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Effective Date: 
4/2008

Documents

Instructions

Updated: 5/2013

Purpose

  • To notify an institutionalized individual and the facility of co-payment amounts to be retroactively reconciled.
  • To notify an institutionalized individual of the right to appeal a retroactive reconciliation of co-payment which causes the individual to owe additional amounts of money to the NF/ICF-IID facility.
  • To notify the individual and the facility of the correction of a payment plan for an SSI recipient.
  • To notify the individual and the facility of a retroactive lowering of co-payment.

Procedure

When to Prepare

  • When co-payment is being retroactively reconciled.
  • When the initial payment plan for an SSI recipient is incorrect.
  • When locking in future co-payment for SSI recipients in NFs and ICF-IID facilities.
  • When co-payment must be retroactively lowered.

Number of Copies

To Retroactively Reconcile Co-Payment — Complete an original and three copies.
To Correct Payment Plan of SSI Recipient — Complete an original and two copies.
To Retroactively Lower Co-Payment — Complete an original and two copies.

Transmittal

To Retroactively Reconcile Co-Payment —

  • Send the original and first copy to the individual/authorized representative, with a prepaid return envelope.
  • Send the second copy to the facility. Hold the facility's copy for 13 days if the reconciliation causes the individual to owe the facility more money. (If the individual has elected hospice, as evidenced by receipt of the Form 3071, Recipient Election/Cancellation Notice, send the facility copy to the hospice provider.)
  • The third copy is sent to Midland for imaging.

To Correct Payment Plan for SSI Recipient — Send the original to the individual and the first copy to the facility. (If the individual has elected hospice, as evidenced by receipt of the Form 3071, Recipient Election/Cancellation Notice, send the facility copy to the hospice provider.) If co-payment is being raised prospectively, also send Form H4808, Notice of Change in Applied Income/Denial of Medical Assistance or TF0001, Notice of Case Action, and hold the facility's copy of the Form H1259 for 13 days.  The second copy is sent to Midland for imaging.

To Retroactively Lower co-payment — Send the original to the individual and the first copy to the facility. (If the individual has elected hospice, as evidenced by receipt of the Form 3071, Recipient Election/Cancellation Notice, send the facility copy to the hospice provider. In state supported living center cases, the Form H0090-I is sent to the reimbursement manager instead of the Form H1259.) The second copy  is sent to Midland for imaging.

Form H4808 or TF0001 must be sent when the ongoing budget is changed.

 

Detailed Instructions

To — Enter the name of the Individual and his mailing address or that of his responsible party.

Mail Code — Self-explanatory.

Date — Self-explanatory.

Eligibility Specialist — Self-explanatory.

Office Address and Telephone Number — Enter the eligibility specialist's complete office address and telephone number. Include the TDD telephone number if the office is equipped with TDD.

Case Name — Self-explanatory.

Client No. — Enter the nine-digit recipient number.

Facility Name — Self-explanatory.

Complete Mailing Address — Enter the facility's complete mailing address.

Notice of Reconciliation of Variable Income/Incurred Medical Expenses — Check this box if the Form H1259 is submitted to retroactively reconcile co-payment in accordance with income averaging/IME procedures.

The amount of income you actually receive each month — Check this box if reconciliation involves variable income.

The amount of allowable medical expenses actually incurred each month — Check this box if reconciliation involves IMEs.

Co-Payment Corrections — Check the appropriate box to indicate whether the co-payment is being corrected due to an income adjustment or incurred medical expenses.

The eligibility specialist enters all income into the TIERS income screens and runs eligibility.  If the reconciliation results in an increase in co-payment, the status will be “No O/P” and the newly calculated co-payment will NOT be sent to Service Authorization System Online (SASO).  The eligibility specialist will view the new co-payment TIERS calculated and use the Left Nav Copay Change screen to send the co-payment increases to SASO on a month by month basis.  All decreases in co-payment will be automatically sent to SASO when the specialist disposes the case.

From — Enter the beginning date of each period of co-payment adjustment (for example: the block of months covered by the co-payment adjustment).

Through — Enter the ending date of each period of co-payment adjustment (for example: the block of months covered by the co-payment adjustment).

When reporting an adjustment to an SSI client's ongoing co-payment, do not enter an ending date. Enter "ONGOING" in this space to lock-in the new co-payment. Reminder: Form H4808 or TF0001 must also be sent when the ongoing budget is changed.

Type Program — Enter for each period of co-payment adjustment the Type Program under which the individual was certified.

Co-Payment — Enter for each period of co-payment adjustment the co-payment as shown on the Service Authorization System Online (SASO).

Corrected Co-Payment — Enter for each period of co-payment adjustment the corrected co-payment.

Amount Facility Owes You — If co-payment as shown on the Service Authorization System Online (SASO) exceeds corrected co-payment, enter the difference here.

Amount You Owe Facility — If corrected co-payment exceeds co-payment as shown on the Service Authorization System On-line (SASO), enter the difference here.

Totals — Enter the totals for the Amount Facility Owes You and Amount You Owe Facility columns.

Comments — Enter any comments that may be of benefit to the individual or the facility.

Signature — Eligibility Specialist — Self-explanatory.

Page 2: HHSC Staff, Mail Code, Office Address, and Telephone Number — Enter the HHSC staff person's name, mail code, complete office address, and telephone number. Include the TDD telephone number if the office is equipped with TDD.