1 Tex. Admin. Code § 360.117 - Cost Sharing
(a) Monthly
premiums. As a condition of establishing initial MBI eligibility and to remain
eligible, a person must pay monthly premiums, as explained in this section,
based on the amount of the person's countable earned and countable unearned
income. A person may be exempt from paying monthly premiums as described in
subsection (h) of this section.
(b)
Countable earned income. For purposes of this section, countable earned income
is as defined in 20 CFR
§
16.1110 and §
416.1111,
minus:
(1) earned income that is excluded by
federal law, as explained in
20 C.F.R.
416.1112(b); and
(2) mandatory payroll deductions for federal
income tax, FICA, and retirement withholding.
(c) Countable unearned income. For purposes
of this section, countable unearned income means unearned income, as defined in
20 C.F.R.
416.1120 -
20 C.F.R.
416.1123, minus the exclusions and exemptions
explained in
20 C.F.R.
416.1124.
(d) Calculation of monthly premium. The
monthly premium amount equals the amount of a person's countable unearned
income for the month that exceeds the Supplemental Security Income (SSI)
federal benefit rate for an individual, plus:
(1) $20 when monthly countable earned income
is above 150% of the federal poverty level (FPL) up to and including 185% of
the FPL;
(2) $25 when monthly
countable earned income is above 185% of the FPL up to and including 200% of
the FPL;
(3) $30 when monthly
countable earned income is above 200% of the FPL up to and including 250% of
the FPL; or
(4) $40 when monthly
countable earned income is above 250% of the FPL.
(e) Upper limit on monthly premiums. The
upper limit for the total monthly premium per person is $500. If the unearned
income premium amount plus the earned income premium amount equals or exceeds
$500, then the total monthly premium remains at $500.
(f) Payment of monthly premiums to establish
initial eligibility. If the calculation explained in subsection (d) of this
section results in an amount greater than $0, HHSC sends the person a written
notice of the person's potential eligibility as described in this subsection.
The initial eligibility period begins with the earliest benefit month and
continues through the end of the latest benefit month identified on the written
notice of the person's potential eligibility. This subsection explains the
procedures that are followed and the requirements the person must meet to
establish eligibility under this section for any or all of the months within
the initial eligibility period. The steps are as follows:
(1) HHSC determines that the person is
potentially eligible if the person meets all eligibility requirements for MBI
other than the requirements of this section.
(2) HHSC sends the person a written notice
(the notice) of the person's potential eligibility. The notice identifies the
earliest month of potential eligibility and the amount of the monthly premiums
due for each month in the initial eligibility period.
(3) The notice also includes:
(A) the total amount in monthly premiums that
must be paid to obtain MBI coverage for the entire initial eligibility period;
and
(B) the deadline by which
payment must be submitted.
(4) The person chooses whether to pay the
monthly premiums for either the entire initial eligibility period or for only a
portion of the initial eligibility period (according to the months during which
the person desires MBI coverage).
(5) The person submits to HHSC, by the
deadline stated in the notice, either the total amount due as explained in the
notice or a lesser amount if the person is not seeking coverage for the entire
initial eligibility period.
(6) If
the person submits payment of less than the total amount due to obtain MBI
coverage for the entire initial eligibility period, HHSC applies the amount
submitted first to satisfy the monthly premium for the month following the
month of the notice, then to each prior month of potential eligibility, in
reverse chronological order. After this, if any amount remaining is less than
the premium for a full month's coverage, HHSC refunds that amount to the
person.
(7) HHSC notifies the
person of MBI eligibility and of the beginning date of MBI coverage, based on
the amount submitted by the person under paragraph (5) of this
subsection.
(8) If no amount is
submitted by the deadline stated in the notice, or if the amount submitted is
less than one month's premium such that it is refunded to the person as
explained in paragraph (6) of this subsection, HHSC denies the person MBI
eligibility. A person denied under this paragraph must file a new application
for MBI before eligibility can be established.
(g) Payment of monthly premiums after initial
eligibility. Monthly premiums after a person establishes initial eligibility
under subsection (f) of this section are due and payable to HHSC no later than
the last calendar day of each month, and are applied to the following month's
eligibility and coverage of MBI benefits. If a monthly premium payment that is
due is not received by HHSC by the end of the month, after written notice, HHSC
may terminate the person's MBI eligibility.
(h) An MBI recipient residing in a federally
declared disaster area is exempt from paying monthly premiums for up to three
months beginning with the month in which the disaster is declared. A recipient
will only be exempt from paying monthly premiums once per disaster.
Notes
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