Downloading a Form to Your Computer
Fillable forms cannot be viewed on mobile or tablet devices. Follow the steps below to download and view the form on a desktop PC or Mac.
- 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."
- Navigate to the folder you saved the file in and Right Click for PC or Ctrl + Click for Mac, then select "Open With" from the menu and select Adobe Acrobat Reader DC.
Note: Open the PDF file from your desktop or Adobe Acrobat Reader DC. Do not click on the downloaded file at the bottom of the browser since it will not open the PDF in Adobe Acrobat Reader DC. It will try to open the file in the browser that results in the same browser error message.
- 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.
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.
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.
Keep the case record copy for one year from the date of MAO certification.
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.