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Revision 25-1; Effective March 1, 2025
Administrative Renewal Process
All MEPD types of assistance (TOAs) go through the annual administrative renewal process. The system begins the administrative renewal process without staff action.
The automated administrative renewal process uses information from the existing case record and electronic data sources (ELDS) to determine if the person remains eligible for Medicaid benefits. The electronic data is requested the weekend before cutoff in the eighth month of the recipient’s certification period. The renewal packets are generated in the ninth month of the recipient’s certification period.
The administrative renewal process uses electronic data to automatically:
- assess the verification required by program type;
- determine the eligibility outcome; and
- send the renewal correspondence to the recipient, the authorized representative (AR) or both.
Note: This automated process does not change the verification requirements for renewals.
If there is enough information to verify continued eligibility, the person’s eligibility is renewed without any staff action, and Form TF0001 is generated. If more information is required, the system automatically generates and mails a renewal form to the recipient, AR or both. The recipient has 30 days to return the signed renewal form and all required verification.
The system generates the applicable correspondence from the list below based on the eligibility outcome of the automated renewal process and the action needed by the person:
- Form H1211, It Is Time to Renew Your Health Care Benefits Cover Letter;
- Form H1233, Redetermination Cover Letter;
- Form H1233-MBIC, Redetermination Cover Letter (Medicaid Buy-In for Children);
- Form H1200, Application for Assistance – Your Texas Benefits;
- Form H1200-A, Medical Assistance Only (MAO) Recertification;
- Form H1200-EZ, Application for Assistance;
- Form H1200-MBIC-R, Application for Benefits – Medicaid Buy-In for Children;
- Form H1200-PFS, Medical Application for Assistance (for Residents of State Facilities); or
- Form H1206ME, Health-Care Benefits Renewal
The renewal cover letter informs the recipient that it is time to renew benefits, provides instructions on how to complete and return the renewal form, along with any required verification documents, and informs the recipient that the information must be returned within 30 days. If the recipient does not return the renewal form and required verification, eligibility is automatically terminated at cutoff in the 12th month for failure to provide the requested information effective the last day of the 12th month. A Form TF0001 is generated.
Recipients can submit a renewal form through any of the following channels:
- online through YourTexasBenefits.com;
- in the local office; or
- by mail, fax or phone.
Notes: Form H1211 and Form H1206ME are generated when the automated renewal process results in Eligibility Approved. Form H1211 informs the recipient to review the information and only return Form H1206ME if the information is incorrect or if there has been a change to their case.
For MEPD programs that require a resource test, an AVS request is submitted with the ELDS request in the eighth month of the certification period.
When processing a renewal, if the AVS Screen does not include an Asset Verification – Automated Admin Renewal report processed on the 8th month of the current renewal cycle, submit an AVS request for the month the renewal form was received and three months prior.
If the renewal form shows that the recipient wants to register to vote, complete the Voter Registration Information section of the Citizen tab in the Individual Demographics logical unit of work (LUW). Select Yes in the Send Voter Registration Application? dropdown to send form VR30, Texas Voter Registration Application, to the mailing address on file. If the recipient contacts the office declining to complete form VR30, mail Form H1350, Opportunity to Register to Vote, to the recipient. Form H1350 records the recipient's decision about registering to vote.
Related Policy
Redetermination Cycles, B-8200
Who May Complete an Application for Assistance, B-3210
Who May Sign an Application for Assistance, B-3220
Voter Registration, C-7000
Asset Verification System (AVS), R-3740
B-8410 Financial Management
Revision 24-4; Effective Dec. 1, 2024
For redeterminations, explore financial management if there has been no activity in the person’s bank account other than interest credited since the last redetermination.
If a person does not report a bank account, trust fund or similar account on the application for assistance, ask the person or the authorized representative how the person’s financial affairs are handled. This includes who cashes the checks and where, who pays the bills and how, and who keeps the money and how the funds are kept.
If the person reveals past unreported liquid resources, determine the value, ownership and accessibility per the policy for the type of resource.
Acceptable verification sources for financial management include:
- Statement from the recipient and the person who handles the recipient’s funds.
- Statement from a knowledgeable third party, such as an administrator or bookkeeper in the facility that knows who receives the recipient’s benefit payments and pays the bills.
- Information received through AVS.
Document the following information in the case record:
- Where checks are cashed and how bills are paid.
- Who handles the person’s checks, pays the person’s bills and maintains the person’s money.
- How much money, if any, the person or anyone else keeps.
- If any funds have accumulated.
- Source of information.
B-8420 Notification of Changes as a Result of Redetermination
Revision 25-2; Effective June 1, 2025
If a redetermination results in one of the following situations, dispose the case and provide the appropriate notice:
Decrease of co-payment - If the recipient's co-payment is decreasing, dispose the case action and send Form TF0001, Notice of Case Action, and Form TF0001P, Provider Notice, to notify the recipient and the facility. To correct the co-payment for a prior period, complete Form H1259, Correction of Applied Income.
Note: Complete Form H1259 manually if a co-payment adjustment involves averaged income or incurred medical expenses. If all amounts are lower in the reconciliation shown on Form H1259, adverse action is not required. If Form TF0001 and Form TF0001P are not automatically generated, ensure a manual Form TF0001, Form TF0001P or both are sent.
- Increase of co-payment - If the recipient's co-payment is increasing, dispose the case action and send Form TF0001 and Form TF0001P to notify the recipient and the facility. If the recipient does not request an appeal by the end of the 12-day notification period, the increased co-payment remains.
- Denial of benefits - If a redetermination results in the termination of benefits, send Form TF0001 to notify the recipient. Send Form TF0001P to notify the facility, if applicable. If the recipient does not request an appeal by the end of the 12-day notification period, the benefits remain terminated.
For redeterminations, if the information provided indicates the person no longer qualifies for the current type of Medicaid, explore eligibility for all other types of Medicaid and the Medicare Savings Programs.
Related Policy
Application Process, B-3100
Notices, R-1300
B-8430 Special Reviews
Revision 10-1; Effective March 1, 2010
A special review occurs between the annual review cycles to evaluate one or more eligibility elements without completing the annual review. The annual review (redetermination) packet is not required for a special review.
The need for a special review is based on policy, a reported change or the eligibility specialist's judgment.
Examples of when special reviews are needed for follow-up:
- On the person's action for applying for potential benefits. An initial 30-calendar day special review is required to evaluate if the person made application after the person has been notified to do so. This may occur before the application is completed. Another special review will be needed to follow up to see if the recipient continues to be eligible.
- When variable income and/or incurred medical expenses are averaged and projected. Special reviews are required at least every six months unless documentation substantiates an exception.
- Within a 90-day time frame when the total countable income is within $10 of the income limit.
- Within a 90-day time frame when the total countable resources are within $100 of the resource limit.
- When any change is anticipated to occur.
For special reviews, document clearly the detailed reason(s) for the special review. Documentation must include:
- specific information regarding the reason a special review is set;
- the name of the individual who is affected; and
- the eligibility area(s) subject to the review.
Include this information on correspondence sent to the person to request information concerning the special review. No redetermination packet is required.
For example, if someone has a private pension and the pension amount is anticipated to increase in the future, set a special review for the anticipated change. The eligibility area will be income. Documentation must specify pension information that will need to be verified at the special review. Include the:
- date on which the anticipated change is to occur;
- type of pension;
- source of pension; and
- frequency of payment of pension that will need to be verified at the special review.
Form H1020, Request for Information or Action, and Form H1020-A, Sources of Proof, are used to request information from the person or authorized representative. Include the due date on Form H1020 or H1020-A. If the recipient calls with questions, follow Appendix XVI, Documentation and Verification Guide, for acceptable verification sources.
Example:
George Black called this morning saying he received a letter requesting verification that he had applied for Veterans Affairs (VA) benefits. He stated that he had applied and was told that it would take at least six months to hear anything.
Document what Mr. Black said. Recipient declaration is acceptable verification that he has applied for additional benefits. Be sure to tell Mr. Black to call and report if he hears anything about his eligibility from the VA.
B-8440 Reserved for Future Use
Revision 24-4; Effective Dec. 1, 2024
B-8450 Special Reviews when Facility Contract Closure or Cancellation Occurs
Revision 21-3; Effective September 1, 2021
When a facility’s Medicaid contract is terminated, the facility notifies the recipient and provides them with the option to move to a Medicaid covered facility.
If the Medicaid recipient continues to live in an uncontracted facility, deny Medicaid eligibility and send Form TF0001, Notice of Case Action, to the recipient and or authorized representative (AR) and TF0001P, Provider Notice of Case Action, to the facility. The person will then be responsible for the full vendor payment for that facility.
If the recipient relocates to a Medicaid contracted facility, process a change of address, verify the person continues to meet all Medicaid eligibility criteria and send out a new TF0001 to the recipient and or AR and TF0001P to the new facility.
Related Policy
Institutional Living Arrangements, B-6300
Redetermination Cycles, B-8200
Notices, R-1300
B-8460 Changes and Program Transfers
Revision 25-4; Effective Dec. 1, 2025
Changes
Changes in circumstances are certain events that may affect a person’s eligibility, continued eligibility or co-payment amount.
All changes must be reported within 10 calendar days of the event, including the following changes in the person’s:
- address;
- living arrangements;
- income;
- resources; and
- marital status.
Act on reported changes within:
- 10 business days for changes that may affect eligibility or co-payment; or
- 30 business days for changes that do not affect eligibility or co-payment.
Send Form H1020, Request for Information or Action, if more information is needed to process the change. Allow the person at least 10 days from the notice date on the Form H1020 to provide the information.
Request verification for the new spouse if an active recipient reports a new spouse. Redetermine eligibility as appropriate for a couple or companion case.
Set a special review to take timely action on a change when it can be reasonably anticipated, such as an increase in pension or retirement income.
Program Transfers
A program transfer occurs when an active recipient is determined eligible for another type of Medicaid or Medicare Savings Program (MSP).
For a program transfer from a community-based Type of Assistance (TOA) to a full verification TOA, request AVS for 60 months to check for possible transfer of assets.
Example: A Community Attendant Services recipient enters a nursing facility (NF) and is determined eligible for NF Medicaid.
A request for a program transfer is considered a change. Process the program transfer within 10 business days of receiving the request.
Redetermine eligibility and verify all required eligibility criteria for the new program, including 30-day consecutive stay, transfer of assets, substantial home equity and spousal impoverishment. Request 60 months of AVS information if the transfer is from a community program to a full verification program.
Send Form H1020 if more information is needed to process the program transfer. Allow the person at least 10 days from the notice date on the Form H1020 to provide the information.
Note: Do not transfer a child to a Medicaid program with lesser benefits during the 12-month continuous eligibility period.
Continuous Medicaid Eligibility
Children under 19 receive 12 months of continuous Medicaid eligibility. Coverage is continuous, regardless of changes, unless the child:
- turns 19;
- moves out of state;
- dies;
- requests a voluntary withdrawal; or
- was invalidly enrolled due to certification in error, or an Office of Inspector General determination of fraud, abuse or perjury.
Do not terminate a child’s eligibility when a change is reported or an agency-generated change is received during the 12-month continuous eligibility period, unless the change is reporting one of the exceptions to continuous coverage listed above. Document the change and address it at the next annual redetermination.
Take action to update the case record if a change of address or a change in contact information is reported during the 12-month continuous eligibility period.
Related Policy
Missing Information Due Dates, B-6420
Continuous Medicaid Coverage, B-6600
Medicaid Certified Person Enters Nursing Facility or Home and Community-Based Services Waiver Program, B-7450
Redetermining Eligibility, B-8200
Responsibility to Provide Information and Report Changes, C-8000
Asset Verification System (AVS), R-3740