Current through Reg. 49, No. 38; September 20, 2024
(a) General. This
section describes the groups of people who are categorically eligible for a
Medicaid-funded program for the elderly and people with disabilities (MEPD)
under the Texas State Plan for Medical Assistance.
(b) Mandatory coverage groups. In accordance
with 42 CFR Part 435, Subpart B, the Texas Health and Human Services Commission
(HHSC) determines eligibility for MEPD for a person who falls into at least one
of the following mandatory coverage groups:
(1) Supplemental Security Income (SSI)
eligible. In accordance with
RSA
435.120, this mandatory coverage group covers
a person who is aged, blind, or disabled and is receiving SSI or deemed to be
receiving SSI. The Social Security Administration (SSA) determines eligibility
for SSI under Title XVI of the Social Security Act. If SSA determines that a
person is eligible for SSI, HHSC accepts SSA's determination as an automatic
determination of eligibility for Medicaid.
(2) Coverage for certain aliens. In
accordance with
RSA
435.139, an alien, as defined in
RSA
435.406, is provided services necessary for
the treatment of an emergency medical condition, as defined in
RSA
440.255.
(3) Disabled adult child. In accordance with
§1634(c) of the Social Security Act (RSA
1383c), this mandatory coverage group covers
a person who:
(A) is at least 18 years of
age;
(B) became disabled before 22
years of age;
(C) is denied SSI
because of receipt of or an increase in Retirement, Survivors, and Disability
Insurance (RSDI) disabled children's benefits received on or after July 1,
1987, and any subsequent increase; and
(D) meets current SSI criteria, excluding the
RSDI benefit described in subparagraph (C) of this paragraph.
(4) Historical 1972 income
disregard. In accordance with
RSA
435.134, this mandatory coverage group covers
a person who:
(A) was receiving both public
assistance and Social Security benefits in August 1972; and
(B) meets current SSI eligibility criteria,
excluding from income the October 1972 cost-of-living adjustment (COLA)
increase in Social Security benefits but not excluding subsequent COLA
increases in Social Security benefits.
(5) Title II COLA disregard (Pickle). In
accordance with
RSA
435.135(a) -
(b), this mandatory coverage group covers a person who:
(A) has been denied SSI for any reason since
April 1977; and
(B) meets current
SSI eligibility criteria, excluding from countable income any Social Security
COLA increases received after the person last received both SSI and Social
Security benefits in the same month.
(6) Disabled widow's or widower's COLA
disregard. In accordance with
RSA
435.137, this mandatory coverage group covers
a person who:
(A) is 50 to 60 years of
age;
(B) is ineligible for
Medicare;
(C) was denied SSI due to
an increase in a disabled widow's or widower's and surviving divorced spouse's
RSDI; and
(D) meets SSI eligibility
criteria, excluding from countable income the RSDI benefit and any subsequent
COLA increases in RSDI.
(7) Early age widow's or widower's COLA
disregard. In accordance with
RSA
435.138, this mandatory coverage group covers
a disabled person who was denied SSI due to early receipt of Social Security
widow's or widower's benefits and:
(A) is at
least 60 years of age;
(B) is not
eligible for Medicare; and
(C)
meets current SSI eligibility criteria, excluding from countable income the
RSDI benefit and any subsequent COLA increases in RSDI.
(8) SSI denied children. In accordance with
§1902(a)(10)(A)(i)(II) of the Social Security Act (RSA
1396a(a)(10)(A)(i)(II)),
this mandatory coverage group covers a person who:
(A) is under 18 years of age;
(B) was receiving SSI on August 22,
1996;
(C) was subsequently denied
SSI because of the change in disability criteria implemented by the Personal
Responsibility and Work Opportunity Reconciliation Act of 1996 (Public Law
104-193); and
(D) meets SSI eligibility criteria, including
the disability criteria in effect before August 22, 1996.
(c) Optional coverage groups. In
accordance with 42 CFR Part 435, Subpart C, HHSC determines Medicaid
eligibility for MEPD for a person who falls into an optional coverage group
described in this subsection. Although federal regulations may allow other
optional coverage groups, HHSC does not provide benefits to a member of an
optional coverage group unless the group is included in the Texas State Plan
for Medical Assistance.
(1) Institutional. In
accordance with
RSA
435.211, this optional coverage group covers
a person who would be eligible for SSI, as specified in
RSA
435.230, if the person were not in an
institutional setting.
(2)
Institutional special income limit. In accordance with
RSA
435.236, this optional coverage group covers
a person who has lived in an institutional setting for at least 30 consecutive
days, as described in §
RSA 358.433
of this chapter (relating to Special Income Limit), and is eligible under the
special income limit.
(3)
§1915(c) waiver program. In accordance with
RSA
435.217, this optional coverage group covers
a person who would be eligible for Medicaid if institutionalized, but is living
in the community and receiving services under a §1915(c) waiver
program.
(d) Other. In
accordance with the Texas State Plan for Medical Assistance, HHSC determines
Medicaid eligibility for MEPD for a person who meets the criteria for one of
the following services:
(1) Primary home care
services. This is a person who needs primary home care services and meets the
criteria established in §1929(b)(2)(B) of the Social Security Act
(RSA
1396t(b)(2)(B))
but is not otherwise eligible for Medicaid.
(2) Program of All-Inclusive Care for the
Elderly (PACE). In accordance with 42 CFR Part 460, this is a person who is
enrolled in a PACE program under a PACE program agreement.
(3)
Susan Walker v. Bayer
Corporation services. A person who has received payments from the
class action settlement of Susan Walker v. Bayer Corporation
may be eligible for Medicaid as a result of excluding from countable resources
the payments from the settlement.
(e) Retroactive coverage. In accordance with
RSA 435.914, HHSC
may determine eligibility for retroactive coverage:
(1) for up to three months before the date of
application for:
(A) an applicant;
(B) a person who has been denied
SSI;
(C) a deceased person, if a
representative for the deceased person requests that HHSC determine eligibility
for retroactive coverage; and
(D) a
person eligible under the SSI-denied-children coverage group in subsection
(b)(8) of this section; and
(2) for up to two months before the month in
which an SSI recipient's Medicaid coverage automatically begins.
(f) Medicare Savings Program. In
accordance with
RSA
1396a(a)(10)(E)
for this mandatory coverage group, HHSC may determine eligibility for a person
who meets the criteria in Chapter 359 of this title (relating to Medicare
Savings Program) for a Medicare Savings Program, which uses Medicaid funds to
help the person pay for all or some of the person's out-of-pocket Medicare
expenses, such as premiums, deductibles, or coinsurance.
(g) Medicaid Buy-In Program. In accordance
with §1902(a)(10)A)(ii)(XIII) of the Social Security Act (RSA
1396a(a)(10)(A)(ii)(XIII))
for this optional coverage group, HHSC may determine eligibility for a person
with a disability who is working and earning income and meets the criteria
established in Chapter 360 of this title (relating to Medicaid Buy-In
Program).
(h) Medicaid Buy-In for
Children. In accordance with §1902(cc) of the Social Security Act
(RSA
1396a(cc)) for
this optional coverage group, HHSC may determine eligibility for a child with a
disability who meets the criteria established in Chapter 361 of this title
(relating to Medicaid Buy-In for Children Program).
