R-1300, Notices

Revision 21-4; Effective December 1, 2021

When processing an application, redetermination or change, the applicant or recipient, and the authorized represented (AR) must be notified of the eligibility determination and co-payment if applicable.

Mail the written notice to the applicant or recipient, and AR within two business days after the date of the eligibility decision. All information on notices must be accurate.

For Eligibility:

On the eligibility notice, include the MED and any co-payment amount.

Note: For Mason Manor cases, see Appendix XXIII, Procedure for Designated Vendor Number to Withhold Vendor Payment, for the appropriate forms and explanation to send.

For Ineligibility:

On the ineligibility notice, explain the reason for the decision and the appropriate chapter of this handbook that supports the decision.

See below for more information on each notice and its purpose:

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

Provides notice to the state institution of the:

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

Form H1226, Transfer of Assets/Undue Hardship Notification

Provides advance notice to applicants and recipients who have transferred assets for less than the fair market value or who have home equity that exceeds the limit. The form notifies the person of the:

  • amount of the uncompensated transfer and the length of the penalty period;
  • possible effect of the transfer of assets on Medicaid services or eligibility;
  • possible effect of excess home equity on Medicaid services or eligibility;
  • process for claiming undue hardship; and
  • opportunity to provide more information about the transfer that may reduce the penalty period.

Send the form within three business days of determining the uncompensated value of any assets transferred for less than the fair market value or excess home equity, if unable to notify the person verbally within the three-day period.

Form TF0001, Notice of Case Action

Notifies a person of:

  • eligibility;
  • ineligibility;
  • copayment amount (if applicable); and
  • right to appeal.

If benefits have been approved, the notice informs the person of:

  • the date benefits begin (Medicaid effective date); and
  • the amount of benefits.

If benefits have been denied, terminated or reduced, the notice informs the person of:

  • the reason for denial;
  • the effective date of the action;
  • the person’s right to appeal;
  • the address and phone number of free legal services available in the area; and
  • that information from a credit report was used, if the information resulted in denial or termination of benefits.

The following forms must also be sent at initial certifications with the eligibility notice Form TF0001:

Form H1247, Notice of Delay in Certification

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

Form H1259, Correction of Applied Income

Provides notice to an institutionalized applicant or recipient of retroactive changes in their co-payment. Includes the following information:

  • the calendar months involved;
  • the adjusted co-payment amount for each month, 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

Provides notice of a couple’s protected resource amount.

Form H1277, Notice of Opportunity to Designate Funds for Burial

Provides notice to applicants or recipients with excess resources that they can 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, Form H1279 provides notice to the applicant or recipient of the initial eligibility period and the following:

  • At the end of the initial eligibility period, only the resources in the name of the institutionalized spouse will be tested against the resource limit.
  • Interspousal transfers are permitted.
  • A transfer-of-assets penalty may be incurred if resources are transferred to anyone other than the spouse.

MEPD Communication Tool

Provides notice of a financial eligibility determination on a referral for Community Attendant Services (CAS) or waiver services.

Provide the following:

  • financial eligibility determination from MEPD or Texas Works eligibility staff;
  • information requested on a pending application or ongoing case;
  • case information not involving an eligibility determination such as a change in address or the authorized representative; and
  • changes in co-payment.

Send to the:

  • Community Care Services Eligibility (CCSE) case manager for CAS cases; or
  • HHSC Program Support Unit (PSU) for waiver cases. Include the co-payment amount, if applicable.

Granted Applications and Redeterminations

Community ProgramsNotice(s) 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-EmergencyForm TF0001
ME-Community AttendantMEPD Communication Tool
ME-Community Attendant with MC-QMB or MC-SLMBForm TF0001 and the MEPD Communication Tool
ME-Medicaid Buy-In (MBI)Form H0053, Medicaid Buy-In Potential Eligibility Notice, must include each eligible month listed in reverse chronological order, each premium amount, total of all premium amount(s) and premium due date.
Institutional ProgramsNotice(s) Sent
ME-Nursing Facility, ME-Non-State Group Home (ICF/IID), ME-State School (State Supported Living Center)Form TF0001, Form TF0001P to facility
Changes in Co-Pay Amount (Raised or Lowered)Form TF0001, Form TF0001P to facility
Waiver ProgramsNotice(s) Sent
ME-Waivers (SPW, MDCP, CLASS, HCS, DBMD)Form TF0001 and MEPD Communication Tool (must include co-pay information on this form)
ME-Waivers with MC-QMB or MC-SLMBForm TF0001 and MEPD Communication Tool (must include co-pay information on this form)

Denied Applications and Redeterminations

Community ProgramsNotice(s) Sent
ME-Pickle, ME-SSI Prior, ME-Disabled Adult Child, ME-Early Aged Widow(er), ME-Disabled Widow(er), MC-QMB, MC-SLMB, MC-QI-1, MC-QDWI, ME-A and D-EmergencyForm TF0001
ME-Community AttendantForm TF0001 and MEPD Communication Tool
Institutional ProgramsNotice(s) 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 ProgramsNotice(s) Sent
ME-Waivers (SPW, MDCP, CLASS, HCS, DBMD)Form TF0001 and MEPD Communication Tool
Medicaid Buy-InNotice(s) Sent
ME-Medicaid Buy-In (MBI)Form TF0001. Note: Staff must confirm the Form TF0001 includes the correct MBI denial reason. If the incorrect reason is listed, manually add the correct reason for denial in the comments section before generating the Form TF0001.

Changes

Institutional ProgramsNotice(s) Sent
Changes in Co-Pay Amount (Raised or Lowered)Form TF0001, TF0001P to facility
Anytime reconciliation is doneInclude Form H1259

Note: Ensure all notices generated outside of TIERS are imaged for the case record. If generated in TIERS, correspondence history will retain the notice(s) and date generated.