Revision 19-3; Effective September 1, 2019

 

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

The following forms must also be sent to the AR 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

Notifies the institution of:

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

Form H1226, Transfer of Assets/Undue Hardship Notification

Gives advance notice of 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.

Send the form by the third day after determining the uncompensated value of any assets transferred for less than the fair market value, 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.

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

Form H1247, Notice of Delay in Certification

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

Form H1259, Correction of Applied Income

Notifies an institutionalized applicant or recipient of retroactive changes in their co-payment. The following information should be included:

  • 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

Advises a couple’s protected resource amount.

Form H1277, Notice of Opportunity to Designate Funds for Burial

Advises 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, notifies 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

  • Notifies a Community Care Services Eligibility (CCSE) case manager of a financial eligibility determination on a Community Attendant Services (CAS) referral.
  • Notifies an HHSC Program Support Specialist (PSU) of financial eligibility determination on a waiver case referral. Notification must include 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: If any of the forms above are generated manually, ensure a copy of the form is sent to be imaged for the case record. If generated in TIERS, correspondence history will list the form(s) and date it was generated.