Program Support Unit (PSU) staff must use the following table to determine if Form H1746-A, MEPD Referral Cover Sheet must be faxed to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist. PSU staff determine if Form H1746-A is required by cross referencing the applicant’s Medicaid type of assistance (TOA) in Texas Integrated Eligibility Redesign System (TIERS).
PSU staff must fax Form H1746-A to the MEPD specialist if a TOA is not listed below. The term not applicable represents fields that are not applicable.
PSU staff must fax Form H1746-A, as a cover page, along with Form H1200, Application for Assistance – Your Texas Benefits, if Form H1200 is received. PSU staff must get Form H1200 before faxing Form H1746-A for some applicants, including those who:
do not have a Medicaid TOA;
are enrolled in the Children’s Health Insurance Program (CHIP) (TA84);
are enrolled in Texas Women’s Health Program (TWHP) (TA41);
are enrolled in the Medicaid for Breast and Cervical Cancer (MBCC) (TP67);
are enrolled with Texas Works-related Medicaid and are transitioning to an adult waiver program; and
were previously denied Supplemental Security Income (SSI) and are reapplying for waiver.
For the purposes of this appendix, the term waiver refers to the Medically Dependent Children Program (MDCP) and STAR+PLUS Home and Community Based Services (HCBS) program, unless specified otherwise.
No Medicaid TOA to Waiver, includes individuals enrolled in the Children’s Health Insurance Program (CHIP)
Individuals without Medicaid must submit Form H1200. PSU staff must fax Form H1746-A along with Form H1200, as a cover page.
Form H1746-A Requirements
TIERS Type of Assistance
Program Name in TIERS
Form H1746-A Required?
Convert to ME-Waiver?
Not Applicable
Not Applicable
Yes
Yes
TP84
CI – CHIP
Yes
Yes
Form H1746-A Instructions
Action Type
Comments
Interest List Release - Application
Test individual for [MDCP or STAR+PLUS HCBS] waiver.
Money Follows the Person - Application
Individual living in a NF is requesting [MDCP or STAR+PLUS HCBS] waiver.
Medical Assistance Only (MAO) to Waiver
Form H1746-A Requirements
TIERS Type of Assistance
Program Name in TIERS
Form H1746-A Required?
Convert to ME-Waiver?
TA10
ME – Waivers
Yes
Not Applicable
TP03
ME – Pickle
No
No
TP18
ME – Disabled Adult Child
No
No
TP21
ME – Disabled Widow(er)
No
No
TP22
ME – Early Aged Widow(er)
No
No
TP87
ME – Medicaid Buy In (MBI)
No
No
Note: Refer to the Waiver to Another Type of Waiver section below if the applicant has TA10 ME-Waivers and is enrolled in another waiver program.
Medicaid Buy-In for Children (MBIC) to Waiver
Form H1746-A Requirements
TIERS Type of Assistance
Program Name in TIERS
Form H1746-A Required?
Convert to ME-Waiver?
TA88
ME-Buy-In for Children
Yes
Yes
Form H1746-A Instructions
Action Type
Comments
Program Transfer
Test MBIC individual for MDCP waiver and transfer Medicaid to ME-Waivers.
Supplemental Security Income (SSI) to Waiver
Form H1746-A Requirements
TIERS Type of Assistance
Program Name in TIERS
Form H1746-A Required?
Convert to ME-Waiver?
TA08
ME – SSI State Group Home
No
No
TP12
ME – Temp Manual SSI
No
No
TP13
ME – SSI
No
No
TA26
ME – SSI Non-State Group Home
No
No
TP38
ME – SSI Nursing Facility
No
No
TP39
ME – SSI State Hospital
No
No
TA02
ME – SSI Waivers
No
No
Note: An SSI member who is residing in a non-community setting that relocates to the community must contact the Social Security Administration (SSA) to report the change in living arrangement.
CAS/SLMB/QI-1/QMB to Waiver
Form H1746-A Requirements
TIERS Type of Assistance
Program Name in TIERS
Form H1746-A Required?
Convert to ME-Waiver?
TP14
ME – Community Attendant
Yes
Yes
TP23
MC – SLMB
Yes
Yes
TP24
MC – QMB
Yes
Yes
TP26
MC – QI-1
Yes
Yes
Form H1746-A Instructions
Action Type
Comments
Program Transfer
Test [CAS, SLMB, QMB, or QI-1] individual for [MDCP or STAR+PLUS HCBS] waiver and transfer Medicaid to ME-Waivers.
Note: An individual can receive ME-Waivers and SLMB or QMB concurrently. An individual cannot receive ME-Waiver and QI-1 concurrently.
Nursing Facility to Waiver
Form H1746-A Requirements
TIERS Type of Assistance
Program Name in TIERS
Form H1746-A Required?
Convert to ME-Waiver?
TP17
ME – Nursing Facility
Yes
Yes
TP41
ME – Skilled Nursing Care
Yes
Yes
Form H1746-A Instructions
Action Type
Comments
Program Transfer
Nursing facility individual transitioning to [MDCP or STAR+PLUS HCBS] waiver on [date]. Transfer Medicaid to ME-Waivers.
Intermediate Care Facility for Individuals with an Intellectual Disability or Related Condition (ICF/IID) to Waiver
Form H1746-A Requirements
TIERS Type of Assistance
Program Name in TIERS
Form H1746-A Required?
Convert to ME-Waiver?
TA12
ME – State Group Home
Yes
Yes
TP10
ME – State Supported Living Center
Yes
Yes
TP15
ME – Non-State Group Home
Yes
Yes
TP16
ME – State Hospital
Yes
Yes
Form H1746-A Instructions
Action Type
Comments
Program Transfer
ICF/IID individual transitioning to [MDCP or STAR+PLUS HCBS] waiver on [date]. Transfer Medicaid to ME-Waivers.
Texas Works-Related Medicaid to Waiver
Applicants with MBCC and those transitioning to adult waiver programs must submit Form H1200 to be tested for continued waiver eligibility. PSU staff must fax Form H1746-A along with Form H1200, as a cover page.
Form H1746-A Requirements
TIERS Type of Assistance
Program Name in TIERS
Form H1746-A Required?
Convert to ME-Waiver?
TA31
MA – Parents and Caretaker Relatives – Emergency
No
No
TP07
MA – Earnings Transitional
No
No
TP08
MA – Texas Temporary Assistance for Needy Families (TANF) Families Level
No
No
TP20
MA – Spousal Support Transitional
No
No
TP40
MA – Pregnant Women
No
No
TP43
MA – Children Under One Year
No
No
TP44
MA – Children Six to 18 Years
No
No
TP45
MA – Newborn Children
No
No
TP48
MA – Children One to Five Years
No
No
TA67
MA – MBCC
Yes
Yes
TP70
Medicaid for the Transitioning Foster Care Youth (MTFCY)
No
No
TA82
Former Foster Care Children (FFCC)
No
No
TP92
Adoption Assistance - Federal Match - With Cash
No
No
TP93
Foster Care - Federal Match - No Cash
No
No
TP94
Foster Care - Federal Match - With Cash
No
No
TP95
Adoption Assistance - No Federal Assistance - No Cash
No
No
TP96
Adoption Assistance - No Federal Assistance - With Cash
No
No
TP97
Foster Care - No Federal Match - With Cash
No
No
TP98
Foster Care - No Federal Match - With Cash
No
No
TP99
MA - Non-AFDC Foster Care
No
No
Form H1746-A Instructions
Action Type
Comments
Program Transfer
Test TW-related Medicaid individual for [MDCP or STAR+PLUS HCBS] waiver.
Note: MA – Parents and Caretaker Relatives – Emergency (TA31) is for undocumented people that do not meet citizenship requirements for Medicaid. Applicants with this TOA would not be eligible for any type of waiver as they do not meet citizenship requirements.
Texas Women’s Health Program (TWHP) to Waiver
Individuals with TWHP Medicaid must submit Form H1200. PSU staff must fax Form H1746-A along with Form H1200, as a cover page.
Form H1746-A Requirements
TIERS Type of Assistance
Program Name in TIERS
Form H1746-A Required?
Convert to ME-Waiver?
TA41
Health Care – Texas Women's Health Program (TWHP)
Yes
Yes
Form H1746-A Instructions
Action Type
Comments
Program Transfer
Test Texas Women’s Health Program individual for [MDCP or STAR+PLUS HCBS] waiver and transfer Medicaid to ME-Waivers.
Note: PSU staff do not discuss the TWHP with anyone other than the certified TWHP member.
Waiver to Nursing Facility
Form H1746-A Requirements
TIERS Type of Assistance
Program Name in TIERS
Form H1746-A Required?
Convert to ME-Waiver?
TA10
ME – Waivers
Yes
No
Form H1746-A Instructions
Action Type
Comments
Program Transfer
[MDCP or STAR+PLUS HCBS] member is transitioning to nursing facility, [NF Name], located at [NF address] on [date].
Waiver to Another Type of Waiver
For the purposes of this appendix, the term Another Type of Waiver refers to:
Community Living Assistance and Support Services (CLASS);
Deaf Blind with Multiple Disabilities (DBMD);
Home and Community-based Services (HCS);
Medically Dependent Children Program (MDCP);
STAR+PLUS Home and Community Based Services (HCBS) program;
Texas Home Living (TxHmL); and
Youth Empowerment Services (YES).
Form H1746-A Requirements
TIERS Type of Assistance
Program Name in TIERS
Form H1746-A Required?
Convert to ME-Waiver?
TA10
ME – Waivers
Yes
Not Applicable
Form H1746-A Instructions
Action Type
Comments
Significant Change
[Waiver name] member transferring to [Other Waiver name] effective [date].
SSI Denial to Waiver
Individuals who are being denied SSI must submit Form H1200 to be tested for MAO Medicaid. PSU staff must fax Form H1746-A along with Form H1200, as a cover page.
Form H1746-A Requirements
TIERS Type of Assistance
Program Name in TIERS
Form H1746-A Required?
Convert to ME-Waiver?
TA08
ME – SSI State Group Home
Yes
Yes
TP12
ME – Temp Manual SSI
Yes
Yes
TP13
ME – SSI
Yes
Yes
TA26
ME – SSI Non-State Group Home
Yes
Yes
TP38
ME – SSI Nursing Facility
Yes
Yes
TP39
ME – SSI State Hospital
Yes
Yes
TA02
ME – SSI Waivers
Yes
Yes
Form H1746-A Instructions
Action Type
Comments
Application
Test SSI Denial individual for [MDCP or STAR+PLUS HCBS] waiver.
Waiver Denial
Form H1746-A Requirements
TIERS Type of Assistance
Program Name in TIERS
Form H1746-A Required?
Convert to ME-Waiver?
TA10
ME – Waivers
Yes
No
Form H1746-A Instructions
Action Type
Comments
Significant Change
[MDCP or STAR+PLUS HCBS] member is not eligible for waiver effective [date].
Appears In
STAR+PLUS Program Support Unit Operational Procedures Handbook
STAR Kids Program Support Unit Operational Procedures Handbook
