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Effective Date: 
1/2019

Documents

Instructions

Updated: 7/2009

Purpose

  • To notify applicants or representatives that they are eligible for the Client Self-Support Medical Programs.
  • To notify Medically Needy applicants or representatives of the amount of spend down.
  • To give clients or representatives information aboutMedicaid services, rights to appeal and their responsibilities.
  • To inform clients or representatives of their rights to a conference and a fair hearing.
  • To inform clients or representatives of the fair hearing procedures and free legal services.
  • To give clients or representatives a way to request a fair hearing.
  • To provide information about the Women, Infants andChildren (WIC) Program.
  • To inform clients whose Medicaid is ending aboutCertificates of Coverage.

Procedure

When to Prepare

Staff prepare Form H1122 when:

  • certifying applications for ongoing and/or prior coverage,
  • adding a person to a case,
  • three months prior has spend down, or
  • a change will not affect Medicaid benefits.

Note: Use Form H1017, Notice of Benefit Denial or Reduction, when:

  • denying applications,
  • denying an active case, or
  • deleting a person from a case.

Number of Copies

An original and two copies.

Transmittal

Mail or give the original and one copy to the client or his representative. File one copy in the miscellaneous/correspondence section of the case record.

If the client signs and returns Form H1122 to request an appeal, send the form with Form H4800, Fair Hearing Request Summary, and attachments to the hearing officer. The client may also request a hearing in person or by telephone.

Form Retention

The requirements are listed in the Manager's Guide for Eligibility Programs.

Detailed Instructions

  1. At the top, enter:
    • the client's name and address,
    • the case or application number,
    • the date the form is given to the client,
    • the name of the certification staff person completing the form, and
    • information about free legal services. If none,enter "none available."

    Check the boxes in sections 2 through 4 that apply to the eligibility decision.

  2. For each certified person, enter the beginning date of coverage. Enter the ending dates of coverage for
    • persons with three months prior eligibility, and
    • pregnant women.
  3. For Medically Needy cases with spend down, enter the spend down amount and the month in which the client has spend down. List each potentially eligible person.
  4. Complete this section when there is a change which does not affect the client's Medicaid benefits.