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Effective Date: 
1/2020

Documents

 

Instructions

Updated: 1/2020

 

Purpose

Form 3072 is used to provide information about county program expenditures to provide statewide information for Texas Health and Human Services Commission (HHSC).

 

When to Prepare

Form 3072 must be completed and submitted monthly to the HHSC County Indigent Health Care Program (CIHCP) in Austin by the 10th day of the month following the report month. Any amendments should be identified as such and submitted on Form 3072. The amended item(s) should be circled.

Submit Form 3072 even if no expenditures were made for the month.

Do not send claim payment ledgers with Form 3027.

 

Transmittal

Submit Form 3072 electronically by email to CIHCP@hhsc.state.tx.us. If you cannot submit Form 3072 by email, you may fax it to HHSC at 512-776-7203. It is not necessary to submit 3072 by mail once it has been faxed and received by HHSC CIHCP.

 

Form Retention

File Form 3072 for county records and maintain at least until the end of the third complete state fiscal year.

 

Detailed Instructions

I. Reimbursable Expenditures During This Report Month – Enter the dollar amount spent in the calendar report month for each of the categories in Items 1 through 11. List only expenditures that are applied to state assistance eligibility/reimbursement.

In Item 11, enter the amount of dollars spent if an intergovernmental transfer (IGT) was made to provide health care services as part of the Texas Healthcare Transformation and Quality Improvement Program waiver. Four percent of the General Revenue Tax Levy (GRTL) may be allowed toward eligibility for state assistance.

Total the expenditures by adding Items 1 through 11. Enter this amount in Item 12.

In Item 13, enter the total of all reimbursements received during the calendar report month. Examples: Medicaid reimbursements for Supplemental Security Income (SSI) appellants, refunds from providers, clients and insurance companies. Do not list state assistance funds.

In Item 14, enter the total amount in error (if any) identified in the 6% Eligibility System Review. Total the deductions by adding Items 13 and 14. Enter this deduction total in Item 15.

For the total expenditures that can be applied to state assistance eligibility/reimbursement, subtract the deduction total listed in Item 15 from the expenditure total in Item 12. In Item 16, enter the total dollar amount applied to state assistance.

II. Expenditure Tracking – The county completes this section with information from county records. List the 4%, 6% and 8% GRTL levels.

Signature of Person Submitting Form and Date – The person submitting the form signs and enters the date.