Chapter C, Rights and Responsibilities

C-1000, Texas Administrative Code Rules

Revision 10-2; Effective June 1, 2010

 

§358.601. Rights.

An applicant or recipient has the right to:

(1) be treated fairly and equally regardless of race, color, religion, national origin, gender, political beliefs, or disability;

(2) have information collected for determining his or her eligibility to be treated as confidential;

(3) request a review of an action;

(4) have his or her eligibility tested for other programs before HHSC denies eligibility;

(5) review all information that contributed to an eligibility decision; and

(6) request a fair hearing to appeal an action by HHSC.

 

§358.602. Disclosure of Official Records and Information.

The Texas Health and Human Services Commission follows 20 CFR §§401-403 concerning disclosure of information about a person, both with and without the person's consent; the maintenance of records; and the general guidelines in deciding whether to make a disclosure.

 

§358.603. Release of Medical Information.

A person requesting assistance on the basis of disability must complete a medical information release form.

 

§358.604. Responsibility To Provide Information and Report Changes.

(a) An applicant or recipient must provide the Texas Health and Human Services Commission (HHSC) the necessary documentation and information to determine eligibility for Medicaid.

(b) An applicant or recipient must report to HHSC certain events that affect benefits in accordance with 20 CFR Subpart G.

 

§358.605. Fraud Referral and Restitution.

(a) The Texas Health and Human Services Commission (HHSC) follows 42 CFR §§455.13-455.16 for issues governing fraud referral and restitution.

(b) HHSC evaluates a person's willful withholding of information for fraud, including:

(1) willful misstatements, oral or written, made by the person or the person's authorized representative in response to oral or written questions from HHSC concerning the person's income, resources, or other circumstances that may affect the amounts of benefits, including understatements or omission of information about income and resources; and

(2) willful failure by the person or the person's authorized representative to report changes in income, resources, or other circumstances that may affect the amount of benefits, if HHSC has clearly notified the person or the person's authorized representative of the person's obligation to report these changes.

 

C-1100 Responsibility of Applying

Revision 10-2; Effective June 1, 2010

 

Federal law requires that anyone who wishes to apply for Medicaid be allowed to file an application, regardless of the person's ultimate eligibility for services. See Chapter B, Applications and Redeterminations, for more information.

In addition to meeting other requirements, a person must file an application to become eligible to receive benefits. An authorized representative may accompany, assist and represent an applicant or recipient in the application or eligibility redetermination process.

Someone who is Supplemental Security Income (SSI) eligible automatically receives Medicaid and does not have to file a separate application unless coverage for unpaid or reimbursable bills during prior months to the SSI application is requested. See Section A-4300, Retroactive Coverage.

To apply for an MEPD program, an application for assistance must be received that is:

  • HHSC approved for MEPD Medicaid,
  • completed according to HHSC instructions, and
  • signed and dated under penalty of perjury by the applicant and/or authorized representative or someone acting responsibly for the applicant (if the applicant is incompetent or incapacitated).

An applicant or authorized representative must also provide all requested information according to HHSC instructions. See Section C-8000, Responsibility to Provide Information and Report Changes.

If someone helps an applicant or authorized representative complete the application for assistance, the name of the person completing the form must appear as requested on the application.

Filing an application will:

  • permit HHSC to make a formal determination whether or not a person is eligible to receive Medicaid; and
  • give a person the right to appeal if there is a disagreement with the determination.

 

C-2000, Confidential Nature of the Case Record

Revision 21-3; Effective September 1, 2021

 

Information that is collected in determining initial or continuing eligibility is confidential. The restriction on disclosing information is limited to information about applicants and recipients. HHSC may disclose general information, including financial or statistical reports; information about policies, procedures or methods of determining eligibility; and any other information that is not about or does not specifically identify an applicant or recipient.

An applicant or recipient may review all information in the case record and in HHSC handbooks that contributed to the eligibility decision.

 

C-2100 Correcting Information

Revision 09-4; Effective December 1, 2009

Applicants/recipients have a right to correct any information that HHSC has about the applicant/recipient and any other individual on the applicant's/recipient's case.

A request for correction must be in writing and must:

  • identify the individual asking for the correction;
  • identify the disputed information about the individual;
  • state why the information is wrong;
  • include any proof that shows the information is wrong;
  • state what correction is requested; and
  • include a return address, telephone number or email address at which HHSC can contact the individual.

If HHSC agrees to change individually identifiable health information, the corrected information is added to the case record, but the incorrect information remains in the file with a note that the information was amended per the applicant's/recipient's request.

Notify the applicant/recipient in writing within 60 days (using current HHSC letterhead) that the information is corrected or will not be corrected and the reason. Inform the applicant/recipient if HHSC needs to extend the 60-day period by an additional 30 days to complete the correction process or obtain additional information.

If HHSC makes a correction to individually identifiable health information, ask the applicant/recipient for permission before sharing with third parties. HHSC will make a reasonable effort to share the correct information with persons who received the incorrect information from HHSC if they may have relied or could rely on it to the disadvantage of the applicant/recipient. Follow regional procedures to contact HHSC's privacy officer for a record of disclosures.

Note: Do not follow procedures above if the accuracy of information provided by a applicant/recipient is determined by another review process, such as:

  • a fair hearing;
  • a civil rights hearing; or
  • another appeal process.

The decision in that review process is the decision on the request to correct information.

 

C-2200 Establishing Identity for Contact

Revision 09-4; Effective December 1, 2009
 
Keep all information HHSC has about an applicant/recipient or any individual on the applicant's/recipient's case confidential. Confidential information includes, but is not limited to, individually identifiable health information.

Before discussing or releasing information about an applicant/recipient or any individual on the applicant's/recipient's case, take steps to be reasonably sure the individual receiving the confidential information is either the applicant/recipient or an individual the applicant/recipient authorized to receive confidential information (for example, an attorney or personal representative).

 

C-2210 Telephone Contact

Revision 11-4; Effective December 1, 2011
 
Establish the identity of an individual who identifies himself/herself as an applicant/recipient using his/her knowledge of the applicant's/recipient's:
  • Social Security number;
  • date of birth;
  • other identifying information; or
  • call back to the individual.

Establish the identity of a personal representative by using the individual's knowledge of the applicant's/recipient's:

  • Social Security number;
  • date of birth;
  • other identifying information;
  • call back to the individual; or
  • the knowledge of the same information about the applicant's/recipient's representative.

Establish the identity of attorneys or legal representatives by asking the individual to provide Form H1003, Appointment of an Authorized Representative, completed and signed by the applicant/recipient.

Establish the identity of legislators or their staff by following regional procedures.

 

C-2220 In-Person Contact

Revision 12-3; Effective September 1, 2012

Establish the identity of the individual who presents himself/herself as an applicant/recipient or applicant's/recipient's representative at an HHSC office by:

  • driver's license;
  • date of birth;
  • Social Security number; or
  • other identifying information.

Establish the identity of other HHSC staff, federal agency staff, researchers or contractors by:

  • employee badge; or
  • government-issued identification card with a photograph.

Identify the need for other HHSC staff, federal staff, research staff or contractors to access confidential information through:

  • official correspondence or telephone call from state office or regional offices, or
  • contact with regional attorney.

Contact appropriate regional or state office staff when federal agency staff, contractors, researchers or other HHSC staff, etc., come to the office without prior notification or adequate identification and request permission to access HHSC records.

Note: Contractors cannot have access to IRS Federal Tax Information (FTI).

 

C-2230 Verification and Documentation

Revision 12-3; Effective September 1, 2012

If disclosing individually identifiable health information, document how you verified the identity of the person if contact is outside the interview.

Verify the identity of the person who contacts you with a request to disclose individually identifiable health information using sources such as:

  • valid driver's license or Department of Public Safety ID card;
  • birth certificate;
  • hospital or birth record;
  • adoption papers or records;
  • work or school ID card;
  • voter registration card;
  • wage stubs; and
  • U.S. passport.

As a condition for receiving federal taxpayer returns and return information from the IRS, HHSC is required pursuant to IRC 6103(p)(4) to establish and maintain, to the satisfaction of the IRS, safeguards designed to prevent unauthorized access, disclosure, and use of all returns and return information and to maintain the confidentiality of that information. The IRS security requirements for safeguarding IRS FTI are outlined in Publication 1075, Tax Information Security Guidelines for Federal, State and Local Agencies, Safeguards for Protecting Federal Tax Returns and Return Information.

MEPD Income Eligibility and Verification System (IEVS) specialists must independently verify the income and resource information from any of the data matches to ensure continuous financial eligibility for the MEPD programs.

For all case actions regarding the clearance of the IEVS match of IRS FTI, MEPD staff must not enter any IRS FTI into TIERS (including comments). Documentation on the TIERS income/resource screen is limited to the approved language indicated in the centralized process available on the Social Services Intranet on the Medicaid Eligibility for the Elderly and People with Disabilities home page at hhs.texas.gov/laws-regulations/handbooks/medicaid-elderly-people-disabilities-handbook.

 

C-2240 Alternate Means of Communication

Revision 09-4; Effective December 1, 2009

HHSC must accommodate an applicant's/recipient's reasonable request to receive communications by alternative means or at alternate locations.

The applicant/recipient must specify in writing the alternate mailing address or means of contact and include a statement that using the home mailing address or normal means of contact could endanger the applicant/recipient.

 

C-2300 Custody of Records

Revision 21-3; Effective September 1, 2021

Records must be safeguarded. Use reasonable diligence to protect and preserve records and to prevent disclosure of the information they contain except as provided by HHSC regulations.

"Reasonable diligence" for employees responsible for records includes keeping records:

  • in a locked office when the building is closed;
  • properly filed during office hours;
  • always in the office except when authorized to remove or transfer them; and
  • electronic file information as referenced in HHS Computer Usage and Information Security training.

Reporting Unauthorized Inspection or Disclosure of Internal Revenue Service (IRS) Federal Tax Information (FTI)

Upon discovery of an actual or possible compromise of an unauthorized inspection or disclosure of IRS FTI including breaches and security incidents, the person making the observation or receiving the information must contact the HHS IRS Coordinator immediately at 512-706-7158. They must also email the HHS Privacy Office Mailbox. If you are unable to personally reach the HHS IRS Coordinator by phone, send a secure email to the HHS IRS Coordinator Mailbox.

The HHS IRS Coordinator will report the incident by contacting the office of the appropriate Special Agent-in-Charge, Treasury Inspector General for Tax Administration (TIGTA) and the IRS Office of Safeguards as directed in Section 10.2 of Publication 1075.

Reporting Unauthorized Inspection or Disclosure of Social Security Administration (SSA) Provided Information

Staff who become aware of an incident of unauthorized access to, or disclosure of, restricted verified SSA information or confidential information must contact the HHS Privacy Office Mailbox immediately.

The HHS Privacy Office will report the incident by contacting the Chief Information Security Office (CISO).

If a person is responsible for a security breach or an employee's employment is terminated, the user's access to all information resources is removed. Supervisors must follow agency procedures for removing access for employees, contractors, vendors or trainees.

 

C-2400 Safeguarding Federal Income Data

Revision 21-3; Effective September 1, 2021

In addition to the measures for custody of records, use the following to safeguard tape match data obtained through the Income Eligibility and Verification System (IEVS) module within the Automated System of Office of Inspector General (ASOIG) application:

  • Use IEVS data only for the purpose of determining eligibility for MEPD, Medicare Savings Program (MSP), Medical Assistance, Temporary Assistance for Needy Families (TANF) and Supplemental Nutrition Assistance Program (SNAP) benefits.
  • Verify IEVS tax data before taking adverse case actions.
  • Review the Annual Safeguards Federal Tax Information Training and the following three laws that explain criminal and civil penalties for unauthorized disclosure of tax data once a year:
    • Section 7213 – Unauthorized Disclosure of Returns or Return Information, a criminal felony punishable upon conviction by a fine as much as $5,000 or imprisonment for as long as 5 years, or both, together with the cost of prosecution.
    • Section 7213A – Unauthorized Inspection of Returns or Return Information, a criminal misdemeanor punishable upon conviction by a fine of as much as $1,000 or imprisonment for as long as 1 year, or both, together with the cost of prosecution.
    • Section 7431 – Civil Damages for Unauthorized Disclosure of Returns and Return Information, permits a taxpayer to sue for civil damages if a person knowingly or negligently discloses tax return information and upon conviction, a notification to the taxpayer.

Related Policy

Custody of Records, C-2300
System Generated IEVS Worksheet Legends of IRS Tax Data, Appendix XVII
IRS Tax Code, Sections 7213, 7213A and 7431, Appendix XVIII

 

C-2500 Disposal of Records

Revision 21-3; Effective September 1, 2021

To dispose of documents with an applicant or recipient's information, follow procedures for destruction of confidential data according to Texas Health and Human Services records management policies.

The approved method of destruction of IRS FTI is shredding. The IRS requires the following safeguards:

  • HHS staff must perform the destruction of IRS FTI at an HHS facility.
  • Destruction of IRS FTI must be documented on Form H1861, Federal Tax Information Record Keeping and Destruction Log.
  • IRS FTI documents should be inserted into the shredder so the lines of print are perpendicular to the cutting line to render the document undisclosable.
  • IRS FTI documents should be shredded to 1 mm x 5 mm (0.04 in. x 0.2 in.) in size (or smaller).

 

C-2600 Procedure for Preventing Disclosures of Information

Revision 12-3; Effective September 1, 2012
  1. If information about an applicant/recipient is requested but cannot be released, inform the inquiring person or agency that federal and state laws and HHSC regulations require that the information being requested remain confidential. Refer the questioner to Title 42 of the United States Code, Section 1396a(a)(7); 42 CFR Sections 431.300-431.307; and Texas Human Resource Code, Sections 12.003 and 21.012. For individually identified health information, refer the requestor to 45 CFR sections 164.102-164.534. For tax information obtained through IEVS, also refer the requestor to the Internal Revenue Service (IRS) Code, Sections 7213, 7213A and 7431. Title 26 US Code Section 6103 is the confidentiality statue that prohibits disclosure of FTI. For human services agencies, it is IRC 6103(1)(7).

Reference: See Appendix XVIII, IRS Tax Code, Sections 7213, 7213A and 7431.

  1. If subpoenaed to appear in court with an applicant's/recipient's record, notify the supervisor immediately. Give the supervisor all the facts about the case and the date and time of the court hearing. The supervisor should contact the lawyer who is requesting the record and determine whether the requested information is confidential. If a problem exists, the supervisor should inform the regional attorney about all relevant facts. Usually, the subpoenaed employee must take the record and appear in court as directed by the summons. When requested to disclose information from the record, ask the judge to be excused from disclosing the information because of the statutory prohibitions stated previously in this section. Abide by the ruling of the judge.

  2. If subpoenaed to appear in court, and no time is allowed to follow the steps specified in this section, take the record and appear in court as directed by the summons. When requested to disclose the information from the record, follow the procedure described in Step 2.

For individually identifiable health information, refer the requestor to 45 CFR Sections 164.102-164.534.

C-3000, When and What Information May Be Disclosed

Revision 11-4; Effective December 1, 2011

 

Notes:

  • See Section C-4000, Confidential Nature of Medical Information, for restrictions on the release of an applicant's/recipient's protected health information under Health Insurance Portability and Accountability Act (HIPAA) privacy regulations.
  • Reasonable efforts must be made to limit the use, request or disclosure of individually identifiable health information to the minimum necessary to determine eligibility and operate the program. The disclosure of individual medical information from HHSC records must be limited to the minimum necessary to accomplish the requested disclosure. Example: If an applicant/recipient authorizes release of income verification, including disability income, do not release related case medical information unless specifically authorized by the applicant/recipient.

Certain information about applicants/recipients may be disclosed provided that no indication exists that the information can be used against the applicant/recipient:

  • Identifying information may be released to funeral homes, police departments or other agencies attempting to locate friends or relatives of deceased applicants/recipients.
  • Replies to inquiries and complaints, written or oral, from public officials or interested citizens about a decision by HHSC affecting a specific applicant/recipient may include general information about that applicant/recipient. In this event, the reply may give the status of the case (that is, whether an application has been filed, the action taken by HHSC and the reason for the action). This information may be released on the basis of a reasonable assumption that the interested person is acting as an agent for, and with the knowledge and consent of, the applicant/recipient.
  • HHSC staff may not respond to inquiries from relatives or friends for addresses of applicants/recipients unless the applicant/recipient gives his/her permission. HHSC informs the applicant/recipient about the inquiry and leaves the decision to him/her.
  • Information may be given to Medicaid providers to assist them in filing claims for payment.

Give applicant/recipient addresses or other case information only to a person who has written permission from the applicant/recipient to obtain the information. The applicant/recipient authorizes the release of information by completing and signing:

  • Form H1003, Appointment of an Authorized Representative; or
  • A document containing all of the following information:
    • the applicant's or recipient's full name (including middle initial) and case number, or full name (including middle initial) and either the date of birth or Social Security number;
    • a description of the information to be released (Note: If a general release is authorized, provide the information that can be disclosed to the applicant/recipient. Withhold confidential information from the case record, such as names of persons who disclosed information about the household without the household's knowledge, and the nature of pending criminal prosecution.);
    • statement specifically authorizing HHSC to release the information;
    • the name of the person or agency to whom the information will be released;
    • the purpose of the release;
    • an expiration event that is related to the applicant/recipient or the purpose of the release or an expiration date of the release;
    • statement about whether refusal to sign the release affects eligibility for or delivery of services;
    • a statement describing the applicant's or recipient's right to revoke the authorization to release information;
    • the date the document is signed; and
    • signature of the applicant or applicant/recipient.

Note: If the case information to be released includes individually identifiable health information, the document also must tell the applicant or recipient that information released under the document may no longer be private and may be released further by the person receiving the information.

Occasionally requests for information from the case records of deceased applicants/recipients are received. In these instances, also protect the confidentiality of the former applicants/recipients and their survivors. See Section C-5300, Deceased Individuals, for information about who can act on behalf of a deceased applicant/recipient regarding individually identifiable health information.

HHSC's Office of the General Counsel handles questions about the release of information under the Open Records Act. All questions and problems encountered by individuals concerning release of information should be referred to the Office of the General Counsel.

 

C-4000, Confidential Nature of Medical Information

Revision 15-2; Effective June 1, 2015

 

Applicants/recipients requesting assistance on the basis of disability must complete a medical information release form.

The Health Insurance Portability and Accountability Act (HIPAA) is a federal law that sets additional standards to protect the confidentiality of individually identifiable health information. Individually identifiable health information is information that identifies or could be used to identify an individual and that relates to the:

  • past, present or future physical or mental health or condition of the individual;
  • provision of health care to the individual; or
  • past, present or future payment for the provision of health care to the individual.

 

C-4100 Privacy Notice

Revision 15-2; Effective June 1, 2015

 

The MEPD eligibility specialist must send each applicant/recipient a copy of the HIPAA — Notice of Privacy Practices or HIPAA — Notice of Privacy Practices (Spanish) upon certification. The privacy notice tells the applicant/recipient about:

  • his or her privacy rights,
  • the duties of HHSC to protect health information, and
  • how HHSC may use or disclose health information without a person's authorization. (Examples of use or disclosure include: health care operations [for example, Medicaid], public health purposes, reporting victims of abuse, law enforcement purposes, sharing with HHSC contractors and coordinating government programs that provide benefits.)

 

C-4200 Applicant/Recipient Authorization

Revision 11-4; Effective December 1, 2011

 

The applicant/recipient may authorize the release of his or her health information from HHSC records by using a valid authorization form. Form H1003, Appointment of an Authorized Representative, includes all the authorization elements required by HIPAA privacy regulations. See Section C-3000, When and What Information May Be Disclosed, for the elements necessary for a valid authorization.

 

C-4300 Minimum Necessary

Revision 09-4; Effective December 1, 2009

 

Reasonable efforts must be made to limit the use, request or disclosure of individually identifiable health information to the minimum necessary to determine eligibility and operate the program. The disclosure of individual medical information from HHSC records must be limited to the minimum necessary to accomplish the requested disclosure. For example, if an applicant/recipient authorizes release of income verification, including disability income, do not release related case medical information unless specifically authorized by the applicant/recipient.

 

C-5000, Personal Representatives

Revision 09-4; Effective December 1, 2009

 

Only an applicant's/recipient's personal representative can exercise the applicant's/recipient's rights with respect to individually identifiable health information. Therefore, only a applicant's/recipient's personal representative may authorize the use or disclosure of individually identifiable health information or obtain individually identifiable health information on behalf of an applicant/recipient. Exception: HHSC is not required to disclose the information to the personal representative if the applicant/recipient is subjected to domestic violence, abuse or neglect by the personal representative. Consult the regional attorney if you believe that health information should not be released to the personal representative.

Note: A responsible party is not automatically a personal representative.

 

C-5100 Adults and Emancipated Minors

Revision 09-4; Effective December 1, 2009
 

If the applicant/recipient is an adult or emancipated minor, including married minors, the applicant/recipient's personal representative is a person who has the authority to make health care decisions about the applicant/recipient and includes a:

  • person the applicant/recipient has appointed under a medical power of attorney, a durable power of attorney with the authority to make health care decisions, or a power of attorney with the authority to make health care decisions;
  • court-appointed guardian for the applicant/recipient; or
  • person designated by law to make health care decisions when the applicant/recipient is in a hospital or nursing home and is incapacitated or mentally or physically incapable of communication. Follow regional procedures to contact the regional attorney for approval.

 

C-5200 Unemancipated Minors

Revision 09-4; Effective December 1, 2009
 

A parent is the personal representative for a minor child except when:

  • the minor child can consent to medical treatment by himself or herself. Under these circumstances, do not disclose to a parent information about the medical treatment to which the minor child can consent. A minor child can consent to medical treatment by himself or herself when the:
    • minor is on active duty with the U.S. military;
    • minor is age 16 or older, lives separately from the parents and manages his own financial affairs;
    • consent involves diagnosis and treatment of a disease that must be reported to a local health officer or the Texas Department of State Health Services (DSHS);
    • minor is unmarried and pregnant and the treatment (other than abortion) relates to the pregnancy;
    • minor is age 16 years or older and the consent involves examination and treatment for drug or chemical addiction, dependency or use at a treatment facility licensed by DSHS;
    • consent involves examination and treatment for drug or chemical addiction, dependency or use by a physician or counselor at a location other than a treatment facility licensed by DSHS;
    • minor is unmarried, is the parent of a child, has actual custody of the child and consents to treatment for the child; or
    • consent involves suicide prevention or sexual, physical or emotional abuse; and
  • a court is making health care decisions for the minor child or has given the authority to make health care decisions for the minor child to an adult other than a parent or to the minor child. Under these circumstances, do not disclose to a parent information about the health care decisions not made by the parent.

 

C-5300 Deceased Individuals

Revision 09-4; Effective December 1, 2009

 

The personal representative for a deceased applicant/recipient is an executor, administrator or other person with authority to act on behalf of the applicant/recipient or the applicant's/recipient's estate. These individuals include:

  • an executor, including an independent executor;
  • an administrator, including a temporary administrator;
  • a surviving spouse;
  • a child;
  • a parent; and
  • an heir.

Consult the regional attorney if you have questions about whether a particular person is the personal representative of an applicant or recipient.

 

C-6000, Fraud and Fair Hearings

Revision 18-4; Effective December 1, 2018

 

C-6100 Appeals

Revision 13-2; Effective June 1, 2013

If an individual is dissatisfied with HHSC's decision concerning his eligibility for any MEPD program, including Medicaid Savings Programs, the individual has the right to appeal through the appeal process established by HHSC. In certain circumstances, the individual is entitled to receive continued benefits or services until a hearing decision is issued. Whether an individual is entitled to continued assistance is based on requirements set forth in appropriate state or federal law or regulation of the affected program. See the Fair and Fraud Hearings Handbook.

Individuals whose medical assistance is denied because of an SSA decision should file an appeal with the appropriate SSA office.

Note: If an individual submits an application during the time the continued benefits are being processed, the application must be processed as normal. See Chapters B-2300, Eligibility Determination, B-3200, Application Process, and B-6400, Processing Deadlines.

 

C-6110 Program Representation at Fair Hearings

Revision 18-4; Effective December 1, 2018  

If an applicant or recipient requests a fair hearing, the burden of proof to uphold HHSC's decision rests with HHSC. The hearing officer is a neutral party and is restricted by law from presenting HHSC's case.

Form H4800, Fair Hearing Request Summary, provides a space for the names of HHSC's representative and supervisor. The supervisor is responsible for ensuring that either the HHSC representative participates in the hearing or that a back-up person is assigned. Additionally, the supervisor should ensure that the designated representative is sufficiently prepared and knowledgeable of the case to represent HHSC during the fair hearing process.

The hearing officer has the responsibility of setting the date and time of the hearing. In those program areas where Form H4800 may be completed by someone other than agency staff (contracted case management, HHSC representatives, etc.), it is important that the hearing officer be given the name(s) of those people who are to be notified of the date and time of the hearing. If there is not sufficient space on Form H4800 to provide this information, list the name(s) on Form H4800-A, Fair Hearing Request Summary (Addendum), Item 3, "Additional Information."

In those program areas where Form H4800 is completed by HHSC staff but someone other than, or in addition to, HHSC staff will appear (Attorney General's Office staff, Workforce Commission staff, home health nurses, nursing facility staff, etc.), the person completing Form H4800 is responsible for providing the hearing officer with the name(s) of those people who are to be notified of the date and time of the hearing. If there is not sufficient space on Form H4800 to provide this information, list the name(s) on Form H4800-A, Item 3, " Additional Information."

 

C-6200 Applicant/Recipient and Provider Fraud Detection and Referral

Revision 11-4; Effective December 1, 2011

 

Applicants/recipients receiving MEPD programs are perceived by HHSC as essentially honest and entitled to the same protection under the law as all other individuals. When potential fraud is indicated, the allegations must be investigated.

HHSC also endorses the concept that people who provide services are essentially honest and are entitled to the same protection under the law as all other individuals. However, if there is an indication of potential fraud, the allegations must be investigated.

The Office of Inspector General (OIG) investigates waste, abuse and fraud in all health and human services programs in Texas. Any state employee or private citizen may report waste, abuse and fraud to the OIG.

HHSC staff, concerned citizens, providers (for example, doctors, dentists, counselors, etc.), Medicaid applicants/recipients and others can help prevent cases of waste, abuse and fraud by notifying OIG.

If applicant/recipient or provider waste, abuse or fraud is suspected in the Medicaid system, complete the OIG's online complaint form, which is available at: https://oig.hhsc.state.tx.us/wafrep/.

If access to the Internet is not available, contact the fraud hotline at 800-436-6184 or mail the complaint to:

Texas Health and Human Services Commission
Office of Inspector General
Mail Code 1361
P.O. Box 85200
Austin, TX 78708-5200

C-7000, National Voter Registration Act of 1993

Revision 10-3; Effective September 1, 2010

 

The National Voter Registration Act of 1993 mandates that HHSC provide the applicant or recipient with an opportunity to register to vote at application, redetermination or when reporting a change of address. Staff must provide all applicants or recipients with an opportunity to register to vote, if the person desires to do so. Staff must:

  • help the applicant or recipient complete Form H0025, HHSC Application for Voter Registration; or
  • provide Form H0025 to the person to complete at home.

The applicant or recipient may choose to:

  • return the completed form to HHSC staff to forward to the local voter registrar; or
  • leave the completed form with HHSC staff.

At the person's request, HHSC staff will provide the same degree of assistance, including bilingual assistance, in completing Form H0025 as provided for the completion of other HHSC forms.

Document in the Agency Use Only section of the application or recertification form any actions taken regarding voter registration.

HHSC staff will not make a determination about the person's eligibility to vote. However, HHSC staff will not be required to offer the opportunity to register to vote to those applicants and recipients who:

  • indicate on the application that they are not U.S. citizens; or
  • are not of voter registration age (that is, under age 17 years and 10 months), as identified by case record information.

HHSC is prohibited from influencing a person's political preference or party registration, displaying any political preference or party affiliation, or making any statement to a person, the purpose or effect of which is to discourage a person from registering to vote.

If the person has any questions regarding the voter registration process that cannot be answered, give the person the Secretary of State's toll-free number at 1-800-252-8683 or the telephone number of the local county voter registrar.

If a person files a completed mail-in voter registration application during a face-to-face interview, an appropriate HHSC employee will review it for completeness in the presence of the person. If the mail-in voter registration application does not contain all the required information and\or the required signature, the HHSC employee will return the application to the person for completion.

HHSC staff will transmit the completed Form H0025 to the local office liaison who will forward it to the appropriate county voter registrar within five days of receipt.

Do not pend, delay or deny benefits:

  • if the person fails or refuses to complete the voter registration information on any form; or
  • when Form H0025 or Form H1350, Opportunity to Register to Vote, is given to the applicant or recipient, the authorized representative or representative payee for completion; or
  • when Form H0025 or Form H1350 is mailed to the applicant or recipient for completion.

 

Change of Address Reported

In the office

Share the mail-in Form H0025 with the person. If the person declines to register to vote, ask the person to sign Form H1350. File Form H1350 in the case record when returned, and retain the form for 22 months.

 

Via a formal report of change form

Form H0025 will be mailed to the applicant or recipient at the new address. If the person contacts the local office to decline the opportunity to register to vote after receipt of Form H0025, mail Form H1350 to obtain the person's signature. File Form H1350 in the case record when the person returns the form, and retain the form for 22 months.

Notes:

  • This does not apply to Form H3618-A, Resident Transaction Notice for Designated Vendor Numbers, or Form H0090-I, Notice of Admission, Departure, Readmission or Death of an Applicant/Recipient of Supplemental Security Income and/or Assistance Only in a State Institution, submitted by nursing facilities, intermediate care facilities for persons with mental retardation, or state supported living centers reporting admissions/discharges.
  • As a result of the initiative to integrate application and eligibility determination processes, a face-to-face interview is no longer required in determining eligibility for Medicaid programs within this handbook. See Section B-6100, Face-to-Face and Telephone Interviews.

C-8000, Responsibility to Provide Information and Report Changes

Revision 10-2; Effective June 1, 2010

 

Providing Information

When a person applies for Medicaid, HHSC will ask for documents and any other information needed to make sure all the requirements for Medicaid are met. HHSC will ask for information about income, resources and other eligibility requirements.

As a requirement of Medicaid, a person must provide HHSC MEPD staff with the necessary documentation and information to determine eligibility for Medicaid.

If HHSC sends an applicant or authorized representative a request for missing information or verification documents, or both, the applicant or authorized representative must provide the requested information to HHSC by the due date given in the request, or eligibility may be denied.

See Section B-6510, Failure to Furnish Missing Information.

 

Reporting Changes

Report to HHSC MEPD staff certain events that affect Medicaid eligibility and co-payment.

HHSC requires that the applicant/recipient or authorized representative must report certain events because they may affect eligibility or continued eligibility or the amount of the co-payment in the cost of care. See Chapter H, Co-Payment.

 

Who, What, When and How of Reporting Changes

Who must make reports? The person(s) responsible for making required reports to HHSC include an:

  • eligible individual;
  • eligible spouse;
  • eligible child; or
  • applicant awaiting a final determination upon an application.

Additional:

  • If the applicant/recipient has an authorized representative and has not been legally adjudged incompetent, either the applicant/recipient or the authorized representative must make the required reports.
  • If the recipient’s co-payment is impacted by either the community spouse or a dependent family member, the recipient, authorized representative, community spouse or dependent family member is responsible for making required reports to HHSC.
  • If the applicant/recipient has an authorized representative (legal guardian) and has been legally adjudged incompetent, the authorized representative (legal guardian) is responsible for making required reports to HHSC.

 

What must be reported?

Although not all inclusive, events that must be reported are:

  • Change of address — Report any change in mailing address and any change in the address where the person (or spouse/dependent family member) lives.
  • Change in living arrangements — Report any change in the make-up of the household; that is, any person who comes to live in the household and any person who moves out of the household.
  • Change in income — Report any increase or decrease in income, and any increase or decrease in the income of:
    • the ineligible spouse who lives with the recipient;
    • the community spouse or dependent family member;
    • the parent, if the recipient is an eligible child and the parent lives with the eligible child; or
    • an ineligible child who lives with the eligible child.
  • Change in resources — Report any resources received or parted with by the:
    • applicant/recipient;
    • ineligible spouse who lives with the recipient;
    • community spouse or dependent family member; or
    • parent, if the recipient is an eligible child and the parent lives with the eligible child.
  • Eligibility for other benefits — Report eligibility for benefits. Responsibility to apply for any other benefits for which a person may be eligible is required. See Section D-6000, Social Security Number (SSN) and Application for Other Benefits.
  • Certain deaths — If the person is an eligible individual, the individual or the individual's authorized representative must report the death of:
    • the eligible spouse;
    • the ineligible spouse who was living with the individual; and
    • any other person who was living with the individual including a parent of an eligible child.

    Additionally, if the recipient’s co-payment is impacted by either the community spouse or a dependent family member, the recipient, authorized representative, community spouse or dependent family member is responsible for making required reports to HHSC.
  • Change in marital status — Report the marriage, divorce or annulment of a marriage of the:
    • eligible individual;
    • parent who lives with the eligible child; or
    • spouse or dependent family member.

      Additionally, report the marriage of an ineligible child who lives with an eligible individual.
  • Medical improvements — If eligible for Medicaid because of disability or blindness, report any medical condition improvement.
  • A termination of residence in the U.S. — Report leaving the U.S. voluntarily with the intention of abandoning residence in the U.S. or leaving the U.S. involuntarily.
  • Leaving the U.S. temporarily — Report leaving the U.S. for 30 or more consecutive days or for a full calendar month (without the intention of abandoning residence in the U.S.).

 

Include in the Reports

When reporting changes either in writing or verbally, include the following:

  • applicant or recipient's name and Social Security number;
  • event and the date it happened; and
  • reporter’s name.

 

Reports are due to HHSC when:

  • an event happens, the report is due within 10 days of the event.
  • HHSC requests a report and provides a due date.

 

C-9000, Interpreter and Translation Services

Revision 19-3; Effective September 1, 2019

 

 

C-9100 Requirement for Interpreter and Translation Services

Revision 13-3; Effective September 1, 2013

 

All Programs

HHSC is required to provide interpreter services and written translated materials to applicants and recipients who are Limited English Proficient (LEP). HHSC also is required to provide an effective method to communicate with applicants and recipients who indicate they are deaf or hearing impaired. Applicants and recipients indicate on Form H1200, Application for Assistance – Your Texas Benefits, or during an interview that they need interpreter services. For more information on procedures, refer to the Eligibility Operations Procedures Manual.  

 

C-9200 Availability of Translated Written Material

Revision 19-3; Effective September 1, 2019

 

All Programs

Staff must inform applicants and recipients about the availability of written or verbal translation services for written materials HHSC sends to them at application and redetermination.

When staff verbally communicate with Limited English Proficient (LEP) applicants or recipients at the time of application, redetermination and change actions, staff must ensure that applicants or recipients understand the eligibility action (Form H1020, Request for Information or Action, and Form TF0001, Notice of Case Action) being taken and the requirements for the application process (including the request for any missing information).

Note: This requirement is not applicable when staff process the case action without talking with the applicants or recipients.

The Vietnamese Translation Interpreter Form is automatically attached to applicable eligibility notices when Vietnamese is selected as the primary household language.