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.

  1. Right Click for PC or Ctrl + Click for Mac on the PDF link and click “Save link as” from the menu.
  2. Select the folder you want to save the file in and then click "Save."
  3. 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.

Effective Date: 
9/2004

Documents

 

Instructions

Updated: 9/2017

 

Purpose

Form H2065-A must be sent in order to:

  • provide notice of eligibility for all Community Care for Aged and Disabled (CCAD) services to both the applicant and the provider agency.
  • provide notice of ineligibility for all CCAD services, with the exception of 1929(b)-funded Primary Home Care. For 1929(b) denials and terminations, Form H2065-C, Notification of Ineligibility or Suspension, should be used. (STAR+PLUS HCBS program denials/terminations are also made via Form H2065-C.)
  • make the individual/member aware that eligibility is contingent on medical approval.
  • notify the individual/member and provider agency of the monthly amount of copayment for which the individual/member is liable.
  • remind the individual/member that all changes (financial, location, medical condition) must be reported to HHSC within 10 days.
  • notify the individual/member of the change in eligibility status or amount/level of service.
  • notify the individual/member of the right to a fair hearing or conference.
  • provide notification of the effective date of the retroactive payment plan (based on the date services began, per provider agency) and dates of prior Medicaid eligibility.
  • advise the individual/member and provider agency of the amount the agency should reimburse the individual/member if the individual/member is not a current Medicaid recipient.

 

Procedure

When to Prepare

Prepare this form for all the situations listed above. The individual/member must be notified via Form H2065-A within specific timelines for the following situations*:

granted applications

within 2 work days

eligibility for or addition of a new service

within 2 work days

increases in amount of service

within 2 work days

decrease in copayment amount

within 2 work days

denied applications

within 2 work days

granting priority status

2 work days

terminations

12 days prior to termination when adverse action is required

decrease in service units

12 days prior to decrease

increase in copayment amount

12 days prior to increase

ineligibility for or loss of priority status**

12 days prior to change

* See Appendix IX for additional details or exceptions.
** This applies only if the client requested priority status.

If the individual/member returns Form H2065-A indicating a desire to appeal, the caseworker/service coordinator forwards Form H2065-A with Form H4800, Petition for Fair Hearing, and attachments to the hearing officer. If the individual/member verbally requests a hearing, the caseworker/service coordinator should send a memorandum outlining the situation, along with Form H4800, to the hearing officer.

 

Number of Copies

The caseworker/service coordinator completes an original and sufficient copies for the individual/member, each provider, and the case record. An additional copy may be needed by a supervised living facility.

 

Transmittal

The caseworker/service coordinator sends:

  • the original and one copy to the individual/member;
  • a copy to the Day Activity and Health Services facility for denial of a facility-initiated case (Item 4231.2);
  • a copy to the Residential Care provider for notifications regarding the amount of the individual/member copayment (Items 4745 and 4778);
  • a copy to the Primary Home Care (PHC) provider agency to inform the PHC of denial of the individual's/member’s Medicaid eligibility (Item 4621.4);
  • a copy to the PHC provider when retroactive reimbursement is involved(Item 4621.2); and
  • a copy to the PHC provider for denial of presumptive eligibility (Item 4621.5).

The caseworker/service coordinator files the remaining copy in the individual's/member’s case folder. If applicable, the caseworker/services coordinator sends an additional copy to the supervised living facility.

 

Form Retention

The case record copy is retained for three years after the case is closed.

 

Detailed Instructions

I. Demographic Information

Date — The caseworker/service coordinator enters the date the form is completed and mailed to the individual/member.

Caseworker — Enter the name of the caseworker/service coordinator.

Office Address and Telephone No. — Self-explanatory. Information should be typed or printed legibly.

II. Eligibility

Service eligibility — Check this box if you are notifying the individual/member of service eligibility. Enter the amount of each specific service being granted, and effective date of the grant. Example: You are eligible to receive 20 hours of Primary Home Care per week effective November 1, 2017.

Medical approval — Check this box if the grant of service is contingent upon medical approval.

Copayment — Check this box if you are notifying the individual/member of a required copayment. Enter the amount of the payment, and when it is to be paid.

Example: You must pay $210 on November 1, 2017, then $230 per month effective January 1, 2018.

Interest List — Check this box if the individual/member has been placed on an interest list, and enter the name of the service.

III. Changes

Service changes — Check this box if you are making service plan changes, regardless of whether the change is considered to be negative or positive. Enter the service being affected, the amount of service being received, and the effective date. Example: The service you have been receiving, 20 hours of Family Care, will be changed to 15 hours of PHC beginning May 1, 2017.

Copayment changes — Check this box to notify the individual/member of a change in the copayment 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.

IV. Ineligibility

Check this box if an applicant or an individual/member is not eligible for a service.

Enter the name of the service for which the individual/member is no longer eligible, and the cause of ineligibility. Example: You are not eligible to receive Home Delivered Meals because your income exceeds the eligibility limit.

If you are completing the Spanish language version (Form H2065-AS), you must record the cause of ineligibility in Spanish. If you are not fluent in Spanish, use the following table to complete the form.

Denial Code

English Statement

Spanish Statement

09

Your income exceeds the eligibility limit.

Sus ingresos sobrepasan el límite de elegibilidad.

10

Your total resources exceed the eligibility limit.

El total de sus recursos sobrepasa el límite de elegibilidad.

11

You do not meet functional eligibility requirements.

Usted no satisface los requisitos funcionales de elegibilidad.

12

You have moved to a nursing facility.

Usted se mudó a una casa para convalecientes.

13

Your Medicaid has been denied.

Se le negó el Medicaid.

14

Your care will now be provided through [name of provider agency].

Ahora usted va a recibir servicios de [name of provider agency].

15

You do not meet the medical need requirement.

Usted no satisface el requisito de necesidad médica.

16

You have failed to follow ERS service requirements.

Usted no cumplió los requisitos de servicio de ERS.

17

You failed to provide the necessary information.

Usted no presentó la información necesaria.

18

You did not follow the service plan.

Usted no siguió el plan de servicios.

19

This denial code is used when denying after the 30-day presumptive eligibility period:

 

 

You do not meet financial eligibility requirements.

Usted no satisface los requisitos económicos de elegibilidad.

20

You or someone in your home has threatened the health or safety of others.

Usted o alguien de su casa amenazó la salud o la seguridad de alguien más.

21

You have no unmet need for services we provide.

Usted no tiene una necesidad que nuestros servicios podrían satisfacer.

27

You require less than six hours of service.

Usted requiere menos de seis horas de servicio.

71

Funds for purchased services are not available.

No hay dinero para pagar servicios contratados.

 

This code is used when transferring an individual/member to STAR+PLUS:
Your services will now be provided by STAR+PLUS managed care.

Ahora usted va a recibir servicios del plan de atención médica administrada STAR+PLUS.

76

We are unable to locate you.
-or-
You have moved out of our service area.

No lo podemos localizar.
-or-
Usted se mudó fuera del área donde ofrecemos servicios.

77

You have voluntarily withdrawn your request for services.

Usted retiró voluntariamente su solicitud de servicios.

78

You refused to pay your share of the cost of care.

Usted se negó a pagar la parte del costo de los servicios que le tocaba pagar.

Effective date of termination — Check this box (in addition to the ineligibility box, above) if you are terminating services.

Example: The service you are receiving will end September 30, 2017.

Basis for Ineligibility — Enter the CCAD Handbook reference reflecting the reason for denial.

Comments

Enter any appropriate comments regarding the individual's/member’s eligibility.