09-2020
 

 

Purpose

Use this form to request CAS or waiver services, share case information and provide supporting documentation with Access and Eligibility Services (AES) eligibility staff.

This appendix provides best practices when submitting the referral cover sheet to AES eligibility staff.

Refer to Form H1746-A, MEPD Referral Cover Sheet, Instructions, for details on completing and transmitting the referral cover sheet.

General Form Completion Procedures

  • Include Form H1746-A as the cover sheet when submitting case information and supporting documentation to AES eligibility staff concerning a CAS or Waiver applicant or recipient. Form H1746-A must be the first document in the packet.
  • A typed H1746-A is recommended for legibility. All required information must be completed. A handwritten H1746-A is acceptable.
  • Do not submit more than one Form H1746-A requesting the same action. Submitting more than one H1746-A for the same action will result in duplicate tasks and may result in assignments to more than one AES staff person.
  • Documents scanned by the Document Processing Center (DPC) are imaged in the HHSC Benefits Portal within three business days. Allow time for the documents to be imaged before performing inquiry to see if a task has been created and assigned.
  • Follow current policy and procedures to determine when information must be faxed, rather than mailed, to AES eligibility staff.

Procedures when determining if documents were transmitted correctly

  • Use the PT Inquiry tab in the State Portal to determine if:
    • the documents imaged into the Portal transmitted correctly and are complete by reviewing Inbound Correspondence; and
    • a task was created for AES eligibility staff by reviewing TIERS Case Comments and Active Tasks.
  • If a task has not been created, resend the documents to the DPC with a new Form H1746-A, and include the original fax confirmation page, if available.
    • In the comments section of the new Form H1746-A, indicate the date the documents were originally sent to the DPC and the reason the documents are being sent again.
  • If a task has been created, resend the documents to the DPC and mark “Supporting Documents” on the new Form H1746-A. This will ensure the documents are linked to the existing task.

Procedures to complete and send a Form H1746-A

  • Thoroughly complete the “Applicant/Consumer Information” section on Form H1746-A. Select the appropriate action based on the type of information being submitted and the program type that requires action. Only one action and program type can be selected on the H1746-A.
  • Complete the sender’s information in full to ensure AES eligibility staff have accurate contact information.
    Note: Without the sender’s phone and fax numbers, AES eligibility staff may not be able to process the request if additional information is needed.
  • In the “Additional Comments” section, include any information that will assist AES staff when processing the request.
  • Fax each application with a corresponding Form H1746-A separately. The Form H1746-A must be the first document in the packet. Do not send multiple applications in a single fax because they will be electronically stored as one document under the case number for the first application. This could result in a HIPPA violation.
  • When mailing multiple applications to the DPC, attach Form H1746-B, Batch Cover Sheet, to the top of each batch containing more than one Form H1746-A and corresponding applications. All applications submitted in a batch using Form H1746-B must be mailed to the DPC and cannot be faxed.
  • Fax or mail Form H1746-A and corresponding documents to the Austin DPC following the “Transmittal” instructions on the H1746-A form instructions.

Specific Form Completion Procedures

Action: Application Action: Application Program Additional Comments
Submit Form H1200, Application for Assistance – Your Texas Benefits, for persons applying for waiver programs.

Form H1746-A and the application must be sent together to avoid two different tasks being created for AES eligibility staff.

Form H1746-A must be the cover sheet to the application.

Select the waiver program being requested.

Indicate if the person, spouse, or both, should be tested.
Indicate “Medical Necessity (MN) and Individual Service Plan (ISP)/Individual Plan of Care (IPC) are pending.”

If the person has an authorized representative as indicated on Form H1200, include the authorized representative’s name and contact information.

 

Submit Form H1200, for Community Attendant Services (CAS).

Form H1746-A and the application must be sent together to avoid two different tasks being created for AES eligibility staff.

Form H1746-A must be the cover sheet to the application.

Select CAS.

Indicate if the person, spouse, or both, should be tested.


If the applicant has a responsible person as indicated on the Form H1200, include the responsible person’s name and contact information.

When submitting a recertification packet for a person whose Medicaid has already been denied, select “Application” as the action.

(This does not apply to STAR+PLUS Home and Community Based Services (HCBS) program.)

Complete an inquiry in TIERS to determine the Medicaid status of the person.

State portal Eligibility Determination Group (EDG) will indicate, “Denied but review requested.”

Select the program being requested. Provide specific comments to explain the situation. If services were delivered for a period  when the  person wasn’t Medicaid eligible, request a retroactive coverage determination.

 

Action: Significant Change Action: Significant Change Program Additional Comments
Send Form H1746-A to communicate any information regarding an applicant or recipient that could potentially effect eligibility. May include change of address, loss of program eligibility, change in living arrangement, new income sources and loss of income. Select the program in which the applicant is currently enrolled or applying for. Provide specific comments to explain the situation to AES eligibility staff.
For a person who is determined financially eligible for CAS but fails to get doctor’s orders or nurse’s approval, send Form H1746-A to AES eligibility staff indicating the person does not meet functional eligibility for CAS.   Select CAS. Indicate “Individual does not meet functional eligibility for CAS.”
Form H1746-A is not submitted to AES eligibility staff to report changes for Supplemental Security Income (SSI) recipients. Advise the person to report the change to the Social Security Administration (SSA).    

 

Action: Supporting Documents Action: Supporting Documents Program Additional Comments
Use Form H1746-A as a cover sheet when supporting documentation is submitted to AES eligibility staff. May include life insurance policies and medical bills for prior months. Select the program in which the person is currently enrolled or applying for. Provide specific comments to explain the situation to AES eligibility staff.

 

Action: Program Transfer Action: Program Transfer Program Additional Comments
Recipient is requesting a program transfer. Consult the Medicaid Program Actions chart to determine when Form H1200 is required. Select the program being requested. For example, if a recipient is transferring from CAS to STAR+PLUS HCBS program, select “STAR+PLUS” as the program.

Indicate the recipient's current program, as well as the program being requested. For example, “Recipient is active CAS and transferring to STAR+PLUS HCBS program.” 

Include the date the recipient will be transferring to the new program.

If the program transfer requires a new Form H1200, indicate, “Form H1200 attached.”

Recipient is leaving the nursing facility after completing an extended stay and returning to the community to receive services.   Select the program the recipient will be receiving in the community.

Indicate the date the recipient is transferring from the nursing facility as well as the statement, “Recipient is transferring from a nursing facility to (program name).”

Include the updated address, phone number and living situation for the recipient.

If the recipient is moving into assisted living, indicate this living arrangement to ensure proper calculation of the copay. Provide the name and address of the assisted living facility.

Do not use Form H1746-A to request a program transfer for SSI recipients.

 

 

 

Note: For program transfers, see the Medicaid Program Actions appendix (Appendix XXXII in the CW-CCAD Handbook) or Appendix XLV, Program Transfer with Form H1200 Guide, to determine when to submit the Form H1200 with the Form H1746-A for active recipients.

 

Action: Add a Program Action: Add a Program Program Additional Comments
Use to request CAS for a person or couple who is active MSP This action routes the task as an application versus a change, and will use application timeframes (45 days) Select CAS.

Provide specific information advising whether the person, spouse, or both, should be tested.

Include the following statement, "Test for CAS."

 

Action: Redetermination Action: Redetermination Program Additional Comments
When submitting a recertification packet to AES eligibility staff because the recipient has requested assistance and it is prior to the effective end date of Medicaidselect “Redetermination” as the action.
(This does not apply to STAR+PLUS HCBS program.)

Complete an inquiry in TIERS to determine the status of the MEPD case.

State portal EDG will indicate, “ME Waivers active and review requested.”

Select the program requiring action.

Provide specific comments to explain the situation.

 

Form H1746-A, Section: Information for MEPD Specialist

Case Worker Community Care for Aged and Disabled Handbook, Appendix XXXV, Long Term Services and Supports (LTSS) information is shared with all applicants.

Select “LTSS information shared” on Form H1746-A.

 

For HHSC programs excluding MDCP, provide the applicant with information on the Medicaid Estate Recovery Program (MERP).

Select “MERP shared” on Form H1746-A.

 

Shared Appendix 05

This appendix appears in the following handbooks:

Case Worker Community Care for the Aged and Disabled (CW-CCAD): Appendix V
STAR Kids Program Support Unit Operational Procedures Handbook (SKOPH): Appendix XV
STAR+PLUS Handbook (SPH): Appendix II
STAR+PLUS Program Support Unit Operational Procedures Handbook (SPOPH): Appendix II