03-2018
 

 

Staff must follow the guidelines below to ensure a correct assignment is made when completing Form H1746-A, MEPD Referral Cover Sheet:

General Form Completion Procedures

  • When Texas Health and Human Services Commission (HHSC) staff submit case information and supporting documentation to Medicaid for the Elderly and People with Disabilities (MEPD) specialists concerning an applicant or individual receiving services, Form H1746-A must be included as the cover sheet.  Form H1746-A must be the first document in the packet.
  • MEPD specialists will accept handwritten forms, but typed is recommended for legibility.
  • HHSC staff must not send more than one Form H1746-A to MEPD specialists requesting the same action because this creates a new task, possibly resulting in multiple assignments to different MEPD specialists. The documents scanned by the Document Processing Center (DPC) are imaged in the HHSC Benefits Portal within three business days. HHSC staff must allow this time for the documents to be imaged.
  • If HHSC staff determine the documents imaged into the Portal did not transmit correctly or completely by reviewing Inbound Correspondence using the PT Inquiry tab in the Portal, HHSC staff must resend the documents to the DPC. Prior to resending the documents, HHSC staff must determine if an MEPD specialist has already been assigned a task by thoroughly reviewing Texas Integrated Eligibility Redesign System (TIERS) Case Comments and Active Tasks using the PT Inquiry tab in the Portal.
  • If HHSC staff determine a task has not been created for MEPD specialists, HHSC must resend the documents to the DPC with a new Form H1746-A, and include the original fax confirmation page, if available.
    • In the comments section of the new Form H1746-A, HHSC staff must indicate the date the documents were originally sent to MEPD and the reason the documents are being sent again.
  • If a task has been created, HHSC staff must resend the documents to the DPC with “Supporting Documents” marked on a new Form H1746-A to ensure the documents are linked to the task.
    • HHSC staff can work from a saved version of Form H1746-A on their desktop when a new form has to be created. The form allows sender information to be saved. Each time the form is opened from the desktop, a unique bar code will be generated.
  • HHSC staff must follow current policy and procedures to determine when information must be faxed to MEPD specialists rather than mailed.
  • HHSC staff must complete the “Applicant/Consumer Information” section on Form H1746-A as thoroughly as possible. Select the appropriate action based on the type of information being submitted to MEPD specialists and program type depending on which program is requiring MEPD action. Only one action and program type can be selected.
  • To ensure the MEPD specialists have accurate contact information for HHSC, the sender information must be completed in full with HHSC as the selected agency and the sender’s name as it appears in the Outlook Global Address List.
  • HHSC staff should provide specific comments in the “Additional Comments” section to aid the MEPD specialist in processing the information being submitted.
  • If multiple applications are faxed to MEPD specialists, HHSC staff must fax each application with its corresponding Form H1746-A separately. Form H1746-A must be the first document in the packet. HHSC staff must not send multiple applications in a single fax because they will be electronically stored as one document under the case number for the first one.
  • If multiple applications are mailed to the DPC, HHSC staff must attach Form H1746-B, Batch Cover Sheet, to the top of each batch containing more than one Form H1746-A and application. All applications submitted in a batch using Form H1746-B must be mailed to the DPC and cannot be faxed.
  • Staff may fax or mail Form H1746-A to Austin. Follow the instructions below.

    Fax the completed Form H1746-A to: Document Processing Center at 1-877-236-4123.

    Notes:

    • Form H1746-A must be the first document in the packet when mailing or faxing the packet.
    • Use two-sided faxing when possible.
    • Do not fax and mail the same documents. This will cause duplication in the system.
    • If sending more than one application, fax each application individually with one Form H1746-A per application, or mail applications in a batch using Form H1746-B.
  • If mailing, send the completed Form H1746-A to:

    Document Processing Center
    P.O. Box 149024
    Austin, TX 78714-9968

    Note: If mailing more than one Form H1746-A in the same parcel, Form H1746-B must be attached.

Specific Form Completion Procedures

Action: Application Action: Application Program Additional Comments
Submit Form H1200, Application for Assistance – Your Texas Benefits, to MEPD specialists for individuals or couples applying for waiver programs.

Form H1746-A, MEPD Referral Cover Sheet, and the application must be sent together to avoid two different tasks being created for MEPD specialists.

Form H1746-A must be the cover sheet to the application.

 

Select the program for which the individual or couple is applying.

Provide specific information advising if the individual, spouse, or both, should be tested. 

Include the following statements, “Test for waiver” or “Test for STAR+PLUS HCBS program” (as applicable), and “Medical Necessity (MN) and Individual Service Plan (ISP)/Individual Plan of Care (IPC) are pending.”

If the individual has an authorized representative as indicated on Form H1200, include the authorized representative’s name and contact information.

Submit Form H1200-EZ, Application for Assistance – Aged and Disabled, for Community Attendant Services (CAS).

Form H1746-A and the application must be sent together to avoid two different tasks being created for MEPD specialists.

Form H1746-A must be the cover sheet to the application.

Select CAS.

Provide specific information advising if the individual, spouse, or both, should be tested.


Include the following statement, "Test for CAS."

If the individual has a responsible person as indicated on Form H1200-EZ, include the responsible party’s name and contact information.

When submitting a recertification packet to MEPD specialists because the individual has requested assistance and Medicaid has already been denied, select “Application” as the action.

(This does not apply to STAR+PLUS Home and Community Based Services (HCBS) program.)

Complete an inquiry in TIERS to determine the status of the MEPD case.

State portal Eligibility Determination Group (EDG) will indicate, “Denied but review requested.”

Select the program requiring MEPD action. Provide specific comments to explain the situation to MEPD specialists. For example, if services were delivered for a period for which an individual wasn’t Medicaid eligible, request retroactive coverage determination.

 

Action: Significant Change Action: Significant Change Program Additional Comments
Send Form H1746-A to communicate to MEPD specialists any information regarding an applicant or individual that could potentially effect eligibility. May include change of address, loss of program eligibility, and change in living arrangement, new income sources and loss of income. Select the program in which the applicant is currently enrolled or applying for. Provide specific comments to explain the situation to MEPD 
specialists.
For an individual determined by MEPD specialists to be eligible for CAS but fails to get doctor’s orders or nurse’s approval, send Form H1746-A to MEPD specialists stating the individual does not meet functional eligibility for CAS.   Select CAS. Include the following statement, “Individual does not meet functional eligibility for CAS.”
Form H1746-A is not submitted to MEPD to report any changes for individuals who receive Supplemental Security Income (SSI). Advise individual to report this information to the Social Security Administration (SSA).    

 

Action: Supporting Documents Action: Supporting Documents Program Additional Comments
Use Form H1746-A as a cover sheet when supporting documentation is submitted to MEPD specialists. May include life insurance policies and medical bills for prior months. Select the program in which the individual is currently enrolled or applying for. Provide specific comments to explain the situation to MEPD specialists.

 

Action: Program Transfer/Addition Action: Program Transfer/Addition Program Additional Comments
Individual is requesting a program transfer or is adding a program. Consult the Medicaid Program Actions chart to determine when Form H1200 is required. Select the program the individual is transferring to or requests to add. For example, if an individual is transferring out of CAS and enrolling into STAR+PLUS HCBS program, select “STAR+PLUS” as the program.

Indicate the current program the individual receives, as well as the program the individual is transferring to or requests to add. For example, “Individual is in CAS and transferring to STAR+PLUS HCBS program.” 

Include the date the individual will be transferring to the new program or the date the program will be added.

If the program transfer requires a new Form H1200, indicate, “Form H1200 attached.”

Individual is leaving the nursing facility after completing an extended stay and returning to the community to receive services.   Select the program the individual is transferring to.

Indicate the date the individual is transferring from the nursing facility as well as the statement, “Individual is transferring from a nursing facility to (program name).”

Include the updated address, phone number and living situation for the individual.

If the individual is moving into assisted living, indicate this living arrangement to ensure proper calculation of the copay and provide the name and address of the assisted living facility.

Form H1746-A is not submitted to MEPD specialists to report a program transfer for individuals who receive SSI.

 

 

 

 

Action: Redetermination Action: Redetermination Program Additional Comments
When submitting a recertification packet to MEPD specialists because the individual has requested assistance and it is prior to the effective end date of Medicaidselect “Redetermination” as the action.
(This does not apply to STAR+PLUS HCBS program.)

Complete an inquiry in TIERS to determine the status of the MEPD case.

State portal EDG will indicate, “ME Waivers active and review requested.”

Select the program requiring MEPD action. Provide specific comments to explain the situation to the MEPD specialist.
Information for MEPD Specialist

Case Worker Community Care for Aged and Disabled Handbook, Appendix XXXV, Long Term Services and Supports (LTSS) information is shared with all applicants.

Select “LTSS information shared” on Form H1746-A.

 

For HHSC programs excluding MDCP, HHSC staff must provide the applicant with information on the Medicaid Estate Recovery Program (MERP).

Select “MERP shared” on Form H1746-A.

For program transfers, see the Medicaid Program Actions appendix (Appendix XXXII in the CW-CCAD Handbook, or Appendix V in the SPH Handbook) or Appendix XLV, Program Transfer with Form H1200 Guide, of the Office of Social Services MEPD Website, to determine when Form H1200, along with Form H1746-A, are needed by the MEPD specialist to complete the program transfer.

 

Shared Appendix 05

This appendix appears in the following handbooks:

Case Worker Community Care for the Aged and Disabled (CW-CCAD): Appendix V
STAR Kids Program Support Unit Operational Procedures Handbook (SKOPH): Appendix XV
STAR+PLUS Handbook (SPH): Appendix II
STAR+PLUS Program Support Unit Operational Procedures Handbook (SPOPH): Appendix II