical Necessity

Revision 20-4; Effective December 1, 2020

To be eligible for Medicaid in an institutional setting, a person must have an approved level of care (LOC) for an intermediate care facility for persons with intellectual disabilities (ICF/IID) or an approved medical necessity (MN) with a nursing facility LOC. Texas Medicaid & Healthcare Partnership (TMHP), the state Medicaid claims administrator, is responsible for determining MN for recipients in Medicaid certified facilities.

Do not approve a person for medical assistance for institutional care unless the person has been in a Medicaid facility for at least 30 days and has an approved LOC or MN determination.

For applicants residing in a Medicare skilled nursing facility, the Medicare determination of need for care is acceptable as verification of a valid MN determination. Form 3071, Recipient Election/Cancellation/Discharge Notice (PDF), substitutes for the MN determination when hospice is elected as referenced in A-5200, Hospice in a Long-Term Care Facility.

Use the previous LOC or MN determination if:

• a person is being reinstated for assistance (a case that was denied in error or a request for a program transfer from SSI to MEPD institutional care); and
• vendor payments were made to the Medicaid facility up to the date of denial based on the previous LOC or MN determination.

Program Support Unit (PSU) staff are responsible for providing verification of an approved LOC or MN determination for a person applying for a Home and Community Based Services (HCBS) waiver program.

An approved MN determination for HCBS waiver eligibility is valid to complete a program transfer from an HCBS waiver Medicaid program to the appropriate institutional care program.

A permanent MN determination remains valid at reapplication if a denied Medicaid recipient is discharged from a Medicaid facility for not more than 30 days.

If the LOC or MN determination is still pending prior to certification and the person meets all other eligibility criteria, place the application on delay pending the approved LOC or MN. If verification of the LOC or MN is not received before the end of the delay period, deny the application for no LOC or MN. If the LOC or MN determination is denied, deny the application.

Reopen the application if verification of an approved LOC or MN is received within 90 days of the date of denial following policy in B-5000, Previously Completed Application.

Related Policy

Previously Completed Application, B-5000
Establish Processing Deadlines, R-3100
Documentation and Verification Guide, Appendix XVI

B-7430 Reserved for Future Use

Revision 20-4; Effective December 1, 2020

B-7431 Denial of Level of Care/Medical Necessity Determination

Revision 13-4; Effective December 1, 2013

If a level of care/medical necessity determination is denied for an MEPD recipient, initiate denial procedures immediately.

A recipient may continue to be Medicaid-eligible as long as the recipient meets all eligibility criteria and:

• has a diagnosis of mental illness, intellectual disabilities or a related condition;
• no longer meets the medical necessity criteria; and
• has lived in a nursing facility for 30 months before the date medical necessity is denied and chooses to remain in the facility.

If the recipient has not been in the facility for 30 months, regular Medicaid denial procedures apply.

If an MEPD recipient in a private Medicaid facility is denied solely because of no level of care/medical necessity determination, refer the person to SSA if available income is less than the SSI full federal benefit rate. Refer SSI recipients who are denied a level of care/medical necessity determination to SSA for rebudgeting to the full federal benefit rate.

B-7440 Alternate Care Services

Revision 21-3; Effective September 1, 2021

Information about all available long-term services and supports must be provided to long term care recipients, their authorized representatives (ARs) and at least one family member of the recipient, if possible. This allows them to make an informed decision about service options.

Form H1204, Long Term Care Options (PDF), provides information on available long-term services and supports. It is included with the TF0001, Notice of Case Action, for all MEPD certifications, except for recipients residing in state supported living centers, state hospitals and state centers.

If an applicant, recipient, AR or family member(s) has questions about available long-term care services, refer them to 2-1-1 for current information.

Form H1746-A, MEPD Referral Cover Sheet (PDF), includes an "LTSS Information Shared" checkbox. Referring agencies will select the box to indicate that Form H1204 has been shared with the person.

B-7450 Medicaid Certified Person Enters Nursing Facility or Home and Community-Based Services Waiver Program

Revision 22-2; Effective June 1, 2022

Eligibility Systems and Payment Systems

Service Authorization System Online (SASO) identifies the recipient as Service Group 1 and allows vendor payment when:

• an active recipient with coverage Code R (either Long Term Care or Texas Works) enters a nursing facility; and
• has a valid medical necessity and facility admission.

The system also automatically assigns a Code 60 (authorization for unlimited medications). This allows all medications to be paid through the vendor drug benefit.

If the nursing facility stay is temporary and the recipient returns home before being transferred to institutional Medicaid, no action is required. Retroactive coverage code changes are not needed.

Texas Works Medicaid to MEPD

If an active Texas Works Medicaid recipient enters a facility for a long-term stay, TIERS receives the nursing facility admission information from the HHSC webservice interface. TIERS automatically denies the Texas Works Eligibility Determination Group (EDG) and creates a pending ME-Nursing Facility EDG. An H1200 Application for Assistance - Your Texas Benefits must be received before testing for ME-Nursing Facility Medicaid. Disposition of both EDGs must be coordinated. There is no need for retroactive coverage code changes. Vendor payment and medications are authorized through SASO.

If a facility notifies HHSC that an active Texas Work Medicaid recipient has entered the facility, staff should advise the facility that an application is required. Once the application is received, process as any other application and coordinate with Texas Works.

Community to Nursing Facility or Home and Community-Based Services Waiver Eligibility Considerations

If an active MEPD Medicaid or Medicare Savings Program recipient enters a facility for a long-term stay or requests waiver services, before completing a program transfer, staff must address all factors that may impact eligibility or co-payment. Staff must explore transfer of assets and substantial home equity and provide required information about annuities, estate recovery and long-term care options. 

Related Policy

Medicaid Estate Recovery Program Notification Requirements, B-2600
Alternative Care Services, B-7440
Notice Requirements for Application and Redeterminations, F-7250
Medicaid Coverage Issues Related to Nursing Facility Costs, H-7300
Medicare Skilled Nursing Facilities, R-1210
Notices, R-1300