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Effective Date: 
5/2012

Documents

Instructions

Updated: 5/2012

Procedure

The applicant must meet financial eligibility to be enrolled in the Texas Home Living (TxHmL) Waiver Program. The Local Authority (LA) will attempt to obtain information about the applicant’s financial eligibility status before processing enrollment in the TxHmL Program. The LA must review the Client Assignment and REgistration (CARE) System screen C63 to verify the applicant’s Medicaid status. If the applicant has not applied for Supplemental Security Income (SSI) through the Social Security Administration (SSA) or Medicaid through the Texas Health and Human Services Commission (HHSC), the LA must direct the applicant to submit an application to the SSA or HHSC as appropriate. The LA must offer to assist the applicant with the application process. If the applicant has been denied Medicaid, the LA will submit this form as per the detailed instructions below.

This form is to be used only for applicants who are being denied the TxHmL Program because of a denial of financial eligibility. The individual will be denied TxHmL program services if they do not meet financial eligibility criteria for the TxHmL program.

Detailed Instructions

If the applicant has been denied SSI or Medicaid, the LA must complete Form 5842 and submit it to HHSC. A copy of the SSI denial letter from the SSA or the Medicaid denial letter from HHSC must be submitted with Form 5842.

Date — Enter the date the LA sent the form to HHSC.

LA Name — Print the name of the LA that is coordinating the enrollment process.

Comp Code — Enter the three-digit component code for the LA.

LA Contact — Print the name of the LA contact who is coordinating the enrollment process.

Area Code and Telephone No. — Enter the area code and telephone number of the LA contact.

Applicant Name — Print the name of the applicant who is requesting enrollment in the TxHmL Program.

Client Assignment and REgistration (CARE) Identification No. — Enter the applicant’s CARE identification number.

Medicaid No. — Enter the applicant’s Medicaid number (if applicable).

Date of Birth — Enter the applicant’s date of birth.

Mailing Address — Enter the applicant’s mailing address, including city, state and ZIP code.

Applicant’s Name — Print the name of the applicant who is requesting enrollment in the TxHmL program.

Signature — Applicant or Applicant’s LAR — Obtain the signature of the applicant or the applicant’s LAR.

Printed Name — Applicant or Applicant’s LAR — Print the name of the applicant or the applicant’s LAR.

Date Signed — Enter the date the applicant or the applicant’s LAR signed the form.

Signature — LA Contact (name listed above) — Enter the signature of the LA contact who is coordinating the applicant’s enrollment in the TxHmL Program.

Job Title — Enter the job title of the LA contact who is coordinating the enrollment.