Revision 17-4; Effective December 1, 2017


P-2100 Notices and Forms

Revision 12-1; Effective March 1, 2012


Form H0055, Verification of Long-Term Care Partnership Policy, is used to request and verify information about a person's LTCP insurance policy.

Form H0056, Notification of Opportunity to Designate Countable Resources, is used to provide a person an opportunity to select the countable resource(s) and the amount of the countable resource(s) the person wishes to designate for the LTCP disregard. It also serves as the written resource designation for any available LTCP disregard.

Form H0057, Long-Term Care Partnership Resource Worksheet, is used as the LTCP resource calculation worksheet.

The LTCP Tracking Spreadsheet is used to track LTCP information for HHSC purposes and to meet federal reporting requirements. This spreadsheet is available on the internal OES MEPD website at


P-2200 Inquiries

Revision 17-4; Effective December 1, 2017


Refer any LTCP non-Medicaid eligibility related inquiries to the following:

  • LTCP and MERP inquiries:
  • LTCP insurance policy and related inquiries: TDI Consumer Help Line 800-252-3439, Austin 512-463-6515
  • Other general LTCP inquiries: LTC Partnership Coordinator at the Medicaid Chip Division 512-491-1803