Downloading a Form to Your Computer
- Right Click for PC or Ctrl + Click for Mac on the PDF link and click “Save link as” from the menu.
- Select the folder you want to save the file in and then click "Save."
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- the MN Clearinghouse with information needed to determine spend down for clients.
- the client with information needed to submit medical bills to the Clearinghouse.
When to Prepare
The advisor prepares two copies of the transmittal side of the card when an applicant must meet spend down to become Medicaid-eligible.
The client completes the insurance information side of the card when he submits medical bills to the Clearinghouse.
Number of Copies
Complete two originals in ink.
- mails one card to the Texas Medicaid and Healthcare Partnership (TMHP) address: Spend Down Unit, PO Box 202947, Austin, TX 78720-2947; and
- gives the client one card and a stamped envelope addressed to the Clearinghouse when the applicant must meet spend down to become Medicaid-eligible.
The client mails the card the first time he sends medical bills to the Clearinghouse.
No retention requirements.
Complete only the transmittal side of the card.
Application No., Case Name, D.O.B., Sex, and Address — Self-explanatory.
TPR (private insurance) — Check the appropriate box indicating whether the client or other household member(s) has health insurance.
Three Months Prior — Check the appropriate box indicating whether the client is applying for three months prior assistance. If yes, indicate which prior month the client is applying for and the spend down amount for that month in the Month, SD Amount section.
The client completes the insurance information side of the card.
Month, SD Amount — Indicate the month(s) and spend down amount(s) for which the client is applying. Do not enter month(s) without spend down or month(s) for which the client has insufficient bills to meet spend down.
*Other Case No(s) — Use this section to cross reference other cases to which the Clearinghouse should refer when working this case. Situations for cross referencing include the following:
- A month previously included in another case is again included in this case.
- Two application months are processed with the same Form H1010-B at the same interview, and both months have spend down.
Include a brief explanation for the cross reference.