SI DAL01730.009 (TX) SSA/State Agreements under Section 1634 (TN 26 - 08/2003)

A. Policy

The Texas Health and Human Services Commission (THHSC) entered into an agreement under Section 1634 of the Social Security Act with the Social Security Administration (SSA) for SSA to make Medicaid eligibility determinations. Supplemental Security Income (SSI) recipients who receive an SSI cash payment or are Section 1619(b) recipients automatically have Medicaid eligibility unless:

  • They fail to meet the Assignment of Rights (AOR) or Third Party Liability requirements (Note: Texas State law makes AOR automatic); or

  • The State has determined that the Medicaid Trust provision applies.

See SI 01730.040 through SI 01730.048 for a discussion of the Medicaid eligibility limitations, including transfer of resources (TOR).

Individuals converted as essential persons, regardless of the State of conversion, are not eligible for Medicaid in Texas until they become eligible for SSI (e.g., age 65).

Please note that effective August 22, 1996, the earliest month of SSI cash payment is the month following the later of the month of filing or the date the individual becomes eligible for SSI (SI 00601.009).

B. Procedure – field office

When an individual files for SSI, the SSA interviewer will provide the applicant with the following information:

  • If the claimant is found eligible for SSI payments and meets all other requirements in SI 01730.040 through SI 01730.048, the claimant will also be eligible for Medicaid. Medicaid coverage through the SSI program will begin with the first month of SSI cash payments.

  • The SSI recipient will receive a Medicaid card (THHSC Form 3087) in the mail from THHSC within 30 days after receipt of the first SSI check. If the Medicaid card is not received timely, the SSI recipient should contact the local THHSC office.

  • The SSI recipient should report all address changes to SSA in order to receive the Medicaid card timely since Texas Medicaid cards cannot be forwarded by the post office.

    NOTE: The THHSC computer system which prints the Medicaid card picks up only the first two lines of the street address from the SSR/SDX. See SM DAL01301.390 for complete SSR coding instructions.

  • If the SSI applicant/recipient has unpaid medical expenses incurred in the 3 months prior to the month of application (shown in the AP field) for SSI, THHSC may be able to cover these unpaid expenses. Medicaid eligibility for this 3-month period requires a Medicaid application with THHSC, and the eligibility decision will be made by THHSC. See SI DAL01730.009D. for an explanation of the E02 process and how it affects the 3-months prior process.

    NOTE: When the Unpaid Medical Expenses (UE) field is coded with a “Y” on the SSR and transmitted to THHSC via the State Data Exchange (SDX) file, THHSC mails a computer-generated notice asking the individual to contact the THHSC office about potential Medicaid for this 3-month prior period.

  • THHSC is responsible for determining what services are covered by Medicaid and for processing bills for services charged to Medicaid.

C. Procedure – THHSC

Although SSA determines Medicaid eligibility for most SSI recipients, THHSC is responsible for administration of the Medicaid program (e.g., the State issues Medicaid cards, determines what medical services are covered, and pays providers). THHSC also makes the Medicaid determination on TOR, AOR, TPL and Medicaid trust cases.

Medicaid cards for SSI recipients who are Texas residents are issued by THHSC based on the payment/eligibility information given the State Office on the SDX file. A Medicaid card is sent to new SSI cash recipients, including previously suspended cases, within 30 days from the time the recipient is in C01/M01/M02/1619(b) payment status on the SSR.

If the SSI recipient is not on the SSR/SDX or the information is incomplete, see manual Medicaid certification (MMC) procedures in SI DAL01730.009E.

D. E02 month and Medicaid entitlement

The Personal Responsibility and Work Opportunity Reconciliation Act of 1996 provides that SSI payments may only begin as of the first day of the month following the later of (1) the date the application is filed or (2) the date the individual becomes eligible for such benefits (SI 00601.009). As a result of this policy, cash SSI payments are not paid for the first month of SSI eligibility; the first month of SSI eligibility is the E02 month. Since no SSI cash payments are paid for the E02 month, no Medicaid certification is made to THHSC by SSA.

However, THHSC decided to provide coverage for the SSI E02 month using a systems default (as explained in SI DAL01730.009D, step 1.) to define the E02 month rather than always using the E02 as determined by SSA. Please note that this is a THHSC agency decision and does not affect or change the SSI program policy or procedures.

  1. THHSC adapted the “3-month-prior-to-SSI-application” Medicaid coverage policy to provide coverage for the E02 month. The THHSC system has defaults which start the “3-month-prior” period with the month immediately prior to the first SSI cash payment month. This results in Medicaid coverage provided by THHSC for the E02 month in most cases, but it may also result in Medicaid coverage for a month of SSI ineligibility. For example, an individual applied in January and the PSY for January, February, and March are E02, N01, and C01, respectively. The THHSC system default considers February to be the E02 month because it is the month immediately before the first C01 month, and Medicaid is provided by THHSC for a month of SSI ineligibility (i.e., N01). The application with THHSC for the “3-month prior” Medicaid coverage would be for the remaining two months of December and January.

  2. Since Medicaid coverage will automatically be provided for new SSI recipients for the “month immediately preceding the SSI payment month”, THHSC will issue a notice inviting recipients with unpaid medical expenses to file for Medicaid coverage for the remaining two months of the “3-month prior” period.

  3. The option for Medicaid for “3-month prior to the date of SSI application” did not change for denied SSI applicants. A notice will be sent advising denied applicants of the option to apply for this Medicaid coverage. Since the SSI claim was denied for benefits, there is no SSI cash payment or E02 month to be considered.

SSA should never certify Medicaid coverage for any month of SSI ineligibility (e.g., N04), the E02 month, the 3-month prior period, or a month of non-SSI cash payment (e.g., E01, N01) unless the non-cash month is a Section 1619(b) month.

E. Manual Medicaid certification policy

A THHSC Manual Certification for Medicaid Eligibility, SS-RVI-300 (04/01), Exhibit 1, should be routinely prepared for situations listed below when SSA makes the Medicaid determination but a correct/complete SSI payment record cannot be provided to THHSC, or the THHSC system cannot determine correct payment information:

  1. Systems limitation cases;

  2. Closed period of SSI entitlement;

  3. Intervening period(s) of SSI entitlement;

  4. SSI claimant dies (see SI DAL01730.009F.4. for qualifying circumstances); or

  5. SSI claimant/reinstated recipient moves out of Texas before payment is initiated.

F. Manual Medicaid certification - DO procedure

For the cases listed in SI DAL01730.009E., the DO should complete Items 1-18 and 20 of the SS-RVI-300, Exhibit 1, and mail it to:

THHSC,
P. O. Box 149030
Mail Code: Y-922
Data Integrity Section
Austin, TX 78714-9030

Use only the 08/03 version of the SS-RVI-300 and do not fax to THHSC.

Certify to THHSC only for the period the SSI recipient is/was a resident of Texas and received an SSI cash payment or is eligible for 1619(b). If the recipient resided outside Texas anytime during the period of eligibility and SSA determines Medicaid eligibility in that State, call the servicing DO for the former out-of-State residence. Have the former DO certify Medicaid to their respective State agency using their State-specific procedures.

A copy of the SS-RVI-300 should be retained in the SSI folder (if available). A third copy may be placed in a central DO location to facilitate control per SI DAL01730.009F.1., step a.

In addition, take the following actions, as appropriate:

1. Systems limitation case

  1. A copy of the SS-RVI-300 should be placed in a central DO location to facilitate control.

  2. Once an SS-RVI-300 has been issued, THHSC will provide Medicaid until one of the conditions in SI DAL01730.009G. occurs. Control the case so that changes in eligibility, payment status and residence (e.g., N01, moves out of Texas) can be reported on the SS-RVI-300, Items 1, 3, 4, 19 and 20, to THHSC Data Integrity.

  3. Send a HCFA-1957 (Report of State Buy-In Problem) to HCFA-CO per HI 00815.088 and HI 00930.001 when the SSI recipient is entitled to Part B buy-in, but the buy-in has not been effectuated. Include a detailed explanation of the period of buy-in based on SSI payment that is not reflected on the SSR.

2. Closed period of SSI entitlement

In closed period of eligibility cases, THHSC receives only one SDX transaction which indicates a record is in non-pay status. Although SSI benefits were paid for a retroactive period, THHSC is not able to establish Medicaid eligibility for the closed period of SSI eligibility and payment because THHSC extracts data from the SDX that only indicates the current non-pay status.

Indicate on the SS-RVI-300 only periods of SSI payments for the retroactive period while a resident of Texas.

3. Intervening period(s) of SSI entitlement

In some cases, THHSC receives an SDX transaction for cases with a “start pay-stop pay-start pay” payment history. When this occurs, THHSC only extracts data from the SDX transaction that provides the Medicaid Effective Date (MEF) for the most current period of eligibility/payment in Texas.

Indicate on the SS-RVI-300 only periods of SSI payments for the retroactive period while a resident of Texas.

4. SSI claimant dies

  1. If a claimant dies after SSA receives the signed SSI application and death occurred after the month of filing, but before adjudication, and there is no one to receive the underpayment, but there are unpaid medical expenses alleged either on the application or by an interested party, complete development with the proper applicant (GN 00204.003) to determine SSI eligibility (i.e., disability and all non-disability requirements). If you do not have a proper applicant, complete the SS-RVI-300 listing the name and address of the “interested party” and refer the case to the State for a Medicaid determination. DO NOT indicate SSI eligibility on the SS-RVI-300 since we are not making an SSI determination. Mail the completed SS-RVI-300 to Texas Health and Human Services Commission, ATTN: Barbara Tejero, Mail Code 2120, 909 W. 45th Street, Austin, TX 78751.

    If SSI eligibility is found, prepare an SS-RVI-300 with the additional information required in SI DAL01730.009F.4, step d.

  2. If a claimant dies after SSA receives the signed SSI application and death occurred after the month of filing, but before adjudication, and there is someone eligible to receive the underpayment, complete development to determine SSI eligibility for payment (i.e., disability and all non-disability requirements).

    If SSI eligibility is found, prepare an SS-RVI-300 with the additional information required in SI DAL01730.009F.4., step d.

  3. If there is a protective statement (oral or written), but the claimant dies before SSA receives a signed SSI application, and an underpayment may be due, someone eligible to receive the underpayment may file an SSI application (GN 00204.005). See SI DAL01730.009K., second paragraph, if these conditions do not exist.

  4. In preparing the SS-RVI-300 for any of the situations in SI DAL01730.009F.4, steps a.-c. above,

    • Provide THHSC with the name and address of the “interested party” or the person receiving the underpayment in Item 10; and

    • Annotate Item 18 with “If alive, claimant would have received SSI payments and been found Medicaid eligible.” and the date of death.

5. SSI claimant/reinstated recipient moves out of State before payment made

Only one State receives an SDX file at a time. There are situations where an SSI claimant moves out of Texas before payments are started. Since the change of address/residency will include a new State and County Code, the SDX file will be sent to the new State of residency. Therefore, THHSC will not be aware that there were SSI payments for a period of time covering residency in Texas.

SSA DOs will become aware of these cases when an inquiry is received from the SSI recipient or from THHSC. In these cases, prepare an SS-RVI-300 only for the period of SSI payment and residency in Texas. Indicate in Item 19 the date the SSI recipient moved out of Texas.

G. Manual Medicaid certification – THHSC

Upon receipt of the SS-RVI-300 (08/03), THHSC-Data Integrity will issue a Medicaid card. The manually-certified Medicaid card should be received by the SSI recipient within 21 days after the SS-RVI-300 is received by THHSC-Data Integrity.

If a case is manually certified for continuing Medicaid eligibility, THHSC will continue to issue Medicaid cards based on the manual certification until:

  1. A record is accreted to the SSR that matches the SSN in Item 4 of the SS-RVI-300 and THHSC receives an SDX record; or

  2. In a systems limitation case, THHSC-Data Integrity is notified by SSA via SS-RVI-300, Items 1.B., 3, 4, 19, and 20, that the SSI recipient is no longer entitled to SSI or has moved out of Texas.

Otherwise, a Medicaid card will continue to be erroneously sent each month.

H. Emergency need for Medicaid card — policy

A THHSC Medicaid card is routinely sent to new or reentitled SSI recipients within 30 days of the time the SDX file indicates the individual is in C01/M01/M02 cash payment status or Section 1619(b) status in Texas.

There are, however, situations when routine procedures will not provide a Medicaid card in time for the SSI recipient to obtain emergency medical attention. Therefore, if:

  • The SSI recipient has been in C01/M01/M02 cash payment status in Texas for less than 30 days; and

  • A medical emergency exists that would endanger a person's life if medication or medical attention is not provided immediately; and

  • The medical provider is refusing to provide services without a Medicaid card, then follow the procedure in Item I. below to provide emergency certification of Medicaid eligibility for the current month only.

A medical emergency is a situation that would endanger a person's life if medication or medical attention is not provided immediately.

NOTE: A request for Medicaid certification for a retroactive period is not considered a medical emergency.

I. Emergency need — DO procedure

If the criteria in SI DAL01730.009H. are met, the DO should take all the following actions in sequence.

  1. Fully complete a “REQUEST FOR EMERGENCY MEDICAID CERTIFICATION” form. A copy is provided in Exhibit 2. This is the only acceptable form to use for an emergency certification.

    All items on the form must be completed or answered “None.” If information is omitted, there may be delays because THHSC may not be able to process the request, or may have to contact the DO for additional information. Describe the life-threatening nature of the emergency in detail, and explain why routine procedures cannot be used. Example: “SSI claim processed as an allowance this week and cash payments are due for this month. General Hospital has a kidney available for transplant, but requires proof of Medicaid before admitting Mr. Kline. Per THHSC caseworker, SSI eligibility/payment is not yet on THHSC computer.”

  2. Obtain authorization from an operations supervisor/MSS (or above) for use of the emergency procedure. The SSA official authorizing the appropriateness of the emergency certification should sign in Item 21.

  3. Call the local THHSC Medicaid caseworker responsible for providing verification of Medicaid eligibility to the client.

    1. Have the THHSC caseworker check the THHSC computer system for current SSI/Medicaid eligibility.

      If Medicaid eligibility is located for the current month, ask the THHSC caseworker to issue a replacement card. Provide the caseworker with information on when the Medicaid card will be picked up and by whom.

      If no SSI eligibility/payment is found, proceed to 3.b. below.

    2. If no current SSI eligibility is found on the THHSC computer system, inform the caseworker that an emergency Medicaid certification is being sent to the THHSC Data Integrity office in Austin.

    3. Provide the caseworker with:

      (1) Details on the life-threatening nature of the emergency; and

      (2) The name, SSN, address and phone number of the SSI recipient and any special instructions needed for contact.

    NOTE: There are some rural THHSC offices that do not have Medicaid caseworkers. If the local THHSC office is uncertain of the procedures to follow, have them contact their manager or the THHSC Data Integrity office in Austin at (512) 706-7150.

  4. FAX the fully completed “REQUEST FOR EMERGENCY MEDICAID CERTIFICATION” (Exhibit 2) to THHSC Data Integrity office in Austin at (512) 706-7150.

    NOTE: FAX procedures apply only to emergency certifications—do not FAX routine manual Medicaid certifications described in SI DAL01730.005E.

  5. Retain the “REQUEST FOR EMERGENCY MEDICAID CERTIFICATION” form in the DO file.

J. Emergency need — THHSC procedure

THHSC Data Integrity will:

  1. Process the fully-completed “REQUEST FOR EMERGENCY MEDICAID CERTIFICATION” within 24 hours;

  2. Establish SSI and Medicaid eligibility for the current month only on the THHSC computer system; and

  3. Call the local THHSC caseworker to authorize completion of State Form 1027 (Medicaid Verification Letter). The local THHSC caseworker will expedite delivery of Form 1027 to the SSI recipient and/or notify the provider of Medicaid eligibility for requested services.

K. Individual dies before filing for SSI

If an individual did not file an SSI application with SSA before death, but an oral inquiry/protective writing exists, an underpayment would be due, and a parent/spouse can be eligible for an underpayment, pursue an application and complete development for payment of the underpayment and Medicaid eligibility (GN 00204.005). See SI DAL01730.009E. for manual Medicaid certification instructions.

If an oral inquiry/protective writing does not exist, or one exists but no underpayment would be due (e.g., death in the E02 month), or no one is eligible for an underpayment (if one were to exist), immediately refer an interested party inquiring about Medicaid coverage for the decedent's unpaid medical expenses to the local THHSC office. The 3-month period of retroactivity for coverage ends with the date an application for Medicaid is filed on behalf of the deceased individual, not with the date of death.

L. Nonreceipt of Medicaid card

When an SSI recipient in C01, M01 or M02 with cash payments, Section 1619(b), or protected payment status contacts the SSA office alleging nonreceipt of the Medicaid card, use the following procedures:

  1. Verify that the correct address, zip code and State/ County code are on the SSR. The State/County code in the ADDR and CMPH segments of the SSR should start with “45” for Texas residents. If protected payments are being paid using G-K systems procedures, the SCR field in the DUPR segment should have 5 zeros (SM 01305.640 and MSS 98N084, dated 04/23/98).

    If the address data is incorrect, transmit the correct information to the SSR. This information will be sent to THHSC via the SDX. Also, take action to complete whatever additional development (e.g., LA) is required by SSI.

  2. SSI Recipient is C01/M01/M02—First Check Generated or Address Changed to Texas Less than 30 Days Ago

    Inform the SSI recipient that SSA has notified THHSC of his or her SSI eligibility for cash payments, but enough time has not elapsed for THHSC to issue the Medicaid card. Explain that he or she should contact THHSC if he or she does not receive the Medicaid card within 30 days after receiving the first SSI check in Texas. If the recipient alleges a current medical emergency, follow procedures in SI DAL01730.009H. and SI DAL01730.009I.

  3. SSI Recipient's Eligibility is Established on the SSR for 30 Days or More

    • If the data is correct, but there has been a change of address or change in payment status within the past 2 weeks, inform the recipient that the change has been reported to THHSC and that any past due Medicaid cards should be received in about two weeks.

      NOTE: See SI DAL01730.009FN. if the change of address was from another State.

    • If the data is correct and no change of address or payment status data has been transmitted within the past 2 weeks, refer the recipient to the local THHSC office.

The local THHSC office can query to determine the recipient's status on the State's computer system and issue a replacement card, if appropriate.

NOTE: The post office does not forward Texas Medicaid cards.

M. Referrals to THHSC for non-SSI recipients

As discussed in A. above, SSA makes Medicaid eligibility determinations for most SSI recipients. Only THHSC makes Medicaid ineligibility determinations for SSI claimants/ recipients. THHSC makes both eligibility and ineligibility determinations for Medicaid in other State programs.

Some of these State Medicaid programs are listed in SI 01715.005 and SI 01715.015 (Special Groups of Former SSI Recipients). Individuals who inquire or appear to be eligible for these Medicaid programs should be referred to the local THHSC office.

1. Title II COLA

Included in the list in SI 01715.015 are SSI recipients who would continue to receive SSI payments but for their title II COLA (Section 503 of P.L. 94-566 and Lynch vs. Rank court case). Annually, at COLA time, THHSC receives two files identifying this protected group:

  • The 503 leads (Pickle) file identifies SSI recipients who lost SSI eligibility because of the title II COLA. The 503 leads file is transmitted to THHSC immediately following the transmission of the COLA file in late November.

  • The Lynch vs. Rank file identifies individuals who would have been identified at COLA time except that they were ineligible for SSI (e.g., N04, M01/M02 with $0 payment) when the file was run, but could be eligible now except for the title II COLA increase. The Lynch vs. Rank file provides information for the current year plus the two preceding years. The file is usually transmitted to States in mid-December.

If an individual meets either of the Medicaid extension provisions (i.e., would have been eligible for SSI except for the COLA increase) and alleges after the beginning of the new year that THHSC has not contacted the individual, a referral may be made to the local THHSC office using Exhibit 3. Photocopy Exhibit 3 as needed. Completion of Exhibit 3 is self-explanatory.

2. Community based alternatives

The Community Based Alternatives program provides home and community-based services to aged and disabled adults as a cost-effective alternative to nursing home care. Individuals must be age 21 or older and meet nursing home income, resource, and medical necessity requirements. Inquiries should be referred to the local THHSC office.

See SI DAL01310.207 for information on Medicaid Waiver programs for children living at home.

N. Medicaid coverage in the month of move

When an SSI recipient moves from another State with intent to reside in Texas, Medicaid eligibility resulting from SSI payment or Section 1619(b) is effective the month after the month of move (SI 01410.030F). This policy has caused concern when the SSI recipient requires medical services in Texas in the month of move. To address this concern the Health Care Financing Administration, which sets Medicaid policy, allows each State to make arrangements with the former State of residence so that the new State can provide Medicaid coverage for the period during the month of move in which the individual resides in the new State.

THHSC can provide Medicaid coverage in the month of move for new Texas residents who meet specific THHSC guidelines and who are eligible for an SSI payment. Local THHSC offices have instructions on procedures to follow, including using the THHSC Form 1300 (Declaration of Texas Residency) to obtain SSI payment information from the local SSA DO. SSA's role is to provide SSI payment information to THHSC for the month of move and to transmit correct address information to the SSR.

Since it is a THHSC determination that State guidelines are met, not SSA, THHSC will initiate the use of the Form 1300. THHSC will mail or fax the Form 1300 with the top two sections completed to the servicing SSA DO. DOs will complete the bottom half of the Form 1300 and mail or fax the completed form to the requesting THHSC office. No other documentation from SSA is required by THHSC.

G-SI_01730.009-1

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G-SI_01730.009-2

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G-SI_01730.009-3

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G-SI_01730.009-4

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