Revision 14-4; Effective December 1, 2014

 

B-3100 Application Process

Revision 14-4; Effective December 1, 2014

 

For Medicaid for the Elderly and People with Disabilities (MEPD), the application for assistance is based on one of the following versions of Form H1200:

  • Form H1200, Application for Assistance — Your Texas Benefits
  • Form H1200-EZ, Application for Assistance — Aged and Disabled, for Medicare savings and Medicaid community-based programs, except Home and Community-Based Services waiver programs
  • Form H1200-PFS, Medicaid Application for Assistance (for Residents of State Facilities) Property and Financial Statement


If requested, give the applicant a receipt (Form H1800, Receipt for Application/Medicaid Report/Verification/Report of Change) to verify the applicant provided an application. An applicant may request Form H1800 by fax or mail. Mail the receipt to the applicant’s listed address.

Addresses for Applicants and Recipients

The United States Postal Service (USPS) is phasing out the use of rural route addresses as a result of local 9-1-1 systems that are converting business and residential rural route addresses to street-style addresses. Ask household members for an updated address if they have a rural route address. A rural route address may contain any of the following to denote a rural route:

  • RR
  • RT
  • Rural
  • Route
  • RD (Rural Delivery)
  • RFD (Rural Free Delivery)
  • RUTA RURAL
  • BUZON
  • BZN

If the household members state they do not have a new address, continue to use the address provided. Take no action if the street-style address is not provided, but ask the household members to report if USPS notifies them of a new address.

 

B-3200 – Application Requirements

Revision 09-4; Effective December 1, 2009

 

Federal law requires that anyone who wishes to apply for a Medicaid program be allowed to file an application without delay, regardless of the person's ultimate eligibility for assistance.

An application form must be mailed within two working days from the receipt of the request for an application.

Use an application form to test eligibility for all Medicaid programs for which a person meets the criteria. A separate application form is not required for each of the different Medicaid programs for the elderly and persons with disabilities.

Consider the application complete with a name, address and signature.

 

B-3210 Who May Complete an Application for Assistance

Revision 16-3; Effective September 1, 2016

 

An individual who may complete or sign an application for an applicant may possibly not be on the list of individuals to whom the Texas Health and Human Services Commission (HHSC) can release the applicant’s individually identifiable health information. See Section C-5000, Personal Representatives, for individuals who may receive or authorize the release of an applicant's individually identifiable health information under Health Insurance Portability and Accountability Act (HIPAA) privacy regulations.

An authorized representative may accompany, assist and represent an applicant or recipient in the application or eligibility redetermination process.

Anyone may assist the applicant, guardian, power of attorney or authorized representative in completing an application form. If someone helps complete the application for assistance, the name of the individual completing the form must appear as requested on the application.

See Section B-3220, Who May Sign an Application for Assistance, to determine who may sign an application for assistance form. The requirements for signing a redetermination form are the same as the requirements for signing an application.

See Section C-1100, Responsibility of Applying.

Most applicants in an institutional setting such as a nursing facility are signed into the facility by someone else. An application and information from the applicant and/or the individual(s) having knowledge of the applicant's fina al circumstances are required.

 

B-3220 Who May Sign an Application for Assistance

Revision 16-3; Effective September 1, 2016

 

An individual who may complete or sign an application for an applicant may not be on the list of people to whom HHSC can release the applicant’s individually identifiable health information. See Section C-5000, Personal Representatives, for individuals who may receive or authorize the release of an applicant’s individually identifiable health information under HIPAA privacy regulations.

An applicant, authorized representative or someone acting responsibly for the applicant (if the applicant is incompetent or incapacitated) may sign an application for assistance. The application for assistance must be signed under penalty of perjury.

If an applicant has a guardian, the guardian must:

  • sign the application for assistance;
  • obtain a copy of the guardianship papers; and
  • work with the guardian in the eligibility process.

If an application is signed by someone other than the applicant or the applicant’s guardian, power of attorney, family member, or a friend who is knowledgeable of the applicant’s finances, the individual must provide a Form H1003, Appointment of an Authorized Representative, signed by the applicant, or evidence of:

  • authority to complete and sign an application on behalf of an applicant;
  • the individual’s relationship to the applicant; and
  • responsibility for the applicant’s care.

If an applicant makes an "X" on the signature line for applicant/recipient, a witness must sign on the witness signature line.

 

B-3221 Valid Signatures

Revision 13-3; Effective September 1, 2013

 

A valid signature on the application is required. Effective Jan. 20, 2006, a faxed "signed" signature is acceptable. Unsigned applications that are not data entered are returned to the applicant for signature and the file date is not protected.

Exceptions:

If an unsigned application is received via fax or mail and is not identified as such before data entry and the data entry date is more than one business day after the receipt date of the application, the date of application is protected and is the receipt date of the application. The missing signature is treated as missing information. Use the following time frames:

  • If the application has no missing information except the traditional or faxed written signature, the written signature is due by the final eligibility determination due date, and the date of application is the date the application was received.
  • If the application has missing information in addition to the traditional or faxed written signature, the signature is due within 10 days of the request to submit a traditional or faxed written signature. If the traditional written signature is received within the 10 days, then the date of application is the date the application was received. If the traditional or faxed written signature is not received within the 10 days, then the date of application is the date the written signature is received.

In the following situations, notify the applicant of the requirement for a signature and treat the signature as missing information. Allow the applicant until the final due date to provide the signature.

  • The applicant applies for any Medicaid program by telephone (2-1-1) and the customer care representative enters the information provided through the state portal and mails a pre-populated application to the applicant.
  • A non-applicant or non-authorized representative completes and submits the application for the applicant through the Self-Service Portal (SSP). The pre-populated application is mailed to the applicant and identifies who submitted the application and requests a traditional written signature from the applicant. The applicant or the person assisting the applicant will be informed of this via a screen in the SSP.

See Section B-6400, Processing Deadlines, related to the final eligibility determination due date.

 

B-3300 Authorized Representative

Revision 11-4; Effective December 1, 2011

 

An authorized representative or bona fide agent is a person who is familiar with the applicant and knowledgeable of the applicant’s financial affairs.

An authorized representative may accompany, assist and represent an applicant or recipient in the application or eligibility redetermination process.

Form H1003, Appointment of an Authorized Representative, allows the applicant/recipient to assign an authorized representative.

 

B-3400 General Procedures

Revision 10-3; Effective September 1, 2010

 

If an applicant or authorized representative contacts HHSC to initiate an application and appears to be eligible for SSI, refer the person or authorized representative to the Social Security Administration. If the person or authorized representative wishes to file an application with HHSC, give the person or authorized representative the appropriate form letter, an application for assistance and Form H0025, HHSC Application for Voter Registration.

Explain that eligibility is determined on the basis of:

  • a completed, signed and dated application for assistance;
  • information obtained from the applicant and authorized representative from the completed form, tape matches and possible interviews; and
  • required verification documents.

When eligibility is based on the special income limit, finalization of the person's eligibility cannot be processed or disposed in the system of record until the 30 days in an institutional setting have been met. A determination that a person requires the services of a licensed nurse in an institutional setting to carry out a physician's planned regimen for total care is also required.

See Section B-6300, Institutional Living Arrangement. Use the special income limit for the month of entry to the Medicaid-certified facility (Medicare-SNF, NF or ICF/MR) if it is anticipated that the person will remain in a Medicaid-certified facility for at least 30 days. The person cannot be determined eligible based on the special income limit until the 30 consecutive days have been met.

See Section J-4000, Assessment and SPRA. When determining the 30-day stay requirement, consider both the days in a medical facility and the days in the Home and Community-Based Services waiver setting.

See Section C-7000, National Voter Registration Act of 1993, for information regarding voter registration.

Note: Explain the availability and benefits of Texas Health Steps (formerly EPSDT) programs for applications for children under age 21.