B-6500, Denials

Before a person is denied for any reason during application, eligibility for QMB/SLMB must also be tested.

Examples:

• An applicant for nursing facility coverage also must be tested for QMB coverage. If the applicant is ineligible for nursing facility coverage but eligible for QMB, certify the applicant for QMB. Indicate on the notice that the applicant is ineligible for nursing facility coverage but eligible for QMB coverage.
• When an MQMB recipient dually eligible for nursing facility coverage leaves the nursing facility to live at home, test for continuing QMB coverage in the new living arrangement.
• When a Community Attendant Services (CAS) recipient who is also QMB-eligible no longer has physician's orders and is ineligible for CAS, do not deny the QMB coverage unless a change in the recipient’s circumstances also results in ineligibility for QMB.

 

B-6510 Failure to Provide Missing Information

Applications

For applications, initiate the written request for verification within 30 calendar days from the date the application is received by the Texas Health and Human Services Commission (HHSC).

If more information or verification is required to complete an application, the applicant or the applicant’s authorized representative (AR) is allowed at least 10 days to provide the information or verification. The final due date must be a workday.

Send Form H1020, Request for Information or Action, to request the needed verification. The Form H1020 provides:

• the information or verification needed;
• the date the information or verification is due; and
• the final decision date.

Note: The final decision date is the date the application may be denied if the required information or verification is not received.

The day Form H1020 is sent is considered day zero of the pending period.

Deny the application if the requested information is not received by close of business on the final decision date provided on the H1020.

If the required information is requested more than 30 days after the file date, allow at least 10 days to provide the required verification. Do not deny the application for the missing information before close of business on the 10th day.

Do not send a second request for missing information for applications.

Delay in Certification

Delay in certification procedures may be necessary if the applicant or the AR is attempting to obtain the information but cannot meet the deadline.

Note: If Asset Verification System (AVS) information impacts eligibility, pend the case and send Form H1020. Allow at least 10 days to provide verification of the new information. Delay in certification procedures may be necessary if the missing information due date is after the application due date.

Redeterminations

All information and verification needed to make an eligibility redetermination decision must be provided.

Send Form H1020, Request for Information or Action, to request the needed verification. The Form H1020 provides:

• what is required;
• the date the verification is due; and
• the date the renewal could be denied if the verification is not received.

The day Form H1020 is sent is considered day zero of the pending period.

Allow at least 10 days to provide the requested verification. The system-generated due date is 10 days from the date of the H1020.

Do not send a second request for previously requested information for redeterminations.

If all previously requested information is returned and new information that impacts eligibility is discovered before disposition, send a new Form H1020 and allow at least 10 days to provide verification of the new information.

Deny the redetermination if the information or verification is not provided by the close of business on the final decision date indicated on the H1020.

Do not deny the redetermination for missing information before close of business on the 10th day.

Related Policy

Date of Application, B-4000
Missing Information Due Dates, B-6420
Establish Processing Deadlines, R-3100
Consideration of AVS Information, R-3744