Effective Date: 6/2010


Word: H0064.doc

PDF: H0064.pdf


Updated: 6/2010


To provide a process for HHSC advisors to refer children deemed eligible for SKIP to the state employee's agency benefits coordinator.


When to Prepare

Complete the SKIP Referral Form H0064 after an eligibility determination is made for a state employee's child(ren) deemed eligible for SKIP.

Number of Copies

Prepare an original and one copy.


Original — Give the original to the client.

Form Retention

File a copy in the case record.

Detailed Instructions

After the advisor makes a Medicaid eligibility decision and identifies a state employee's child(ren) eligible for SKIP, complete all identifying information on the SKIP Referral Form H0064. Enter the date, advisor name, office address, and telephone number.

Employee Name — Enter the name of the state employee.

Employee SSN — Enter the state employee's SSN.

Child(ren)'s Name(s), Date of Birth, SSN and Relationship to Employee — Enter the names and SSNs of the children eligible for SKIP.

Reason for Medicaid Denial

Indicate the reason the applicant's child(ren) are not eligible for Medicaid. Enter adjusted gross income (AGI) and HH size.

Having trouble viewing or downloading a form?

Get Help