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Effective Date: 
9/2017

Documents

 

Instructions

Updated: 9/2017

 

Purpose

This form provides a means for the applicant to inform the Texas Health and Human Services Commission of the applicant's health plan choice.

 

Procedure

When to Prepare

Form H2053-B is prepared by Program Support Unit (PSU) staff and is sent with Form 2600-A/Form 2600-AS, MDCP Waiver Release Letter – Medical Assistance Only, or Form 2600-B/Form 2600-BS, MDCP Waiver Release Letter – Supplemental Security Income. PSU staff enter the health plan names for their service delivery area on the lines provided.

Number of Copies/Transmittal

PSU staff send the original to the applicant/responsible party. The applicant/responsible party checks one of the boxes choosing their health plan. The applicant/responsible party completes and returns this form to PSU within 30 calendar days from the date of the STAR+PLUS Home and Community Based Services (HCBS) program or MDCP Release Letter.

Form Retention

The Health and Human Services Enterprise Administrative Report and Tracking System (HEART) is the repository for the electronic case record. Paper copies of Form H2053-B and H2053-BS are not retained. PSU staff open a case record in HEART and upload a copy of the completed Form H2053-B and H2053-BS to the system.

 

Detailed Instructions

Name — PSU staff enter the applicant's name.

Social Security No. — PSU staff enter the applicant's Social Security number.

Type of Service — PSU staff check the box for either STAR+PLUS HCBS program or Medically Dependent Children Program. A paragraph will appear informing the applicant how to begin the application process.

Please select a health plan by checking one of the boxes below — PSU staff enter health plan names on the lines provided, using the Add Line or Remove Line features. Note: The applicant/responsible party will check the box of the health plan the applicant/responsible party chooses.

Signature of Applicant/Responsible Party — The applicant/responsible party signs the form after checking the box for the health plan.

Date — The applicant/responsible party enters the date and returns the form to PSU.