Effective Date: 
3/2018

Documents

Instructions

Updated: 03/2018

Purpose

To provide the Texas Health and Human Services Commission (HHSC) Provider Claims Services with information necessary to initiate and close vendor payments for:

  • transfer of assets penalty period (Mason Manor), or
  • excess home equity (Home Equity Manor).

Procedure

When to Prepare

The Medicaid for the Elderly and People with Disabilities (MEPD) specialist prepares Form H3618-A for eligible Medicaid applicants/recipients being admitted to, and discharged from, a designated vendor number such as Mason Manor or Home Equity Manor.

Number of Copies

The MEPD specialist prepares an original and two copies.

Transmittal

Send original to:
HHSC — Provider Claims Services
P.O. Box 149030, Mail Code W-400
Austin, TX 78714-9030.
Image and retain a copy in the case record.

Detailed Instructions

Complete appropriate Items 1, 2, 3, 4, 5, 6, 7 and/or 8 on each Form 3618-A transaction.

1. Medicaid Recipient Number — Do not use the application number.

2. Social Security Number — Enter the individual's Social Security number, if available.

3. Medicare or RR Retirement Claim Number — Enter the individual's Medicare number or enter the railroad retirement claim number, if known.

4. Name of Resident — Enter the last name, then first name as it appears in HHSC records.

Items 5 and 6 are for the designated vendor numbers. By placing someone in one of the designated vendor numbers, no vendor payment will be paid to the facility for the individual.

5. Designated Vendor Number for Mason Manor — Enter the current Mason Manor designated vendor number for penalty of transfer of assets or enter 5997.

6. Designated Vendor Number for Home Equity Manor — Enter the current Home Equity Manor designated vendor number for excess home equity or enter 5988.

7. Section in Which Resident Is Located — If the resident is located within a nursing facility, check Box 3. If the resident is located within an ICF/IID facility, check the correct section box.

8. Transaction — Use this section to initiate or release vendor non-payment status.

Transfer Penalty

Use Item 8.a. to initiate vendor non-payment status for an applicant and an active recipient.

Begin Date of Penalty: For an applicant with a transfer penalty, this will be the penalty start date. This will function to keep the individual Medicaid eligible, but in a vendor non-payment status. For a current recipient, this will be the start of the vendor non-payment status because restitution will have been requested from the penalty start date through adverse action.

Enter the beginning date or start date of the penalty period. Example: 01-01-07. Enter the current vendor number and the appropriate designated vendor number (Example: 5997 for Mason Manor) to start the penalty period.

Use Item 8.b. to release the vendor non-payment status and initiate vendor payment to the facility where the individual resides.

End Date of Penalty: This will be the last day of penalty period. If the anticipated end date is more than 12 months from initiating the vendor non-payment status, monitor the case and, as appropriate, set a special review to release the vendor non-payment status.

Excess Home Equity

Use Item 8.a. to initiate vendor non-payment status for an applicant and an active recipient.

Begin Date of Penalty: For an applicant with excess home equity, this will be the start date of the vendor non-payment status. This will function to keep the individual Medicaid eligible, but in a vendor non-payment status. For a current recipient, this will be the start of the vendor non-payment status because restitution will have been requested from the excess home equity start date through adverse action.

Use Item 8.b. to release the vendor non-payment status and initiate vendor payment to the facility where the individual resides.

End Date of Penalty: This will be the last day of the penalty period. Normally do not complete Item 8.b. for excess home equity. In an excess home equity case, at review or reported change monitor the value of the home equity. If home equity value is lower than the threshold, release the vendor non-payment status and initiate vendor payment based on the documented verification submitted that justifies the value.

Comments — Use this space for corrections.

MEPD Specialist Name — Self-explanatory.

Employee Number — Self-explanatory.

Telephone Number — Self-explanatory.

Facility Name and Mailing Address — Enter the complete name and mailing address of the facility where the individual is residing and mail a copy to the facility. Also mail a copy to HHSC Provider Claims Services.

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