Revision 19-4; Effective December 1, 2019

 

Notice of the eligibility decision must be mailed to the applicant or recipient, the authorized representative (AR), or a combination within two business days from the date of the decision unless specified otherwise.

The following forms must also be sent at initial certifications:

Form H0090-I, Notice of Admission, Departure, Readmission or Death of an Applicant/Recipient of Supplemental Security Income and/or Medical Assistance Only in a State Institution

Notifies the institution of the:

  • action taken on the application; and
  • amount of income available to be applied to the vendor rate for the applicant or recipient’s maintenance, support and treatment.

Form H1226, Transfer of Assets/Undue Hardship Notification

Provides advance notice to applicants and recipients who have transferred assets for less than the fair market value or who have home equity that exceeds the limit. Notifies the person of the:

  • amount of the uncompensated transfer and the length of the penalty period;
  • possible effect of the transfer of assets on Medicaid services or eligibility;
  • possible effect of excess home equity on Medicaid services or eligibility;
  • process for claiming undue hardship; and
  • opportunity to provide additional information about the transfer that may reduce the penalty period.

Send the form within three business days of determining the uncompensated value of any assets transferred for less than the fair market value or excess home equity, if unable to notify the person verbally within the three-day period.

Form TF0001, Notice of Case Action

Notifies an applicant or recipient of their:

  • eligibility;
  • ineligibility;
  • copayment amount (if applicable); and
  • right to appeal.

If benefits have been approved, the notice informs the individual of:

  • the date benefits begin or Medicaid effective date; and
  • the amount of benefits.

If benefits have been denied, terminated or reduced, the notice informs the person of:

  • the reason for denial;
  • the effective date of the action;
  • the person’s right to appeal;
  • the address and phone number of free legal services available in the area; and
  • that information from a credit report was used, if the information resulted in denial or termination of benefits.

At certification, send Form H1204, Long Term Care Options, and Form 8001, Medicaid Estate Recovery Program Receipt Acknowledgement, with the Form TF0001.

Form H1247, Notice of Delay in Certification

Provides notice to an applicant or recipient and a facility administrator of a delay in certification and the right to appeal.

Form H1259, Correction of Applied Income

Provides notice to an institutionalized applicant or recipient of retroactive changes in their co-payment. Include the following information:

  • the calendar months involved;
  • the adjusted co-payment amount for each month, which is based on a comparison of projected variable income or incurred medical expenses with actual variable income or incurred medical expenses received;
  • totals for the projection period of the amount the facility owes the applicant or recipient and the amount the applicant or recipient owes the facility; and
  • the right to appeal.

Form H1274, Medicaid Eligibility Resource Assessment Notification

Provides notice of a couple’s protected resource amount.

Form H1277, Notice of Opportunity to Designate Funds for Burial

Provides notice to applicants or recipients with excess resources of the option to designate liquid resources as burial funds and have up to $1,500 in burial funds excluded from the eligibility determination.

Send Form H1277 to the applicant or recipient before denying for excess resources.

Form H1279, Spousal Impoverishment Notification

For spousal impoverishment applications, provides notice to the applicant or recipient of the initial eligibility period and the following:

  • At the end of the initial eligibility period, resources in the name of the institutionalized spouse will be tested against the resource limit for an individual.
  • Interspousal transfers are permitted.
  • There may be a transfer-of-assets penalty if resources are transferred to anyone other than the spouse.

MEPD Communication Tool

Provides notice of a financial eligibility determination on a referral for Community Attendant Services (CAS) or waiver services.

Provides the following:

  • financial eligibility determination;
  • information requested on a pending application or ongoing case;
  • case information not involving an eligibility determination such as a change in address or the authorized representative; and
  • changes in co-payment.

Send to the:

  • Community Care Services Eligibility (CCSE) case manager for CAS cases; or
  • HHSC Program Support Unit (PSU) for waiver cases. Include the co-payment amount, if applicable.

Granted Applications and Redeterminations

Community Programs Forms Sent
ME-Pickle, ME-SSI Prior, ME-Disabled Adult Child, ME-Early Aged Widow(er) Form TF0001
ME-A and D-Emergency Form TF0001
ME-Community Attendant MEPD Communication Tool
ME-Community Attendant with MC-QMB or MC-SLMB Form TF0001 and the MEPD Communication Tool
MC-QMB, MC-SLMB, MC-QI-1, MC-QDWI Form TF0001

 

Institutional Programs Forms Sent
ME-Nursing Facility, ME-Non-State Group Home (ICF/IID) Form TF0001, Form TF0001P to facility
Changes in Co-Pay Amount (Raised or Lowered) Form TF0001, Form TF0001P to facility
ME-State School (State Supported Living Center) Form TF0001, Form TF0001P to facility

 

Waiver Programs Forms Sent
ME-Waivers (SPW, MDCP, CLASS/HCS/DBMD) Form TF0001 and MEPD Communication Tool
ME-Waivers with MC-QMB or MC-SLMB Form TF0001 and MEPD Communication Tool (must include co-pay information on this form.)

 

Denied Applications and Redeterminations

Community Programs Forms Sent
ME-Pickle, ME-SSI Prior, ME-Disabled Adult Child, ME-Early Aged Widow(er), MC-QMB, MC-SLMB, MC-QI-1, MC-QDWI, ME-A and D-Emergency Form TF0001
ME-Community Attendant Form TF0001 and MEPD Communication Tool

 

Instituitional Programs Forms Sent
ME-Nursing Facility, ME-Non-State Group Home (ICF/IID), ME-State School (State Supported Living Center) Form TF0001, Form TF0001P to facility

 

Waiver Programs Forms Sent
ME-Waivers (SPW, MDCP, CLASS/HCS/DBMD) Form TF0001 and MEPD Communication Tool

 

Changes

Institutional Programs Forms Sent
Changes in Co-Pay Amount (Raised or Lowered) Form TF0001, TF0001P to facility
Anytime reconciliation is done: Include Form H1259

Note: Ensure all manually generated forms are imaged for the case record. If generated in TIERS, correspondence history will list the form(s) and date it was generated.