Effective Date: 
3/2002

Documents

Instructions

Updated: 4-1990

PURPOSE

To inform clients of their rights and responsibilities concerning transitional Medicaid benefits.

PROCEDURE

When to Prepare

Certification office staff provide Form H1017-B in conjunction with Form H1017 or Form H1017-A when denying the household's TANF benefits and transferring them to TP 07 or TP 37 transitional Medicaid.

Number of Copies and Transmittal

Certification office staff attach one copy of Form H1017-B to Form H1017 or Form H1017-A and give or mail both forms to the household. It is not necessary to attach a copy of Form H1017-B to the case record copy of Form H1017.

Form Retention

There is no retention requirement.

DETAILED INSTRUCTIONS

When providing Form H1017-B to the client in person, certification office staff should verbally explain the transitional Medicaid reporting requirements.

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