Form H1279, Spousal Impoverishment Notification

Instructions

Updated: 4/2007

Purpose

• To notify the client or responsible party, in spousal impoverishment applications, of the initial eligibility period.
• To notify the client or responsible party that at the end of the initial eligibility period, resources in the name of the institutionalized spouse will be tested against the resource limit for an individual.
• To notify the client or responsible party that interspousal transfers are permitted.
• To notify the client or responsible party of a potential transfer-of-assets penalty if resources are transferred to anyone other than the spouse.

Procedure

When to Prepare

Complete Form H1279 when an applicant in a spousal impoverishment case is certified for medical assistance only (MAO) and a spousal protected resource amount (SPRA) was used in determining resource eligibility.

Number of Copies

Complete an original and one copy.

Transmittal

Send the original to the client or responsible party at the same time that Form H1230, Notification of Eligibility — Regular Medicaid Benefits, is sent.

Keep the copy in the case record.

Form Retention

Keep the case record copy for one year from the date of MAO certification.

Detailed Instructions

Heading — Enter the name of the client and his mailing address or that of the responsible party.

Date — Enter the date Form H1279 is mailed in conjunction with Form H1230, Notification of Eligibility — Regular Medicaid Benefits.

HHSC Staff — Self-explanatory.

Office Address and Telephone No. — Enter the complete office address and telephone number of the eligibility specialist.

The Health and Human Services Commission will conduct an annual ... review no later than ... — Enter the month and year that is twelve months from the month and year of certification.