Revision 20-0; Effective November 2019

 

3100 General Principles

Revision 20-0; Effective November 2019

 

Use the application, documentation and verification procedures established by HHSC or a less restrictive application, documentation or verification procedure.

  • Issue Form 3064, Application for Health Care Assistance, to the applicant or his representative on the same date that the request is received.
  • Accept an identifiable application.
  • Assist the applicant with accurately completing Form 3064 and getting all needed verifications and information if the applicant requests help in completing the application process. Anyone who helps fill out the Form 3064 must sign and date it.
  • If the applicant is incompetent, incapacitated or deceased, someone acting responsibly for the client (a representative) may represent the applicant in the application and the review process, including signing and dating Form 3064 on the applicant’s behalf. This representative must be knowledgeable about the applicant and his household. Document the specific reason for designating this representative.
  • Determine eligibility based on residence, household, resources and income.
  • Allow at least 14 days for requested information to be provided, unless the household agrees to a shorter time frame, when issuing Form 3068, Request for Information.
  • Use any information received from the provider of service when making the eligibility determination, but counties, public hospitals and hospital districts may require further eligibility information from the potentially eligible resident, if necessary.
  • The date that a complete application is received is the application completion date, which counts as Day 0.
  • Determine eligibility not later than the 14th day after the application completion date. If eligibility is not determined within this 14-day period, the applicant is considered eligible and the provider must be notified.
  • Issue written notice of the county’s decision on Form 3077, Notice of Eligibility, or Form 3082, Notice of Ineligibility. If the county denies health care assistance, the written notice shall include the reason for the denial and an explanation of the procedure for appealing the denial.
  • Review each eligible case record at least once every six months.
  • Use the “Prudent Person Principle” in situations where there are unusual circumstances in which an applicant’s statement must be accepted as proof if there is a reasonable explanation why documentary evidence or a collateral contact is not available and the applicant’s statement does not contradict other client statements or other information received by staff.
  • Current eligibility continues until a change resulting in ineligibility occurs and Form 3082 is issued to the household.
  • Consult the county’s legal counsel to develop procedures regarding disclosure of information.
  • The applicant has the right to:
    • Have his application considered without regard to race, color, religion, creed, national origin, age, sex, disability or political belief;
    • Request a review of the decision made on his application or recertification for health care assistance; and
    • Request, orally or in writing, a fair hearing about actions affecting receipt or termination of health care assistance.
  • The applicant is responsible for:
    • Completing Form 3064 accurately;
    • Signing and dating Form 3064;
    • Providing all needed information requested by staff.  If information is not available or is not sufficient, the applicant may designate a collateral contact for the information. A collateral contact could be any objective third party who can provide reliable information. A collateral contact does not need to be separately and specifically designated if that source is named either on Form 3064 or during the interview; and
    • Reporting changes, which affect eligibility, within 14 days after the date that the change occurred.

 

3200 Processing an Application

Revision 20-0; Effective November 2019

 

There are eight steps for processing an application:

  • Accept the identifiable application.
  • Determine if an interview is needed.
  • Interview the applicant or his representative face-to-face or by telephone if an interview is necessary.
  • Check that all information is complete, consistent and sufficient to make an eligibility determination.
  • Request needed information pertaining to the four eligibility criteria: residence, household, resources and income.
  • Repeat Steps 4 and 5 as necessary
  • Determine eligibility based on the four eligibility criteria.
  • Issue the appropriate form, either Form 3082 or Form 3077.

Step 1: Accept the identifiable application.

On Form 3064, Application for Health Care Assistance, document the date that the identifiable Form 3064 is received. This is the application file date.

Step 2: Determine if an interview is needed.

Eligibility may be determined without interviewing the applicant if all questions on Form 3064 are answered and all additional information has been provided.

Step 3: Interview the applicant or his representative face-to-face or by telephone if an interview is necessary.

If an interview appointment is scheduled, issue Form 3067, Appointment Notice, including the date, time and place of the interview. If the applicant fails to keep the appointment, reschedule the appointment, if requested, or follow the Denial Decision procedure in Step 8.

Step 4: Check that all information is complete, consistent and sufficient to make an eligibility determination.

Step 5: Request needed information pertaining to the four eligibility criteria: residence, household, resources and income.

  • Decision Pended – If eligibility cannot be determined because components that pertain to the eligibility criteria are missing, issue Form 3068, Request for Information, listing the due date and additional information that needs to be provided. If the requested information is not provided by the due date, follow the Denial Decision procedure in Step 8. If the requested information is provided by   the due date, proceed with Step 6.
  • Decision Pended for a Supplemental Security Income (SSI) Applicant – If eligibility cannot be determined because the person is also an SSI applicant, issue Form 3068, listing the due date and additional information that needs to be provided, including the SSI decision. If the SSI application is denied for eligibility requirements, proceed with Step 6 whether or not the SSI denial is appealed.

 
Step 6: Repeat Steps 4 and 5 as necessary.

Step 7: Determine eligibility based on the four eligibility criteria.

Document information in the case record to support the decision.

Step 8: Issue the appropriate form, either Form 3082 or Form 3077.

  • Denial Decision – If any one of the eligibility criteria is not met, the applicant is ineligible. Issue Form 3082, Notice of Ineligibility, including the reason for denial, effective date of the denial, if applicable, and an explanation of the procedure for appealing the denial. Reasons for denial include, but are not limited to:
    • Not a resident of the county;
    • A recipient of Medicaid;
    • Resources exceed the resource limit;
    • Income exceeds the income limit;
    • Failed to keep an appointment;
    • Failed to provide information requested;
    • Failed to return the review application;
    • Failed to comply with requirements to obtain other assistance; or
    • Voluntarily withdrew.
  • Eligible Decision. If all eligibility criteria are met, the applicant is eligible. Determine the applicant’s eligibility effective date. Current eligibility begins on the first calendar day in the month that an identifiable application is filed or the earliest, subsequent month in which all eligibility criteria are met. Exception: The eligibility effective date for a new county resident begins the date the applicant is considered a county resident. For example, if the applicant meets all four eligibility criteria, but doesn’t move to the county until the 15th of the month, the eligibility effective date will be the 15th of the month, not the first calendar day in the month that an identifiable application is filed.)
    • The applicant may be retroactively eligible in any of the three calendar months before the month the identifiable application is received if all eligibility criteria are met.
    • Issue Form 3077, Notice of Eligibility, including the eligibility effective date.

 

3300 Denial Decision Disputes

Revision 20-0; Effective November 2019

 

Responses Regarding a Denial Decision

If a denial decision is disputed by the household, the following may occur:

  • The household may submit another application to have their eligibility redetermined;
  • The household may appeal the denial; or
  • The county may choose to reopen a denied application.

Eligibility Dispute

If a provider of assistance and a governmental entity or hospital district cannot agree on a household’s eligibility for assistance, the provider or the governmental entity or hospital district may submit Form 3073, Eligibility Dispute Resolution Request, within 90 days of the date that the eligibility determination is issued.

HHSC initiates the resolution process by notifying the appropriate entities and requesting any necessary information. HHSC will make a decision within 45 days. An appeal may be submitted in writing within 30 days. HHSC shall issue a final decision within 45 days after the date on which the appeal is filed.

Employment Services Program

Reference Section 1000, Program Administration.

 

3400 Case Record Maintenance

Revision 20-0; Effective November 2019

 

Case Record Review

Issue the household Form 3064, Application for Health Care Assistance. Follow the steps in Section 3200,  Processing an Application, beginning with Step 2, Determine if an interview is needed.

Case Filing Record

Documents relating to eligibility and claim payments may be kept in the same case record or in separate case records. Case record documents may be kept in the order of the chart below.

Left Side of Case Record or Claim Payment Record Right Side of Case Record or Eligibility Record
From top to bottom:
 
  • Form 3069, Health Care Services Record, for current state fiscal year
  • Claims for current fiscal year
  • Divider
  • Form 3081, Appellant – Provider Assignment, if applicable
  • Divider
  • Form 3069 for previous state fiscal years
  • Claims for previous state fiscal years
From top to bottom:
 
  • Current Form 3077, Notice of Eligibility, or Form 3082 , Notice of Ineligibility
  • Current Form 3064, Application for Health Care Assistance
  • Current Form 3065, Worksheet
  • Current Form 3067, Appointment Notice, if applicable
  • Current Form 3068, Request for Information
  • Current verifications
  • Current miscellaneous documents

Changes

Changes are situations that occur in a household that may affect the eligibility of the household.

Follow the steps in Section 3200, beginning with Step 4, Check that all information is complete, consistent and sufficient to make an eligibility determination, to determine the effect of the change on the household’s eligibility.

If a change results in the household’s ineligibility, the eligibility end date is the date that Form 3082 is issued to the household.