Downloading a Form to Your Computer
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To notify the:
- individual of Medically Dependent Children Program (MDCP) eligibility;
- individual of termination of MDCP services;
- individual of suspension of MDCP services; and
- Medicaid for the Elderly and People with Disabilities (MEPD) specialist of the change in eligibility status.
For all other case actions, Form 2065-B, Notification of Waiver Services, should be used.
When to Prepare
The Texas Health and Human Services Commission (HHSC) case manager prepares the form when notifying the applicant of application denial or the individual of termination or suspension of waiver services. For case actions that require advance notice, the case manager sends the notice 30 calendar days before the last day of eligibility.
The form must be completed in plain language that can be understood by the applicant or individual. Acronyms for program names may be used on the form only after the complete program name has been spelled out and designated with its acronym. For example, the acronym MDCP may only be used after the program name has been cited as Medically Dependent Children Program (MDCP).
Number of Copies/Transmittal
The HHSC case manager completes an original for the applicant or individual and copies for each provider, the MEPD specialist (when applicable) and the case record.
The case record copy is retained for three years after the case is closed.
If the applicant's or individual's language preference is clearly documented in the case record, the case manager prepares the form in the preferred language. If language is not documented, both English and Spanish forms must be prepared.
This form is found on the HHSC forms website.
Name and Address — Enter the applicant's or individual's name and mailing address in the space provided.
Date — Enter the date the form is being completed. This date must match the date entered on the line labeled Date next to the HHSC case manager's signature on the bottom of the form.
HHSC Case Manager — Enter the case manager's name.
Office Address and Telephone No. — Enter the case manager's mailing address, including the street address or P.O. Box, Mail Code, city, state, ZIP code and telephone number. Information should be typed or printed legibly.
Notification of Ineligibility or Suspension of Waiver Services
The last day you are eligible to receive _________services is _________— Check this box if an individual’s services are being terminated. Enter the name of the program being terminated. Enter the last day the individual is eligible to receive services.
You are not eligible for — Check this box when denial is initiated by the waiver program. Enter the name of the waiver program being denied.
Your _________ services are suspended. The last day you will receive services is _________ — Check this box if the individual’s services have been suspended. Enter the name of the program and the last day the individual will receive services, which is the date of suspension.
Decision Based On
MDCP Rule — Check this box when a denial, termination or suspension is initiated by the MDCP program. The case manager will enter the appropriate rule number that provides the basis for denial, termination or suspension. Under Reason for Denial, Termination or Suspension, enter the plain language phrase that applies to the denial, termination or suspension. See Attachments B, C or D for specific instructions.
Enter the specific reason the applicant or individual does not meet the criteria stated in the Reason for Denial, Termination or Suspension. Use appropriate comments regarding the applicant's or individual's denial, termination or suspension.
Example 1: If services have been suspended for reckless behavior resulting in imminent danger to the provider as reflected in the rule, the case manager must put in the comments:
"You will be contacted by HHSC staff and the provider to determine if the problem that caused the suspension of services can be resolved. If the problem causing suspension of services cannot be resolved by (date), your services will be terminated."
Example 2: If services are being denied or terminated because the applicant or individual does not meet medical necessity criteria, the case manager must put in the comments:
"You are not eligible for [name of service] because you do not require licensed nursing care on a routine basis (medical necessity). Texas Medicaid & Healthcare Partnership (TMHP) previously sent you a letter explaining why you do not meet medical necessity.
The last day that the following providers are authorized to deliver services is — Enter the termination or suspension date on which services by each provider are to be terminated or suspended. This is the last date services can be provided.
Provider — Enter the name of each provider that is no longer authorized to deliver services.
Type — Enter the type of provider:
- AA — Adaptive Aids (for MDCP only)
- FMS — Financial Management Services
- HCSSA — Home and Community Support Services Agency
- MHM — Minor Home Modifications (for MDCP only)
- OHR — Out-of-Home Respite
Vendor — Enter the vendor number of the provider.
Signature and Date — The case manager must sign and date on the date the case manager completed Form 2065-C.
Name — Enter the name of the applicant or individual from Page 1.
Number — Enter the applicant's or individual's identification number. This is the client number, Medicaid number or individual number assigned through the Texas Integrated Eligibility Redesign System (TIERS) or the Service Authorization System (SAS).
Request for Fair Hearing — The applicant or individual checks the box if he wishes to appeal. He prints his name, signs and dates the form, and returns it to HHSC.