Texans can dial 2-1-1 (option 6) for information on COVID-19 and local community resources on health care, utilities, food, housing and more. More COVID-19 information.
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.
If still having trouble viewing or downloading a form, click here.
Form 2065-A must be sent in order to:
- provide notice of eligibility for all Community Care for Aged and Disabled (CCAD) services to the individual applying for services;
- provide notice of ineligibility for CCAD services;
- provide notice of suspension for CCAD services;
- notify the individual of the right to a fair hearing and to request a conference;
- notify the individual of a change in eligibility or the amount or level of service;
- provide notice of a transfer between one type of personal attendant service to another;
- notify the individual and provider of the monthly amount of copayment or room and board payment, or both, that the individual must pay;
- remind the individual that all changes (financial, location, medical condition) must be reported to the Texas Health and Human Services Commission (HHSC) case worker within 10 days; or
- provide notification of the retroactive payment plan and dates of prior Medicaid eligibility and advise the individual/provider of provider reimbursement, if appropriate.
When to Prepare
Prepare this form for all the situations listed above. The form must be sent to the individual within specific timelines for the following situations*:
|certified applications||within 2 business days after the decision|
|eligibility for or addition of a new service||within 2 business days after the decision|
|increases in amount of service||within 2 business days after the decision|
|decrease in copayment amount||within 2 business days after the decision|
|denied applications||within 2 business days after the decision|
|granting priority status||within 2 business days after the decision|
|suspension of services||within 2 business days after the decision|
|terminations||12 calendar days before termination when adverse action is required|
|decrease in service units||12 calendar days before decrease|
|increase in copayment amount||12 calendar days before increase|
|ineligibility for or loss of priority status**||12 calendar days before change|
* See the Case Worker Community Care for Aged and Disabled (CW-CCAD) Handbook, Appendix IX, Notification/Effective Date of Decision, for additional details or exceptions.
** This applies only if the individual requested priority status.
If the individual returns Form 2065-A indicating a desire to appeal or orally requests a hearing, the HHSC case worker completes Form H4800, Fair Hearing Request Summary, to be entered in the Texas Integrated Eligibility and Redesign System (TIERS) Fair Hearings.
Number of Copies
The HHSC case worker completes an original and sufficient copies for the individual, the provider, if appropriate, and the case record. An additional copy may be needed by a residential care facility.
The HHSC case worker sends the original and one copy to the individual. A copy is also sent to the provider in these situations:
- Day Activity and Health Services (DAHS) facility for denial of a facility-initiated referral;
- Residential Care (RC) provider for notifications regarding the amount of the individual copayment and room and board, or when the individual is being denied due to failure to pay required fees; and
- Primary Home Care (PHC)/CAS provider when retroactive reimbursement is involved.
The HHSC case worker files the remaining copy in the individual's case folder.
The case record copy is retained for three years after the case is closed.
Date — The HHSC case worker enters the date the form is completed and mailed to the individual. This is the completion date and is considered as day zero for time frame calculation.
HHSC Case Worker — Enter the name of the HHSC case worker.
Office Address, Area Code and Telephone No. — Enter the HHSC case worker's office address, area code and telephone number. Information should be typed or printed legibly.
Individual Name and Address — Enter the individual's name and mailing address.
Notification of Eligibility
Check this box if the individual is being notified of service eligibility. Enter the amount of each specific service being approved , the unit of service (per day, per week, per month) and effective date of the service. Do not enter the number of days of service (i.e., five days per week), except for DAHS.
|Program Name||Program Name
|Adult Foster Care or Residential Care||Cuidado Temporal de Adultos o Atención Residencial||You are eligible to receive one unit of Adult Foster Care (or Residential Care) per day, effective May 1, 2017.|
|Family Care||Servicios de Atención Familiar||You are eligible to receive 20 hours of Family Care per week effective May 1, 2017.|
|Community Attendant Services||Servicios de Ayudante en la Comunidad||You are eligible to receive 20 hours of Community Attendant Services per week effective May 1, 2017.|
|Day Activity and Health Services (DAHS)||Servicios de Salud y Actividades Durante el Día||You are eligible to receive Day Activity and Health Services five full days a week (10 units per week).
In comments, explain: (one unit = a half day). If the individual is authorized for half days, state the number of half days. Be sure the individual knows the number of days per week he is authorized to attend DAHS.
|Emergency Response Services||Servicios de Respuesta de Emergencia||You are eligible to receive one unit of Emergency Response Services per month, effective May 1, 2017.|
|Home Delivered Meals||Comidas a Domicilio||You are eligible to receive five Home Delivered Meals per week, effective May 1, 2017.|
|Primary Home Care
(with a negotiated date)
|Servicios de Atención Esencial en Casa||You are eligible to receive 20 hours of Primary Home Care per week effective the negotiated date.|
|Primary Home Care||Servicios de Atención Esencial en Casa||You are eligible to receive 20 hours of Primary Home Care per week effective May 1, 2017.|
Required Payments: Room and Board — Check this box if the individual is being notified of a required room and board amount. Enter the amount of the payment and when it is to be paid. The first entry is for a partial month prorated amount and the second entry is for the ongoing monthly amount. If the individual enters on the first of the month, both amounts are the same. Example: You must pay $210 on May 1, 2017, then $230 per month effective June 1, 2017.
Required Payments: Copayment — Check this box if the individual is being notified of a required copayment. Enter the amount of the copayment and when it is to be paid. The first entry is for a partial month prorated amount and the second entry is for the ongoing monthly amount. If the individual enters on the first of the month, both amounts are the same. Example: You must pay $210 on May 1, 2017, then $230 per month effective June 1, 2017.
Notification of Ineligibility, Termination or Suspension of Services
Check this box if an individual is not eligible for a CCAD service or if a CCAD service is being terminated or suspended.
- Check the first box in this section if an application or request for a new service is being denied.
- Check the second box within the section if ongoing services are being terminated. Enter the name of the service being terminated and the last day the individual will receive services. Enter the cause of ineligibility.
- Check the third box if services are being suspended. Enter the name of the service and the last day services will be delivered. Enter the reason for the suspension. In the comments section, provide additional information regarding the suspension.
See Appendix XVIII, Time Calculation, for additional information.
When completing Form 2065-AS (the Spanish version), the cause of ineligibility must be recorded in Spanish. If not fluent in Spanish, staff may use Attachment A of Form 2065-A for a Spanish translation.
Rule/Handbook Reference — Enter the rule reference, unless one is not available, then use CW-CCAD Handbook reference reflecting the reason for denial/termination.
Your ________________services will continue without interruption — Check this box and enter the name of any other services for which the individual is eligible that are not being terminated and will continue.
Notification of Change
Check this box if a service plan change is being made. Enter the service being affected, the amount of service currently being received, the amount of service to be delivered once the change is effective and the effective date. For a reduction in service, the effective date is the first date the reduction will be in effect. Example: The service you have been receiving, 20 hours of Family Care, will be changed to 15 hours of Family Care beginning May 1, 2017.
Note: The completion date of Form 2065-A is counted as “day zero.” The next day is “day one” and 12 days are allowed for notification. The effective date is the day after the 12th day.
Notification of Change in Copayment/Room and Board
Check this box to notify the individual of a change in the copayment or room and board amount, regardless of whether an increase or decrease is involved. Enter the new amount, and the date on which payment of the new amount will be effective. Example: Your copayment will change to $330 per month, beginning June 1, 2017.
Enter any appropriate comments regarding the individual's eligibility.
Signature and Date— The HHSC case worker must sign and date Form 2065-A. The date of the HHSC case worker's signature should match the date Form 2065-A was completed and mailed, as indicated in the date box at the top of the form.
Name — Enter the name of the individual from Page 1.
Number — Enter the individual's identification number. This is the individual number, Medicaid number or individual number assigned through TIERS or the Service Authorization System (SAS).
Request for Fair Hearing — The individual checks the box if he wishes to appeal. The individual signs, prints his name, dates the form and returns it to the HHSC case worker.
Name of Case Worker — Enter the name of the case worker assigned to the applicant's or individual's case.
Case Worker’s Telephone No. — Enter the telephone number (including area code) of the case worker.
Supervisor's Name and Telephone No. — Enter the name and telephone number (including area code) of the case worker's supervisor.
Program Manager's Name and Telephone No. — Enter the name and telephone number (including area code) of the program manager.