Revision 17-3; Effective September 1, 2017

 

The Medicaid for the Elderly and People with Disabilities (MEPD) eligibility specialist must mail notice of the decision to the applicant/recipient within two working days from the date of the decision unless specified otherwise.

The following forms must be sent to the recipient or the recipient's authorized representative at all 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

Used to notify the institution of:

  • action taken on the applicant/recipient’s application; and
  • the amount of income available to be applied to the vendor rate for the applicant/recipient’s maintenance, support and treatment on those applications completed by the Medicaid eligibility specialist.

Form H1226, Transfer of Assets/Undue Hardship Notification

Used to give advance notice to applicants/recipients who have transferred assets for less than the fair market value of the:

  • possible effect of the transfer 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.

You must send the form by the third day after determining the uncompensated value of any assets transferred for less than the fair market value, if you are unable to notify the individual verbally within the three-day period.

Form TF0001, Notice of Case Action

Used to notify:

  • an applicant/recipient that they are eligible for full Medicaid benefits in either an institutional or community-based setting. Also used to notify the applicant that they are eligible for one of the Medicare Savings Programs;
  • an applicant/recipient that they are ineligible for full Medicaid benefits in either an institutional or community-based setting. Also used to notify the applicant that they are ineligible for one of the Medicare Savings Programs;
  • an institutionalized applicant/recipient that their co-payment amount is being raised or lowered, the effective date of the change, and the basis for such action (for example, a change in regular monthly income or in the projection of variable income);
  • an applicant/recipient who is eligible for ongoing Medicaid coverage of their eligibility/ineligibility for three months prior Medicaid coverage; and
  • an applicant/recipient of their right to appeal.

On certifications, Form TF0001 includes Form H1204, Long Term Care Options, and Form 8001, Medicaid Estate Recovery Program Receipt Acknowledgement, as attachments.

Form H1247, Notice of Delay in Certification

Used to notify an applicant/recipient and a facility administrator of:

  • a delay in certification and the right to appeal; and
  • a delay in certification when:
    • the applicant/recipient has not been in the facility or a Home and Community-Based Services waiver for 30 consecutive days;
    • a decision regarding medical necessity for nursing care or regarding level of care for ICF/IID has not been received;
    • an applicant cannot be certified by the 90th day because a disability determination has not been received;
    • the nursing facility certification is pending;
    • new resource/income information is received after the 30th day of the pending application;
    • the applicant/recipient is in the process of resource spend-down (i.e., the applicant is over the resource limit at the time of application, but is expected to be eligible within 90 days from the original application due date); or
    • there is some other reason (this option requires supervisor's sign off).

Form H1259, Correction of Applied Income

Used to notify an institutionalized applicant/recipient that a retroactive reconciliation of applied income is being performed, including:

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

Form H1274, Medicaid Eligibility Resource Assessment Notification

Used to advise a couple requesting a resource assessment of their protected resource amount.

Form H1277, Notice of Opportunity to Designate Funds for Burial

Used to advise applicants/recipients with excess resources that they can 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/recipient by the third day after determining that:

  • the applicant/recipient has excess resources causing ineligibility; and
  • the applicant/recipient has liquid resources to which the burial fund exclusion could be applied.

Form H1279, Spousal Impoverishment Notification

For spousal impoverishment applications, used to notify the applicant/recipient or responsible party of the initial eligibility period and to advise that person of 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

  • Used to notify a Community Care Services Eligibility (CCSE) case manager of a financial eligibility determination on a Community Attendant Services (CAS) referral.
  • Used to notify an HHSC Program Support Specialist of financial eligibility determination on a Waiver case referral. Notification must include co-payment information when it is for a Waiver case.

 

Granted Applications

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 and Form H1230-TP30-Att, Notification of Eligibility – Emergency Medicaid Program.
ME-Community Attendant MEPD Communications Tool
ME-Community Attendant with MC-QMB or MC-SLMB Form TF0001 Notification 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) MEPD Communication Tool
ME-Waivers with MC-QMB or MC-SLMB Form TF0001 and the MEPD Communication Tool (must include co-pay information on this form.)

 

Denied Applications

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 to applicant/recipient and the MEPD Communication Tool

 

Institutional 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 to applicant/recipient and the MEPD Communication Tool
  • Mail an application form within two working days from the receipt of the request.
  • Initiate all requests for pending information in writing and within the first 30 days of the filing date.
  • Send Form H1020, Request for Information or Action. Deny the application if no response is received within the appropriate deadlines.
  • Send a qualified income trust packet to the applicant at the time of denial if the denial was based on excess income for waiver or institutional programs. This is not applicable to the ME-Community Attendant Services (CAS) program.

 

Reviews

Denials

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

 

Institutional 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 to applicant/recipient and the MEPD Communication Tool
Changes in Co-Pay Amount (Raised or Lowered) Form TF0001 to applicant/recipient and the MEPD Communication Tool

 

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

Reviews:

  • The Texas Integrated Eligibility Redesign System (TIERS) automatically mails the redetermination packet or equivalent to the individual.
  • If there is no response from the individual, TIERS will auto deny the case if TIERS is in ongoing mode.
  • If there is no response from the individual and TIERS is not in ongoing mode, initiate denial on the 13th day and send Form TF0001 to the individual informing him of denial.
  • If a streamlined review packet was mailed to the individual, do not deny the case for failure to return a review packet.

Note: At the time of the review:

  • For ME-Waivers and ME-Community Attendant, no MEPD Communication Tool notification is required if there is no change in the case.
  • When adding MC-QMB or MC-SLMB, send Form TF0001.

If using a streamlined redetermination process, notices sent to the recipient must include the following statement: "The Deficit Reduction Act of 2005 requires that the issuer (company) of an annuity owned by a recipient must be notified that the state is the remainder beneficiary."