Effective Date: 
9/2007

Availability

Note: This is a secure form and is not available through this site. This form must be ordered at a local HHSC office.

 

Instructions

Updated: 7/2015

 

PURPOSE

To provide an eligible individual with a document that verifies eligibility for Medicaid benefits.

 

PROCEDURE

When to Prepare

Use Form H1027-A only in the following situations.

  1. A presumptively eligible individual needs immediate care.

    Note: Do not issue Form H1027-A based on an assumption of eligibility unless the person has a completed Form H1266, Short-term Medicaid Notice: Approved, showing the date the person is approved for coverage.
     
  2. A newly certified individual needs immediate medical care, and the eligibility specialist has determined eligibility and disposed the Eligibility Determination Group (EDG) in the Texas Integrated Eligibility Redesign System (TIERS). 
    • An eligible individual has lost, not received or has no access to the individual’s Your Texas Benefits (YTB) Medicaid card. For example, a Texas Women’s Health Plan recipient, especially an adolescent, needs confidential family planning services.

      Authorized issuers must verify current eligibility and Medicaid limitations (such as an emergency medical condition, lock-in status, presumptive eligibility or a managed care plan). Before issuing Form H1027-A, authorized issuers must verify eligibility by:
  • observing the conditions in the note above for presumptively eligible individuals,
  • contacting Data Integrity (DI), or
  • checking the person’s Medicaid history in TIERS.

If verification is impossible because of computer problems, follow regional procedures to verify eligibility.

Do not issue Form H1027-A routinely. Only intake screeners or Medicaid, Community Care for Aged and Disabled (CCAD), foster care, or adoption assistance eligibility specialists and supervisors are authorized to complete the form.

Note: Before issuing the form, the authorized issuer completing Form H1027-A must get supervisory approval showing verification of:

  • current eligibility, and
  • lock-in or emergency status.

Upon approval, the supervisor (or someone who is the acting supervisor, for example, a Texas Works Advisor III) must sign and date Form H1027-A and return it to the authorized issuer. If the supervisor does not work in the office where the form is issued, the lead eligibility specialist may approve Form H1027-A. The supervisor may also give approval by telephone. If the supervisor gives approval by telephone, enter "Approved by," the supervisor's name and the initials of the person getting the approval.

Complete manual Form H1027-A in ink or type, or print the form from TIERS correspondence.

Number of Copies

The manual form is a three-part form. Keep and image the pink copy.

For TIERS-generated forms, print the original and give it to the individual after Texas Health and Human Services Commission (HHSC) staff have signed the form. Since TIERS Correspondence history will show when Form H1027-A is issued, staff do not have to make a copy of the form to send for imaging into the state portal.

Transmittal

Manual form

Issue a manual Form H1027-A when it is not possible to generate the form from TIERS and the individual cannot print a temporary YTB Medicaid form from YourTexasBenefits.com.

Give the original and yellow copy to the individual or the individual’s payee, guardian, authorized representative or another person acting in good faith for the individual. DO NOT give the form to a medical provider. Tell the person to give the yellow copy to the pharmacy vendor. Submit the pink copy for imaging.

Mail Form H1027-A if the individual cannot pick up the form in person. If a person asks for Form H1027-A to get family planning services, do not mail Form H1027-A to the person unless the person agrees to the mailing, because family planning services require confidentiality.

If mailing is necessary, do the following:

  • Date the affidavit section of the original and both copies.
  • Include instructions to the individual to sign the original and yellow copies.
  • Mail the original and yellow copies to the individual.
  • Document in TIERS Case Comments the date the form was mailed to the individual.
  • Submit the pink copy for imaging.

TIERS-Generated Form

  • Generate the form in TIERS Correspondence.
  • Have required HHSC staff sign the form.
  • Give the original to the individual or the individual’s payee, guardian, authorized representative or another person acting in good faith for the individual. DO NOT give the form to a medical provider.
  • Tell the individual to sign the form.

Mail Form H1027-A if the individual either asks for the form to be mailed or cannot pick up the form in person. If a person asks for Form H1027-A to get family planning services, do not mail the form to the person unless the person agrees to the mailing, because family planning services require confidentiality.

If mailing is necessary, do the following:

  • Get required HHSC staff signatures.
  • Include instructions to the individual to sign the form.
  • Mail the form and instructions to the individual.
  • Document in TIERS Case Comments the date the form was mailed.

Form Retention

Keep the case record image for a minimum of three years after the case is closed or denied.

 

DETAILED INSTRUCTIONS FOR MANUAL FORM H1027-A

Use these instructions for completing the manual Form H1027-A in the event the form cannot be generated from TIERS and the individual cannot print a temporary YTB Medicaid form from YourTexasBenefits.com.

Store local supplies of manual Form H1027-A in a locked file cabinet. For more information, refer to your regional security plan.

If the person does not yet have a client number:

  • check the corresponding box, and
  • move to the eligibility verification section.

If the person has a client number but has lost, not yet received or has no access to a current YTB Medicaid card:

  • check the corresponding box, and
  • move to the eligibility verification section.

Complete the eligibility verification section to show the date you verified eligibility and whether you verified it by:

  • contacting the DI unit,
  • checking TIERS Individual — Medicaid History, or
  • following regional procedures.

H1027-A Individual Medicaid History

Complete this section according to instructions for each entry.

Client Name— Enter the name of each certified member of the group who needs immediate medical care. Draw a diagonal line across unused lines to prevent unauthorized additions to the certified group.

Note: Issue a separate Form H1027-A for a certified group member who is in lock-in status.

Date of Birth— Enter each person's date of birth as shown on the certification document or TIERS inquiry.

Client No.— Enter the nine-digit client number for each person listed. For individuals without a client number, enter "to be assigned."

Eligibility Dates— Enter the date (MM/DD/YYYY) the person became eligible for Medicaid benefits, and enter the last day of the month in which Form H1027-A is issued.

Important: Medicaid eligibility is limited to the calendar month in which Form H1027-A is issued.

Exception: For individuals with Emergency coverage, enter the earlier of:

  • the last day of the current month, or
  • the last day of treatment for the emergency condition that is in the current month.

Medicare Claim No.— Enter the Medicare claim number (Social Security claim number) for each person, if the person has a Social Security claim number.

STAR/STAR+PLUS Health Plan Information— Enter the name of the health plan for each person who is enrolled in the STAR or STAR+PLUS Health Plan.

Managed care shows the person’s primary care physician (PCP) name and identifies the managed care plan by its code number (for example, 10). See Section C-1116, Managed Care Plans, of the Texas Works Handbook for plan names and toll-free telephone numbers.

Plan information is arranged by managed care service area. Each service area shows the counties covered in that area. Plans reflect the plan name and plan's toll-free telephone number. HHSC maintains and updates the handbook as changes occur.

Note: The following Medicaid recipients are eligible for unlimited paid prescriptions:

  • Nursing facility residents
  • Individuals age 20 and under, through the month of their 21st birthday
  • Community Living Assistance and Support Services (CLASS) or other non-Supplemental Security Income (SSI) community-based waiver individuals
  • Individuals who are on the STAR/STAR+PLUS Health Plan (individuals with Medicare who are enrolled in STAR+PLUS may be limited to three prescriptions per month)

Signature — Client and Date— The person to whom Form H1027-A is given must read the affidavit portion of the form and sign and date the original. If the form is given to a payee, guardian or other representative of the individual, that person must sign in the appropriate space.

Office Address and Telephone No.— Enter the office address and telephone number in this space at the lower left corner.

Worker Information— Enter the authorized issuer's name and telephone number. The authorized issuer must sign and date the form.

Supervisor Information— Enter the supervisor's name and telephone number. The supervisor must sign and date the form. If the supervisor does not work in the office where the form is issued, the lead eligibility specialist may approve Form H1027-A.

DETAILED INSTRUCTIONS FOR TIERS-GENERATED FORM H1027-A

From the left navigation bar, select Correspondence > Generate Manual Corres.

Search Case Information Page

  • Enter the Case or Application number.
  • Select the Type from the drop-down menu.
  • Click Search.

H1027-A TIERS Generated Form H1027-A

  • Select the Individual Name.
  • Click Next.

Search Document Information Page

  • Select Benefit Issuance for Document Type.
  • Click Search.
  • Click the hyperlink for Form 1027-A or other appropriate Medicaid eligibility verification.

H1027-A TIERS Generated Form Screenshot 2

Form 1027-A Detail Information — Additional Info Page

  • Select the EDG number.
  • Select the current month.
  • Select the Individual.
  • Click Generate Form.

Repeat this process for each person.

H1027-A TIERS Generated Form Screenshot 3

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