Body
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.