Revision 24-4; Effective Dec. 1, 2024

Although often used interchangeably, denials and terminations are different types of adverse case actions.

• A denial refers to a determination of ineligibility for Medicaid benefits that a person is not currently receiving. A denial action may occur when processing an application, a request for a new type of benefit, or a program transfer request.
• A termination refers to a determination of ineligibility for ongoing Medicaid benefits that a person is currently receiving. A termination action may occur when processing a renewal or redetermination based on a change in circumstances.

Unless otherwise specified, the policy in the following sections applies to both denials and terminations.

Procedural Denials

A procedural denial occurs when a person is ineligible for benefits because they failed to provide all information needed to make an eligibility determination. Examples of actual procedural denial reasons on the TF0001, Notice of Case Action, include:

• Individuals was sent forms to renew benefits. They didn't return the forms by the due date.
• You failed to provide required information by the due date.

Non-Procedural Denials

A non-procedural denial occurs when a person is not eligible for benefits based on the information provided. They do not meet one or more specific financial or non-financial eligibility requirements, and there are no exceptions that would make them eligible. Examples of non-procedural denial reasons on the TF0001 notice include:

• The money Individuals gets (income) is more than allowed for this program.
• The value of the things this person is paying for or owns is more than allowed by program rules.
• [Client] didn't give proof showing that they live in Texas.
• [Client] has not shown that they are either a citizen or a non-citizen who is qualified to receive benefits.

Determine Medicaid Eligibility on All Bases

Consider Medicaid eligibility on all bases prior to denying or terminating Medicaid eligibility. Determine if the person is eligible for any other Medicaid and Medicare Savings Program (MSP) benefits, including both Modified Adjusted Gross Income (MAGI) and non-MAGI types of assistance (TOAs).

If the person is eligible for another type of Medicaid or MSP program, transfer to the new TOA without requiring a new application. If more information is needed to determine eligibility for another TOA, including transfers from a non-MAGI program to a MAGI program or vice versa, pend the case and request only the information needed. Do not request a new application or verification of information available through an electronic data source.

Example: A person submits Form H1200, Application for Assistance - Your Texas Benefits, to apply for Waiver Medicaid for a minor child. The child does not have an established disability determination and is not eligible for Waiver Medicaid. Based on the information provided, the system cascades to Children’s Medicaid (CMA). Confirm the eligibility determination is correct and certify the child for CMA without requiring a Form H1010, Texas Works Application for Assistance - Your Texas Benefits, or Form H1205, Texas Streamlined Application.

Related Policy

Previously Completed Application, B-5000
Denials, B-6500
Potential Resource Exclusions, F-5200

Revision 09-4; Effective December 1, 2009  

When reviewing an MEPD case, verify medical necessity/level of care determination if:

• the recipient's medical necessity or level of care determination has been denied, or
• the recipient has relocated to a different facility and no medical necessity/level of care determination has been received.

If the medical necessity/level of care determination has been denied, do not sustain the review.

Reference: See Section B-7431, Denial of Level of Care/Medical Necessity Determination, for procedures when medical necessity/level of care is denied.

Revision 19-3; Effective September 1, 2019

Date of Death Matches

HHSC matches recipients on active TIERS Eligibility Determination Groups (EDGs) with records from the Social Security Administration (SSA), Texas Bureau of Vital Statistics (BVS), the Centers for Medicaid and Medicare Services (CMS), and HHSC Webservices to identify deceased persons and automatically remove them from active EDGs. If unable to process the death data automatically, TIERS creates tasks for staff to perform more research to determine the validity of the computer match. TIERS will attempt to update the Date of Death (DOD) information for all active and inactive person(s).

Death Verification Sources

Take action to clear any discrepancies when DOD data is received on an active or inactive person within TIERS and the system is unable to automatically dispose the case. When the system cannot dispose the case, a series of alerts are created for staff to explore and request additional verification of the death data.

Primary source of verification of death is the Bureau of Vital Statistics (BVS).

If BVS is not available, verify the date of death using two of the following sources:

• Social Security Administration (SSA);
• statement from guardian or other authorized representative;
• copy of death certificate;
• statement from a doctor;
• newspaper death notice (obituary);
• statement from a relative or household member;
• statement from funeral director; or
• records from hospital or other institution where the person died.

Note: If BVS is received but the date of death does not match previously reported information, accept BVS as verification and dispose the case. No additional verification is needed because BVS is considered the primary verification source.

Example: DOD data received from an SSA interface shows a DOD of 01/15/2019 but, the same person had a DOD of 01/13/2019 listed in TIERS. Alert 812, Verify Discrepancy in Date of Death for Individual is created for additional action. Staff verify the DOD by contacting the nursing home where the person was residing prior to death and also locate the person's obituary online. Staff enter the DOD based on the additional information and clear the alert

For detailed processing instructions, staff may review the Eligibility Services State Processes document and the Change and Alert Guide.

Related Policy

Social Security Administration Deceased Individual Report, R-4110

Revision 24-4; Effective Dec. 1, 2024

Pregnant or postpartum women who lose eligibility for the following types of assistance automatically transition to Medicaid for Pregnant Women (TP 40) coverage for the remainder of their pregnancy and 12-month postpartum period:

• ME - Waivers
• ME - State Group Home
• ME - Pickle
• ME - SSI
• ME - State School
• ME - Non-State Group Home
• ME - State Hospital
• ME - Medicaid Buy-In
• ME - Medicaid Buy-In for Children (MBIC)
• ME - Nursing Facility
• ME - Disabled Adult Child
• ME - Disabled Widow(er)
• ME - Early Aged Widow(er)

Note: ME - Community Attendant is not full Medicaid. Community Attendant Services (CAS) provides payment for attendant care only. Recipients certified on ME - Community Attendant must submit an application to determine eligibility for Pregnant Women (TP 40).

If a pregnant or postpartum woman loses ongoing eligibility for their current Medicaid coverage, 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 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 MEPD eligibility, and pregnancy information is received through an interface, the woman is automatically certified for TP 40 with postponed verification and 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 years old.

Children Under 19

If pregnancy verification is not provided by the 30^th day, TP 40 coverage is terminated and the MEPD type of assistance is re-established based on continuous eligibility for children under 19 policy.

If a child who is certified on CHIP during their pregnancy or postpartum period becomes eligible for SSI, MEPD Facility, or MEPD Non-Facility TOA, the CHIP coverage is terminated to allow the transition to SSI, MEPD Facility, or MEPD Non-Facility TOA. The household will receive a denial notice showing the child is not eligible for CHIP for the remainder of their pregnancy and 12-month postpartum period because they are eligible for Medicaid.

Related Policy

Continuous Medicaid Coverage, B-6600
Pregnancy and 12-Month Postpartum Coverage After SSI Denial, B-7120