The Texas Medical Assistance Program provides, under Title XIX (Medicaid) of the Social Security Act, certain benefits to all individuals who meet the department's definition of eligible recipients. Eligible recipients are:

1. (1) individuals who are:

   1. (A) Temporary Assistance for Needy Families (TANF) recipients whose eligibility criteria are outlined in Chapter 3 of this title (relating to Income Assistance Services);
   2. (B) Pregnant women and children whose eligibility criteria are outlined in Chapter 4 of this title (relating to Medicaid Programs--Children and Pregnant Women); or
   3. (C) Medically needy recipients whose eligibility criteria are outlined in Chapter 2 of this title (relating to Medically Needy Program).
2. (2) certain children in approved foster care plans;
3. (3) individuals who are receiving supplemental security income (SSI) cash benefits under Title XVI of the Social Security Act. The Social Administration (SSA) establishes initial and continuing eligibility by using SSI eligibility criteria. These individuals are eligible for Medicaid benefits as long as they are eligible to receive SSI cash benefits. SSA notifies the department when an individual is added to the SSI eligibility rolls, and the department sends the recipient notification of Medicaid eligibility, identification cards, and an explanation of Title XIX benefits;

4. (4) individuals who live in a Title XIX-approved long-term care medical facility and who would be eligible for SSI cash benefits if they were living outside the facility except that their incomes exceed the SSI payment standard but are less than a special income limit established by the department. An individual must live in one or more institutions throughout at least 30 consecutive calendar days to be eligible under the special income limit:

   1. (A) individuals in approved sections of Title XIX intermediate care and skilled nursing facilities may be of any age, as long as they are otherwise eligible;
   2. (B) individuals in approved Title XIX intermediate care facilities or approved Title XIX intermediate care units in institutions for mental retardation may be any age, as long as they are otherwise eligible;
   3. (C) if the individual leaves the Title XIX facility to enter a Title XIX-approved hospital and upon release from the hospital re-enters a Title XIX facility, he remains eligible for Medicaid. If he is released from the hospital to a living arrangement other than a Title XIX facility, he is no longer eligible;

5. (5) individuals who are eligible for vendor payments in Title XIX-approved long-term care facilities and whose incomes exceed the special income limit because of a cost-of-living increase in any pension or retirement benefits. These individuals continue to be eligible for Title XIX coverage under Type Program 51:

   1. (A) to maintain eligibility under this program, these individuals must continue to live in a Title XIX medical facility, to require long-term care, and to meet all SSI eligibility standards except for income;
   2. (B) countable income, excluding the amount of the applicable pension or retirement benefit increase(s), must be less than the special income limit established by the department;
   3. (C) in redetermining eligibility, the department excludes all future cost-of-living increases in any pension or retirement benefits as long as an individual remains eligible under Type Program 51;

6. (6) individuals in a Title XIX-approved medical facility for whom vendor payments were made under Title XIX for the month of December 1973. These individuals remain eligible for Title XIX benefits under Type Program 02, subsequent to January 1, 1974, as long as they:

   1. (A) remain in the facility continuously, except for brief home visits not to exceed three days;
   2. (B) continue to meet the department's December 1973 eligibility standards;
   3. (C) continue to need care as determined under utilization review plans and other professional audit procedures applicable under the Title XIX program. If the individual leaves the Title XIX medical facility to enter a Title XIX-approved hospital, and upon release from the hospital re-enters a Title XIX facility, he is considered to have remained in a Title XIX facility on a continuous basis. If upon release, however, he enters a living arrangement other than a Title XIX facility, his Medicaid eligibility ends;
7. (7) individuals who were receiving both public assistance and Social Security benefits in August 1972. These individuals continue to be eligible for Title XIX coverage under Type Program 03. They must meet SSI eligibility criteria in the current month, with the exclusion of the amount of the October 1972 20% increase. Subsequent increases in Social Security benefits, however, are not exempt for this group;
8. (8) individuals who were denied SSI benefits for any reason since April 1977. These individuals may be eligible for continued Title XIX coverage under Type Program 03, if they meet all current SSI eligibility criteria except for any Social Security cost-of-living increases received since they last received both SSI and Social Security benefits in the same month. The earliest cost-of-living increase that can be excluded under Type Program 03 is the increase received in July 1977;

9. (9) individuals who are covered under Rider 49 provisions, and who were receiving Level II intermediate care in a Title XIX nursing facility on March 1, 1980. These individuals continue to be eligible for Title XIX medical benefits upon discharge from the facility, if they continue to meet:

   1. (A) the categorical and financing eligibility criteria last used to determine eligibility in the nursing facility; and
   2. (B) the criteria for Level II intermediate care as determined by the long-term care units of the Texas Department of Health (TDH). This eligibility category is also available to individuals who were Medicaid eligible and receiving Level III intermediate care or skilled nursing care in a Title XIX nursing facility on March 1, 1980, and who are subsequently determined to meet Level II intermediate care. Department staff determine continued eligibility using the criteria for Type Programs 02, 03, 14, or 51, depending upon which criteria applied when the recipient last lived in a Title XIX nursing facility;

10. (10) individuals who were denied SSI benefits because of an increase in or receipt of RSDI disabled children's benefits. These individuals may continue to be eligible for Medicaid if they:

    1. (A) are at least 18;
    2. (B) become disabled before they are 22;
    3. (C) are denied SSI benefits because of entitlement to or an increase in RSDI disabled children's benefits received on or after July 1, 1987, and any subsequent increase; and
    4. (D) meet current SSI criteria, excluding the children's benefit specified in this paragraph;

11. (11) disabled individuals who were denied SSI benefits because of receipt of Social Security early aged widow's or widower's benefits may continue to be eligible for Medicaid until they are eligible for Medicare. Medicaid benefits cannot begin before July 1, 1988, regardless of when an individual became eligible for or was denied SSI. To be eligible, an individual must:

    1. (A) be at least 60; and
    2. (B) continue to meet current SSI eligibility criteria if the early aged widow's or widower's benefit is excluded;
12. (12) individuals who are aliens living illegally in the United States (as mandated by the Omnibus Reconciliation Act of 1986 and the Immigration Reform Control Act of 1986). The Medicaid coverage is limited to emergency medical conditions (as defined by the National Heritage Insurance Corporation), and aliens are required to meet all of SSI criteria;
13. (13) individuals who apply for AFDC, SSI, or medical assistance only (MAO) are eligible for Medicaid coverage of unpaid medical bills during the three months before application. When a bona fide agent requests application services, this provision also covers deceased individuals;
14. (14) individuals who are non-Medicaid eligible but may receive Title XIX primary home care services. Waiver 5 eligibility does not entitle the client to any other Title XIX services;
15. (15) children who are medically handicapped and are eligible to receive waiver services of a licensed nurse and other HCFA-approved home and community-based Medicaid services;
16. (16) individuals who are enrolled in Medicare Part A; have income below established poverty levels; have resources no more than twice the limit for the SSI program. These individuals may be eligible to be qualified Medicare beneficiaries (QMBs). QMB clients do not receive regular Medicare benefits;
17. (17) children who were receiving SSI benefits as of August 22, 1996, and were subsequently denied because of the change in disability criteria required by Public Law 104-193. This coverage is mandated by Public Law 105-33, the Balanced Budget Act of 1997, effective July 1, 1997.

Source Note:The provisions of this §358.105 adopted to be effective April 17, 1989, 14 TexReg 1083; amended to be effective July 1, 1997, 22 TexReg 12791; amended to be effective August 26, 1999, 24 TexReg 6515; transferred effective September 1, 2004, as published in the Texas Register September 17, 2004, 29 TexReg 9013.