C-520, Form H1000-A and Form H1000-B Completion Instructions

C—520.1 Section I, Items 01 - 31

Revision 02-3; Effective April 1, 2002

All Programs

Items 01 through 39 are listed on the Notice of Application. On the NOA, complete all items except Items 32 and 39. Items 02, 06, 07, 08, 09, 13, 15, 16, 17 and 25 cannot be deleted, but may be updated.

ITEM 01: Case Number

All Programs

If known, enter the previously assigned case number. To reassign a number, ensure that the case name is identical to the name as it appeared at the time of denial. The reassigned case number must have been active within the past year for non-public assistance (PA) Supplemental Nutrition Assistance Program (SNAP) and within the past two years for PA SNAP, TANF and Medical Programs for Families and Children.

ITEM 02: Category

TANF and Medical Programs

On the NOA, enter the code in the left-hand box that describes the type of assistance. Enter changes or corrections in the right-hand box.

2 — TANF/Medical Programs

5 — Refugee Cash Assistance (RCA)

SNAP

On the NOA, enter the code in the left-hand box that describes the type of assistance. Enter changes or corrections in the right-hand box.

6 — PA SNAP

8 — All members are refugees, other than Cuban/Haitian entrants, receiving TANF or RCA (Aid Type 5)

9 — Non-PA SNAP

ITEM 03: Sequence No. (SEQ)

All Programs

For a TANF/Medical Programs NOA, enter code Y if the case name received TANF/Medical Programs within the past two years.

The sequence is computer-printed on 1000-B turnaround. The initial Form H1000-B from the Form H1000-A input document is always sequence 02. Use only the most current sequence to update information. The sequence number cannot exceed the number 99. After 99 the sequence begins at 02 again.

ITEM 04: Page

All Programs

If more than one form is required, enter the page number in the first space and the total number of pages in the second space.

ITEM 05: Print Date

All Programs

Computer printed on 1000-B turnaround. This is the date the information from the input form is entered into SAVERR.

ITEM 06: Budgeted Job Number

All Programs

Enter the first eight alphanumeric characters of the budget job number assigned to the application.

ITEM 07: Mail Code

All Programs

Enter the mail code of the budgeted job number assigned to the application.

ITEM 08: Date Filed

All Programs

Enter the file date of application for assistance. Use month, day, year sequence.

Note: When adding a child to a new program, the file date is the date of the reported change.

SNAP

Also enter the date on the SNAP Form H1000-B, Record Of Case Action, when a new Form H1010-B, Application for Assistance - Part B: Information We Need to Know, is received.

Medical Programs

For reopened three months prior applications, enter the date the applicant requests the application be reopened. Enter the month and year of the original file date in Item 134, Three Months Prior Application Date.

ITEM 09: Case Name

All Programs

Enter on the NOA the individual's last name, comma, first name, space, middle name, or initial until the name is complete or the maximum of 22 positions is reached. The 22 positions include alphanumeric characters, commas, and spaces. If the last name includes Jr, Sr, etc., enter this after the last name(Example: SmithJr,Robert).

ITEM 10: Case Name Change

All Programs

To report a change or correction in case name, enter the complete name in the 22 positions provided in the format described in Item 9, Case Name. If the case name is on a line other than "a," Section II, of the NOA, enter

• the correct name in Item 10; and
• a pound sign (#) on line "a" of Section II, Item 33, Client Name, if you are removing the person reported on line "a."

If the new case name is not reported on the NOA, add the person's name and information on the first available line of Section II, Item 33, Client Name. Enter the appropriate codes in Item 40 for all programs and in Item 41 for TANF and SNAP on the line where the new case name is listed.

The computer automatically realigns names to ensure the correct name is on line "a." Do not attempt to move names from line to line on Form H1000-A or Form H1000-B.

ITEM 11: Reserved

ITEM 12: Employee Number

All Programs

Enter the employee number of staff assigned the application.

ITEM 13: Mailing Address, First Line

All Programs

Enter the street number and name, rural free delivery, or post office box number using these abbreviations:

Ave — Avenue

Blvd — Boulevard

Cir — Circle

CT — Court

Dr — Drive

Gen Del — General Delivery

Hwy — Highway

Ln — Lane

PO Box — Post Office Box

Rd — Road

RFD — Rural Free Delivery

RR — Rural Route

St — Street

Do not use a pound sign (#) as a part of an address. See example in B-222.1, Mailing Addresses for Issuing Benefits, for cases with P.O. Box addresses.

TANF

When a TANF case has a guardian or protective payee, use their mailing address in Items 13-17.

ITEM 14: Mailing Address, Second Line

All Programs

Use this space if additional lines are required for the mailing address.

ITEM 15: City

All Programs

Enter the name of the city or town used in the mailing address.

ITEM 16: State

All Programs

Enter the two-letter postal abbreviation of the state used in the mailing address. Allowed abbreviations are:

TX — Texas

AR — Arkansas

LA — Louisiana

NM — New Mexico

OK — Oklahoma

ITEM 17: ZIP Code

All Programs

Enter the ZIP code of the mailing address.

ITEMS 18 - 24 ARE NOT PRINTED ON THE NOA.

TANF and Medical Programs

Use Items 18-23 to mail Form H3087, Medicaid Identification, to a temporary address. To change any of these items on a Form H1000-B, Record of Case Action, input document, re-enter all items. Use a pound sign (#) to delete items.

ITEM 18: Temporary Address, First Line

TANF and Medical Programs

Enter the temporary mailing address.

ITEM 19: Temporary Address, Second Line

TANF and Medical Programs

Use this space if additional lines are required for the temporary address.

ITEM 20: Temporary Address, City

TANF and Medical Programs

Enter the name of the city or town.

ITEM 21: State

TANF and Medical Programs

Enter the two-digit postal abbreviation of the state.

ITEM 22: ZIP Code

TANF and Medical Programs

Enter the ZIP code.

ITEM 23: Temporary Address; Months; Begin Month

TANF and Medical Programs

Months: Enter the number of months, not to exceed three, that Form H3087, Medicaid Identification, is to be sent to a temporary address.

Begin Month: Enter the month the temporary address becomes effective.

ITEM 24: Residence Address

All Programs

Enter the residence address, street, and city only if different from the mailing address. Always enter the entire address.

TANF and TP 40

Enter the telephone number, if provided, for an application from a pregnant woman.

ITEM 25: County

All Programs

Enter the three-digit code for the county associated with advisor's BJN.

Note: For TANF and Medical Programs, enter the individual's residence code in Item 164. See C-350 for the county codes.

Items 26 – 27 are not printed on the NOA.

ITEM 26: Protective Payee (TANF/Medical Programs); Authorized Representative (FS)

Enter the last name, comma, first name, space, middle name or initial until the name is complete or the maximum of 22 positions is reached. Enter the name of the institution in usual word order omitting commas, if the guardian is an institution (such as, First National Bank), or the representative payee is a licensed residential child care facility. The 22 positions include alphanumeric characters, comma, and space. If staff make an entry in this item, they must also make an entry in Item 27, Modifier.

TANF and Medical Programs

Enter the name of the legal guardian (exactly as shown on guardianship papers), protective payee, or representative payee.

SNAP

Enter the name of the authorized representative. If the authorized representative is an institution such as a halfway house, enter the name of the employee designated by the institution to act as authorized representative on its behalf.

ITEM 27: Modifier (M)

All Programs

Enter the code that identifies the person listed in Item 26.

TANF and Medical Programs

P — Protective Payee

Note: Also use P for those cases in which a representative payee is designated to receive and manage the benefits for an individual who is incompetent or incapacitated.

R — Representative Payee

SNAP

I — Authorized representative is a member of household (under the same roof).

O — Authorized representative is not a member of household (not under the same roof).

F — Authorized representative is an employee of a drug and alcohol treatment/group living arrangement facility.

ITEM 28: Indicator (I) Code

TANF

Enter on NOA. Enter only changes or corrections on Form H1000-A, Form H1000-B and Form H1000-C.

For TANF, enter code M in this item if potential eligibility is based on an incapacity determination.

For TANF-SP, make no entry. SAVERR prints U when TP 61 transfers to TP 07, 20, or 37.

SNAP

1 — Streamlined reporting (SR) household with total gross monthly income that is less than or equal to 130% FPIL.

2 — SR household with total gross monthly income that is greater than 130% FPIL.

3 — Non-SR household.

ITEM 29: Action Notice (MMDDYY)

All Programs

On Form H1000-A/B, enter the date you give the individual Form H1017, Notice of Benefit Denial or Reduction. This entry is mandatory for all denials except for Application Filed in Error, denials. For Medical Program individuals, enter the date you give the individual Form H1122, Medicaid Action Notice.

ITEM 30: Medical Delay

Medical Programs

Use for emergency medical conditions. Make an entry, using four alphanumeric characters, when more than 10 days elapse between giving/mailing a request for medical information and the date the local office receives the information. Enter code E and the number of days over 10. Example: E015.

TANF

Use when a TANF applicant applies in pay for performance and must demonstrate cooperation. A period of up to 40 days is excluded from the timeliness calculation. Enter Code E and the number of days after the interview date needed to demonstrate cooperation. Example: E030. Do not allow more than 40 days.

ITEM 31: Medical Programs Application Indicator

Medical Programs

Make an entry only on the NOA. Enter

• W to identify a TP 40 application or TANF application with a pregnant woman; or
• Y to distinguish Medical Programs applications from other Category 02 applications. Do not enter on Form H1000-B.

C—520.2 Section II, Items 32 - 39

Revision 10-4; Effective October 1, 2010

All Programs

This section contains identifying information for each person listed on the form. Always use line "a" to enter information about the head of household (case name). Items 32, 33, 34, 35, 36, and 39 cannot be deleted, but may be updated.

ITEM 32: Client Number

All Programs

When certifying a case, for each person listed in Section II, enter

• the nine-digit individual number or
• Code 2. This code tells SAVERR to check for an existing client number. If a number exists, SAVERR will reassign the client number. If a number does not exist, SAVERR will assign a number.

If Form H1000-A, Notice of Application, or Form H1000-B, Record of Case Action, will not process because of error message 307, "client is already active in same program on another case," research the case to determine if the individual is currently active in another case in the same program.

SAVERR does not assign a client number on denied initial applications.

See C-800, Automated Support Systems, for individual merge/separate information.

To reassign a client number without an entry in Item 50, Client Number Validation, enter Code 2 in Item 32 and the person's name, birth date, social security account number, and social security claim number so that they match the information already in the computer file.

To correct biographical information enter:

• up to three corrections on the input document. Ensure that at least one item matches the information already on file.
• the client number in Item 32 and Item 50, Client Number Validation.

Using Item 50 allows the client number to be reassigned, but hierarchy may still prevent using the biographical data.

ITEM 33: Client Name

All Programs

Enter the name(s) of the people listed on Form H1010-B. Type the last name, comma, first name, space, middle name or initial until the name is complete or you reach the maximum 22 positions. The 22 positions include alphanumeric characters, comma, and spaces.

The only spaces allowed are after the first name. Do not use spaces within a last or first name. If the name includes a Jr., Sr., II, III, etc., it must follow the last name. Example: SmithJr, John Z. Enter the individual's name from line a in Item 09, Case Name, instead of Item 33.

Some eligible non-U.S. citizens traditionally use a name order that is different from the customary U.S. order (first name, middle name, last or family name). Advisors should determine name order according to U.S. custom, and enter it appropriately on Form H1000-A and Form H1000-B. Example: Vietnamese name on I-94: Nguyen(last) Thi(first) Mai(middle) Enter on Form H1000-Aand Form H1000-B: Nguyen,Thi Mai.

Medical Programs

Enter the names of all persons in the budget group. This group includes all the eligible and ineligible people whose needs, income, resources, and medical expenses are used to determine eligibility and/or spend down.

ITEM 34: Birth Date

All Programs

Enter the birth date for each person listed.

ITEM 35: Sex

All Programs

Enter the sex for each person listed.

M — Male

F — Female

ITEM 36: Race

All Programs

Enter the code that describes the race, color, national origin for each person listed:

1 — White (not Hispanic) – People whose origins derive from the original people of Europe, North Africa, or the Middle East.

2 — Black (not Hispanic) – People whose origins derive from the black racial groups of Africa.

3 — Hispanic – People of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin.

4 — American Indian or Alaskan Native – People whose origins derive from the original people of North America.

5 — Asian or Pacific Islander – People whose origins derive from the original people of the Far East, Southeast Asia, the Indian subcontinent, or the Pacific Islands. This area includes China, Japan, Korea, the Philippine Islands, and Samoa.

6 — State Office Use Only – A code entered by the computer if the worker makes no entry or enters an inappropriate code. Staff must take action to correct.

ITEM 37: Social Security Number (SSN)

All Programs

Enter the social security number (SSN) for each person listed. Following the nine-digit entry is a space used to indicate the verification status of the SSN. A computer printed asterisk (*) indicates Social Security Administration verified the SSN. A verified SSN cannot be changed on Form H1000-B and Form H1000-C. If you determine the number is incorrect, send a memorandum with the correct SSN to State Office Data Integrity (SODI), to make a change:

SODI Section, Data Base Support Unit 
P.O. Box 14930, MC Y92-2 
Austin, TX 78714-9030

Or fax to the Data Base Support Unit at 512-706-7140.

SODI Section notifies the staff by memo when the change is made.

A blank space following the SSN indicates the SSN was entered by the advisor but is not verified.

ITEM 38: Social Security Claim Number

All Programs

Enter the benefit claim number for people enrolled in Medicare or for people who receive social security or Railroad Retirement (RR) benefits. If a person is receiving benefits under more than one number, use the number shown on the Medicare card. If there is no claim number assigned, leave blank.

Note: If entering a RR benefit claim number in Item 38, total the household's RR benefits in Item 55, not in Item 43.

Following the claim number is a code indicating whether the state is paying Medicare premiums for the individual or the individual has private medical insurance. The codes apply to all cases, but are not printed on the SNAP Form H1000-B and Form H1000-C. Reports that include biographical information have these codes. They are

0 — No insurance.

1 — Medicare premium paid by state.

2 — Private medical insurance.

3 — Private medical insurance and Medicare premium paid by state.

The presence of a code 1 or 3 indicates SSA validated the number and the number cannot be changed on Form H1000-B and Form H1000-C. If you determine a verified number is incorrect, send a memorandum with the correct number to Data Control Section, Special Programs Support Unit, State Office, Y-922, to make a change.

THIS COMPLETES THE ALLOWABLE ENTRIES ON THE NOTICE OF APPLICATION.

ITEM 39: Education/Service Code

TANF

Enter an education code for each person in the certified group who is 16 or older (including a child who will be 16 during the month of certification). Note: Do not change the code unless it was incorrect at the time the initial tier level was set or the individual has been denied for at least one complete month before reapplying.

SNAP

Enter an education code for each person with a Code 2, 3, 4, R, V, W, X, or Y in Item 41, Work Registration. Note: Education codes entered for TANF individuals will be printed on the next Form H1000-B that processes, whether registered for SNAP ESP or not.

TANF and SNAP

Enter a code in the first digit of Item 39 to indicate the highest educational level/grade each person has completed. Do not consider vocational/technical schools when determining education level.

C—520.3 Section III, Items 40 - 50

Revision 11-3; Effective July 1, 2011

All Programs

Section III (a-k) is an extension of Section II (a-k). Each line in Section III relates to the corresponding line in Section II and is used to provide additional information about the people listed. Example: The status-in-group code for the case name in Section II, line a, is reported in Section III, line a. Items 40 and 46 for Temporary Assistance for Needy Families (TANF) and Medical Programs, and Item 41, for TANF and the Supplemental Nutrition Assistance Program (SNAP), cannot be deleted but may be updated.

If an active case is denied, all monetary amounts for the case are kept in the System for Applications, Verifications, Eligibility Reports and Referral (SAVERR) files until the case is purged. The amounts kept in SAVERR files are those budgeted for the latest month of eligibility.

The same is true for individual income amounts. The amount shown, however, is the latest amount of income budgeted in any program. If the individual is moved to another case, the individual income amounts can be updated. Staff can change individual income amounts if denying an active case. This action does not update the TANF case income but does update the SNAP case income.

TANF and Medical Programs

When a certified recipient becomes a payee or case name, medical effective date is automatically deleted. For TANF, the ESP code is also deleted.

ITEM 40: Status-in-Group

All Programs

Status-in-group (SIG) codes identify the people's relationship to the case. Enter all codes that describe the people listed on Form H1000-A, Notice of Application, Form H1000-B, Record of Case Action and Form H1000-C, Secondary Client Input. A maximum of six codes may be used for one person.

TANF and Medical Programs

Assign each person listed one primary code. Use secondary codes only in combination with a primary code. Use secondary codes when required or to provide additional information. Note: For TP 30 case, include only one person with an eligible primary code (SIG 8 or 4) per case.

SNAP

Always enter a code to identify the head of household. Use other codes when appropriate. Use the head of household codes with any of the other codes listed under other codes. Only one person in the case, however, may be given a code indicating head of household.

TANF

Primary Codes

2 – Disqualified/Ineligible Child or Second Parent— Identifies a child or second parent who would be a required member of the certified group but who is disqualified or ineligible for another reason, including noncompliance with the unmarried minor parent domicile requirement.

3 – Noncertified child – Identifies the only deprived child of the certified caretaker/second parent.

5 – Certified Child – Identifies a child included in the certified group for TANF or refugee cash assistance (RCA) cases.

7 – Second Parent — Identifies the second parent in a TANF-SP case.

Do not use Code 7 for a Supplemental Security Income (SSI) recipient, to identify the case name, or for more than one member.

8 – Caretaker — Identifies the caretaker in TANF cases.

Do not use Code 8 for an SSI recipient or for more than one member.

9 – Payee – TANF payee only includes:

• SSI recipients (legal parents and other caretaker relatives), or
• other caretaker relatives who act as head of the TANF household and who are not eligible for TANF or do not want to be included as a caretaker (See A-222, Who is Not Included).

0 – Case Name Only — Identifies a legal parent disqualified for:

• intentional program violation;
• alien status/citizenship requirements;
• failure to comply with employment services, child support, SSN or third-party resource (TPR) requirements;
• failure to timely report the temporary absence of a certified child;
• being a fugitive;
• noncompliance with the unmarried minor parent domicile requirement; or
• a felony drug conviction (not deferred adjudication) for an offense committed on or after April 1, 2002. This disqualification is permanent. See A-222, Who is Not Included.

Secondary Codes

E – Federally Recognized Tribe or Unaccompanied Refugee Minor(URM) — Identifies individuals who are either members of a federally recognized Indian tribe or a URM. These individuals are exempt from mandatory enrollment in Medicaid managed care.

G – Reached End of State Time Limit — Identifies a person who used the maximum number of TANF months in a time limit and has a five year freeze out date on SAVERR. This code can be used with all primary SIG codes.

H – Eligible Refugee — Identifies a person identified as an eligible Amerasian, refugee, asylee, victim of severe trafficking or Cuban/Haitian entrant by the U.S. Citizenship and Immigration Services (USCIS) on Form I-94 or other USCIS document. Continue using Code H until the individual has resided in the U.S. for five years. Code H may be combined with any primary codes. Note: Entry of Code H requires an entry in Item 48.

I – Ineligible Child – Identifies a child who is ineligible for TANF for a reason other than being disqualified or being an SSI recipient. Use Code I only with Code 2.

K – Child of a Minor Child – Identifies the child of a minor parent who is also included in the TANF grant. Use Code K only with Code 5.

L – Minor Parent with a Dependent Child – Identifies a minor parent who has a dependent child on the same case. Use Code L with Codes 5, 7, 8, 9 or 0.

M – Eligible Only for Three Months Prior Medical Assistance— Identifies a person who is eligible for medical assistance during any or all of the three months before the month of application, but who is not currently eligible for medical assistance. Use Code M with Codes 5, 7 or 8.

N – Ineligible for Retroactive Medical Assistance and Current Assistance — Identifies a member of the dependent group who must be reported to certify a case for three months prior Medicaid coverage. Use this code for a member of the dependent group who is ineligible for retroactive medical assistance and current assistance. Use Code N with Codes 5, 7 or 8 to identify members of an OTTANF case. Note: If all people in a case are status-in-group N, the case must be Type Programs 11, 71 or 72.

O – Department of State Health Services (DSHS) Child with Special Health Care Needs— Identifies a child who is exempt from mandatory enrollment in Medicaid managed care.

P – Private Health Insurance — Identifies a certified person who has private health insurance other than Medicare or Medicaid benefits. Use Code P with Codes 5, 7 and 8.

Q – Proof of THSteps Screening — Identifies a child who the automated system indicates as delinquent in screening, but for whom the individual has provided proof of THSteps screening. This code does not remain on SAVERR. Use Code Q only with Code 5.

R – HHSC Employee — Identifies a person who is an HHSC employee. Use Code R with all primary codes.

S – Alien with Acceptable Alien Status — Identifies a noncitizen whose alien status allows him to receive TANF. Use Code S with all primary codes. Note: Do not use this code for refugees (SIG H).

T – Ineligible Alien — Identifies a person ineligible due to alien status. Use Code T with Codes 9, 0 and 2Y.

U – Ineligible — No U.S. Citizenship Proof— Identifies a person ineligible due to no proof of U.S. citizenship. Use Code U with Codes 0, 2I or 2Y.

V – Living in Nursing Home — Identifies a person who is temporarily in a nursing home. Use Code V with Codes 0, 3, 5, 6, 7 and 8.

W – Disqualified Child – Identifies a child disqualified for failure to comply with employment services or SSN requirements. Also identifies a minor parent certified as a child, who is disqualified for not cooperating with child support requirements. Use Code W only with Code 2.

X – Deceased – Identifies a deceased person. Use Code X with Codes 5, 6, 7 and 8. Enter the date of death in Item 47 when using Code X.

Y – Disqualified Second Parent — Identifies a legal parent who would be required to be included as a second parent but who is disqualified. Use Code Y only with Code 2.

Z – Migrant — Identifies members of a migrant household. Use Code Z with all primary codes.

SNAP

Head of Household Codes

A — The head of household is a household member.

G — The head of household is a nonmember.

GK — The head of household is disqualified for a reason other than an intentional program violation (IPV).

GT — The head of household is disqualified for an IPV.

Other Codes

B – Student — Identifies a member who is eligible to participate even though he is a student enrolled at least half time in a curriculum that requires a high school diploma or equivalent for entrance.

C – ABAWD not meeting the work requirement — Identifies an able-bodied adult without dependents (ABAWD) who is not meeting the 18-50 work requirement.

D – ABAWD meeting the work requirement — Identifies an ABAWD who is working 20 or more hours per week or is in a work program that meets the 18-50 work requirement.

F – Treatment Facility Residents — Identifies a

• participating resident of an approved drug and alcohol treatment/group living arrangement facility; or
• resident of a public institution who jointly applies for SSI and SNAP.

H – Eligible Refugee — Identifies a person identified as an eligible Amerasian, refugee, asylee, victim of severe trafficking, or Cuban/Haitian entrant by the U.S. Citizenship and Immigration Services (USCIS) on Form I-94 or other USCIS document. Continue using Code H until the individual has resided in the U.S. for five years. Note: If the Category is 8 and Aid Type is 5, all household members must be coded H.

K – Disqualified for a reason other than an IPV— Identifies a member who is disqualified for any reason other than an IPV. Even though this person is not eligible to receive SNAP, enter his biographical data.

M – Migrant, Out of Work Stream — Farm workers who travel to work in agriculture or a related industry during part of the year but who are presently residing at their permanent or home base.

R – HHSC Employee — Identifies a person who is currently an HHSC employee.

S – Eligible Alien — Identifies a noncitizen whose alien status allows him to receive SNAP. Use Code S with all primary codes. Note: Do not use this code for refugees.

T – Disqualified for Intentional Program Violation— Identifies a person who is disqualified for intentional program violation. This person is not eligible to receive SNAP; however, all biographical data, income, and expenses are entered. When using Code T, make an entry in Item 49, Disqualification Code and Date.

U – Seasonal Farm Worker — Farm workers who do not leave their permanent residence to work in agriculture or a related industry.

W – Migrant, in Work Stream — Farm workers who are presently employed away from their permanent residence or home base.

Medical Programs

Primary Codes

2 – Disqualified/Ineligible Child or Second Parent— Identifies a child or adult who is not eligible for Medicaid, but who is included in the budget group. Do not use SIG Code 2 for an ineligible person who is the case name. On GWS, the SIG labeled "Other Rel Spouse" also results in this SIG. The "Other Rel Spouse" label is used to identify the spouse of the "Caretaker/Other Rel." This individual is not eligible for Medicaid but is included in the budget group.

4 – Eligible child – Identifies a child who meets the Medicaid eligibility requirements for the current period and/or prior period or who would meet those requirements if still alive.

7 – Second Parent — Identifies either the

• eligible spouse of a dependent child's natural or adoptive parent, or stepparent; or
• second adult in an RMA case.

Do not use Code 7 for an SSI recipient, to identify the case name, for more than one member, or unless a caretaker is certified.

8 – Caretaker — Identifies the

• eligible pregnant woman;
• eligible caretaker in the home;
• independent child who applied for himself, and, if applicable, his siblings; or
• first adult or single adult in RMA cases.

Do not use Code 8 for an SSI recipient (see Code 9-Payee) or for more than one member.

On GWS, the SIG labels "Caretaker/Parent" and "Caretaker/Other Relative" result in this SIG if the individual is eligible for Medicaid on the case.

9 – Payee — Identifies the ineligible case name/payee only. Use SIG Code 9 when the person with the case name is not part of the budget group. Use this code when SSI recipients act as case names/payees.

0 – Case Name Only — Identifies the ineligible caretaker who is part of the budget group and is the case name. On GWS, the SIG labels "Caretaker/Parent" and "Caretaker/Other Rel" result in this SIG if the individual is not eligible for Medicaid on the case. Only one person per case may be coded 0.

Use SIG 0Y for legal parents who are disqualified for TPR, SSN or Child Support noncooperation. On GWS, the SIG label will remain "Caretaker/Parent."

Secondary Codes

E – Federally Recognized Tribe or Unaccompanied Refugee Minor(URM) — Identifies individuals who are either members of a federally recognized Indian tribe or a URM. These individuals are exempt from mandatory enrollment in Medicaid managed care.

H – Eligible Refugee — Identifies a person who is a refugee. Use Code H with all primary codes in Categories 1 through 5.

I – Ineligible Child – Identifies a child disqualified for Medical Program. Use Code I only with Code 2.

K – Child of a Minor Child – Identifies the child of a young mother who is also included in the budget group. Use Code K only with Code 4.

L – Minor Child with a Child of Her Own — Identifies a mother 18 years old or younger who has a child of her own in the same budget group. Use Code L with Codes 4, 7, 8 or 0.

M – Eligible Only for Three Months Prior Medical Assistance— Identifies a person who is eligible for medical assistance during any or all of the three months before the month of application, but who is not currently eligible for medical assistance. Use Code M with Codes 4, 7 or 8.

N – Ineligible for Retroactive Medical Assistance and Current Assistance — Identifies an ineligible member of the budget group who must be reported to certify a case for three months prior Medicaid coverage. Use this code for a member of the budget group who is ineligible for retroactive medical assistance and current assistance. Use Code N only with Code 2.

O – DSHS Child with Special Health Care Needs— Identifies a child who is exempt from mandatory enrollment in Medicaid managed care.

P – Private Health Insurance — Identifies a certified person who has private health insurance for hospitalization, accidental injury or sickness, other than Medicare or Medicaid benefits. Use Code P with Codes 2, 4, 7, 8 or 0.

Q – THSteps, Family Planning, or Other Service Needs— Identifies a Medicaid recipient, from birth through 18, who does not want THSteps or family planning services or who does not require assistance with other health or income-related needs. Use Code Q only on applications with Codes 4, 7 or 8.

R – HHSC Employee — Identifies a person who is an HHSC employee. Use Code R with all primary codes.

S – Alien with Acceptable Alien Status — Identifies a noncitizen whose alien status allows him to receive Medicaid. Use Code S with all primary codes. Note: Do not use this code for refugees (SIG H).

T – Ineligible Alien — Identifies a noncitizen whose alien status makes him ineligible for program benefits. Use Code T with Codes 2, 9 or 0.

U – No U.S. Citizenship Proof — Identifies a person ineligible due to no proof of U.S. Citizenship. Use Code U with Codes O, 2I or 2Y.

V – Living in Nursing Home — Identifies a person who is temporarily in a nursing home. Use Code V with Codes 4, 7 or 8.

W – Disqualified Child – Identifies a child disqualified for failure to comply with or SSN requirements, or a minor parent who is disqualified for not cooperating with child support requirements. Use Code W only with Code 2.

X – Deceased – Identifies a deceased person. If using Code X, enter the date of death in Item 47, Death/Denial Date. Use Code X with Codes 4, 7 or 8.

Y – Disqualified Caretaker or Second Parent— Identifies a legal parent who would be required to be included as a caretaker or second parent but who is disqualified for citizenship, TPR, SSN or Child Support noncooperation. Use Code Y only with Codes 2 and 0.

Z – Migrant — Identifies members of a migrant household. Use Code Z with all primary codes.

ITEM 41: (W)

TANF and SNAP

Enter an employment services code for each person listed in Item 33. The form will not process if this item is left blank.

If Form H1000-A, Form H1000-B or Form H1000-C is processed for ongoing benefits at application or complete review/recertification, SAVERR only allows a code in Item 41 that corresponds to the appropriate age, based on Item 34, Birthdate. Forms H1000-A (Form H1000-B for SNAP recertifications processed after cutoff of the last benefit month) are edited based on the date the form processes. Other Forms H1000-B are edited based on the form effective date.

For TANF, SAVERR has age edits for codes A and F.

For SNAP, SAVERR has age edits for codes 2, 3, 4, A, F, R, V and W. If Item 78, Type Review, is coded N or I, SAVERR only edits new entries in Item 41 for correctness.

TANF

SNAP

TP 40, TP 43, TP 44, TP 48 and TP 55

Enter a citizenship verification code for each person in the certified group who is a U.S. citizen. The codes specify what level of citizenship verification was used to verify citizenship, if an affidavit was used, or if good cause was allowed. When using an affidavit, a fourth level verification, enter 5 instead of 4. The levels of verification sources are found in A-358.1, Citizenship.

ITEMS 42 - 45:

All Programs

Enter income information in Items 42-45, 55 and 56 as appropriate for each individual listed in Item 33. Leave an item blank if the household does not have that type income.

TANF

Do not enter income for persons whose status-in-group is

3 – an SSI child, 
9 – a payee, or 
2I – an ineligible child.

Note: Enter the deductible amount of any diverted income in Item 58, Deductions, for any individual whose gross income is entered on Form H1000-A, Form H1000-B and Form H1000-C. No individual's deductions should exceed his income.

SNAP

For people disqualified for citizenship, 18-50 work requirement or SSN, enter the prorated amount of income attributed to the household.

Medical Programs

Enter income information for SIG Codes 2, 4, 7, 8 and 0. For TP 45 cases, make no entry in Items 42-44, 55 and 56.

ITEM 42A: Type Income

All Programs

Enter one of the following codes to indicate the type of income entered in Item 44.

A Veterans Affairs (VA) benefits 
C Unemployment Insurance benefits 
P Pension benefits (other than RSDI, SSI, VA or RR) 
M Combination of unemployment benefits with benefits from a pension, VA, or both 
W Combined income from VA and a pension

ITEM 42B: Gross Earned

All Programs

Enter the monthly amount of countable gross earned income and net self-employment income, up to seven numeric characters. Also make an entry in Item 118, and in Items 119-122, if appropriate.

ITEM 43: RSDI

All Programs

Enter the monthly amount of Social Security (RSDI) benefits for each person whose income is considered. Note: If you enter an amount in this item, you must also make an entry in Item 38.

ITEM 44: VA

All Programs

Enter the monthly amount of VA benefits, unemployment insurance benefits, pension, or any combination of these.

When entering an amount in Item 44, also make entries in Item 42A and Item 118.

ITEM 45: SSI

All Programs

SAVERR will print the active penalty codes for each individual on the Form H1000-A, Form H1000-B and Form H1000-C turnaround.

SNAP

Enter the monthly SSI benefit amount.

ITEM 46: Medical Effective Date

TANF and Medical Programs

Enter the beginning date of Medicaid coverage for each person certified for cash and/or medical coverage. Leave blank for status-in-group Codes 0, 2, or 9 and 3 for TANF.

There are many edits associated with the medical effective date. If the correct medical effective date cannot be entered, submit Form H1107, Request for Forced Change of Medical Coverage, to State Office Data Integrity (SODI) Section, SDX Eligibility Unit, State Office, Y-922.

If a recipient has previous medical coverage with HHSC, enter the nine-digit client number or Code 2 in Item 32, Client Number.

TP 55 and 30

For applications with spend down, enter the earliest possible Medicaid eligibility date (MED) for each SIG 4, 7 and 8.

TP 30

Enter the date the emergency conditions started. Use the date the practitioner entered on Form H3038, Emergency Medical Services Certification.

ITEM 47: Death/Denial Date

TANF and Medical Programs

If appropriate, enter the date of denial (always the last day of the month) or date of death(always the actual date of death) for each person.

The following situations require an entry for certified group members.

• A case is released from hold to deny benefits. If the members of the certified group are not eligible for Medicaid benefits for the hold effective month, enter the last day of the month before the hold effective month.
• A case is released from hold and an eligible individual's SIG is changed to an ineligible SIG.

If the case is active and the individual's status-in-group code is changed from eligible to ineligible, do not enter a date in Item 47.

If an active case is denied, this item shows the effective date of denial of Medicaid coverage for all individuals who have medical coverage.

TP 55 and 30

Edits for cases with spend down will not allow a date in this item that is later than the application month.

TP 30

Make an entry only for the certified member (open/close code 090).

ITEM 48: FS-Med Cost; PA-Refugee

TANF and Medical Programs

Enter the code that indicates Voluntary Resettlement Agency (VOLAG), nationality, and U.S. entry date for each refugee. The first digit is the VOLAG code, the second and third digits are the nationality code, and the fourth through seventh digits are the two-digit month and the last two digits of the year of U.S. entry.

Example: An Indochinese resettled by World Relief Services who entered the U.S. in June 1979 is entered 7160679.

Note: Information recorded in Item 48 cannot be changed via Form H1000-A, Form H1000-B and Form H1000-C. To change this item, send a memorandum requesting the change to State Office Data Integrity, Special Programs Support Unit, Y-922.

SNAP

Enter the total monthly amount of medical costs of each person who is eligible for the deduction. Allowable expenses of a person who is no longer a household member are entered on line "a" of this item and credited to the head of household. Do not reduce this amount by $35. If none, leave blank.

ITEM 49: Disq. Code and Date

SNAP

Only the State Office Claims Investigation Unit (SOCIU) can enter, change or authorize deletion of entries in this item. Use this item in active or denied SNAP cases if a member has been disqualified for an intentional program violation (also see Item 40). The entry must always be six full characters. Contact the SOCIU if changes must be made in this field.

The first character SOCIU enters is:

T administrative disqualifications for offenses that occurred prior to Sept. 22, 1996; 
S administrative disqualifications for offenses that occurred on or after Sept. 22, 1996, or disqualifications for convictions due to trafficking; 
C court-ordered disqualifications; or 
M disqualifications due to receipt of multiple benefits in one month.

The second digit SOCIU enters is:

• 1, 2 or 3 depending on whether this is the person's first, second, or third disqualification for intentional program violation (see B-912, IPV Disqualification Penalties, for lengths of penalties associated with each violation); or
• 4 if the disqualification is a permanent disqualification for trafficking in SNAP benefits or program access devices of $500 or more.

The remaining characters SOCIU enters are:

• the last month of the disqualification period entered in the MMYY format, or
• PERM if the disqualification is permanent.

SOCIU enters the same information whether the case is active or denied, and the penalty period is the same regardless of case status.

Example: For an offense that occurred after Sept. 22, 1996, a person is disqualified for an intentional program violation through May 1999. This is the person's second disqualification. SOCIU enters "S20599" to show that the disqualification is his second and that he is disqualified through May 1999. If the disqualification is his third, SOCIU enters "S3PERM" to show the disqualification is permanent.

ITEM 50: Client Number Validation

All Programs

Enter the client number if validation of the number entered in Item 32 is required. See instructions for Item 32. Use the validation only if reassigning a client number or changing individual biographical information.

Warning Messages

All Programs

SAVERR prints warning codes if the last input document is incomplete, questionable or invalid. If the head of household has had a name change because of hierarchy, the old name is printed after any warning messages in Item 50. The following format is used for all error messages: AAABBCCC

AAA — Form item number 001-191; client items 32-50 will be shown A32-K32, through K50. When a client item is shown without line indicator, 032-050, then the comparison of all entries within that item caused the error.

BB — One of the following two-digit qualifiers: 

EC – ERROR CODE NUMBER "CCC" 
EQ – EQUAL 
GE – GREATHER THAN OR EQUAL 
GT – GREATHER THAN 
LE – LESS THAN OR EQUAL 
LT – LESS THAN 
NA – NOT ALLOWABLE WITH THE ENTRY OR LACK OF ENTRY IN"CCC" 
NE – NOT EQUAL

CCC — Form item number 001-191; or error code number 300-999; or one of the following "KEY" words: 

ALP – ALPHABETIC 
BLK – BLANK 
CUR – CURRENT PROCESS MONTH 
DAT – VALID DATE 
FIL – VALUE ALREADY ON FILE 
N-3 – today minus 3 months 
N-6 – today minus 6 months 
N12 – today minus 12 months 
N24 – today minus 24 months 
N45 – today minus 45 days 
NAM – NAME FORMAT 
NOW – PROCESS DATE OF FORM 
NUM – NUMERIC 
NXT – NEXT PROCESS MONTH 
VAL – VALID

TANF

C—520.4 Section IV, Items 51 - 59

Revision 08-4; Effective October 1, 2004

ITEM 51: Total Earned

All Programs

This computer-printed item is the sum of the entries in Column 42B, Gross Earned.

ITEM 52: Total RSDI

All Programs

This computer-printed item is the sum of the entries in Column 43, Retirement, Survivors, and Disability Insurance (RSDI).

ITEM 53: Total VA

All Programs

This computer-printed item is the sum of the entries in Column 44, VA.

ITEM 54: Total SSI

SNAP

This computer-printed item is the sum of the entries in Column 45, SSI.

ITEM 55: Total RR

All Programs

Enter the total monthly railroad retirement benefits for people whose income is considered. Include any railroad retirement benefits received by a person disqualified because of SSN or citizenship policy and attributed to the household. If none, leave blank.

ITEM 56: Other Income

All Programs

Enter the total monthly unearned income from all sources not included in other data boxes. If none, leave blank.

TANF

This may include applied income, countable child support, or alien sponsor's income.

SNAP

This includes the portion of other income of a disqualified person, or a sponsor's income, attributed to the household.

Medical Programs

This may include the TANF grant, total gross child support, and countable income from an alien's sponsor.

ITEM 57: Total Income

All Programs

This computer-printed item is the sum of the entries in Items 51 through 56.

ITEM 58: Deductions

TANF

Enter the standard work related expense deductions for SIG 2W, 2Y, 5, 7, 8 and 0 members with earned income counted against recognized needs. The deductions cannot exceed the members' monthly earnings. Also enter any amounts diverted from the income of a:

• caretaker,
• disqualified legal parent (SIG 0), or
• disqualified second parent (SIG 2Y).

If there are no deductions, leave blank.

Note: Do not enter child care expenses or the 90% earned income deduction in this item. See instructions for Items 149-152.

SNAP

Enter the household's total monthly dependent care costs, the amount of legally obligated child support paid to or for a nonhousehold member and the remaining farm loss.

Medical Programs

Enter income deductions for everyone whose income is considered in the case, including ineligible people. Enter work-related expenses, child support disregard and any diversions for everyone. If there are no deductions, leave blank. Note: Do not include child care expenses (see instructions for Items 149-152).

ITEM 59: Adjusted Gross Income

All Programs

Enter the adjusted gross income. Enter 0 if there is no adjusted gross income.

TANF

The total case income, minus Item 58 equals Item 59, unless child care costs are entered in Item 152 or the automated 90% earned income deductions is used. For these exceptions, the total income minus Items 58, and 152 (child care and 90% earned income deduction amounts) equals Item 59.

Medical Programs

The total case income minus Items 58 and 152 (child care) must equal Item 59.

C—520.5 Section V, Items 60 - 77B

Revision 05-4; Effective August 1, 2005

ITEM 60: Shelter

SNAP

Enter the total amount of the household's monthly shelter costs. Enter zero, if there are no shelter expenses. Coordinate this item with Item 90, Utility Standard Code.

ITEM 61: Adj Gross Income

SNAP

Computer printed on Form H1000-B and Form H1000-C. Make no entry.

ITEM 62: Excess Shelter

SNAP

Computer printed on Form H1000-B and Form H1000-C. Make no entry.

ITEM 63: Net Income

SNAP

Enter the household's rounded net income. Enter zero, if there is no net income.

ITEM 64: Blank

ITEM 65: Benefits

SNAP

Computer printed on Form H1000-B and Form H1000-C. Make no entry.

ITEM 66: Total Needs

TANF

Enter the total budgetary needs figure for all members of the TANF group. Enter a new figure each time the certified group size changes.

Medical Programs

Enter a new figure on Form H1000-B and Form H1000-C each time the household size changes. Item 66 must agree with Items 40, 125, and 126.

ITEM 67/67A: Recog/Max (Recognizable Needs/Maximum Grant)

TANF and Medical Programs

These figures are computer printed. There is no 67A entry for Medical Programs.

ITEM 68/68A: AGI (Adjusted Gross Income)

TANF and Medical Programs

These figures are computer printed. Item 68 equals the entry in Item 59. For TANF, Item 68A is the rounded down figure of Item 68. There is no Item 68A entry for Medical Programs.

ITEM 69: Unmet

TANF and Medical Programs

This figure is computer printed and is the balance of Item 68 subtracted from Item 67.

TANF

This item shows an unmet need of

• at least one cent for active TP 01, 11, and 61 cases; and
• zero cents for TP 07 and 37 cases.

Medical Programs

ITEM 70: Recommended Grant Amount

TANF

This figure is computer printed and is the balance of Item 68A subtracted from Item 67A. The minimum grant of $10 is printed in Item 70 if the balance is less than $10. This item indicates benefit amount, less recoupment, if applicable. This amount is printed only for TP 01 and 61 cases.

Medical Programs

This item is computer printed. SAVERR prints a spend down amount in Item 70 if the amount in Item 69 is a negative amount. Otherwise, Item 70 will be blank.

ITEM 71 - 77-B: MAO Only

Make no entry.

C—520.6 Section VI, Items 78 - 110

Revision 10-2; Effective April 1, 2010

SNAP

Items 78, 83, 84, and 90 cannot be deleted, but may be updated. Items 86, 87, 88, 89, and 93 may be deleted with a pound sign.

ITEM 78: TR (Type Review)

SNAP

Make no entry on Form H1000-A, Notice of Case Action. SAVERR returns Form H1000-B, Record of Case Action, and Form H1000-C, Secondary Client Input, sequence 02 with Code C. Enter one of the following codes on later Form H1000-B and Form H1000-C:

C — Complete review

I — Incomplete review

N — Non-review activity (case maintenance)

State Office Review Codes

M — SNAP "end-of-month" conversion

O — SNAP conversion that occurs at September cutoff effective October (Example: SNAP allotment conversion)

1 — SNAP annual RSDI/SSI conversion

ITEM 79: App. Codes (Application Codes)

SNAP

Enter the three-digit code from the list below that describes the type of application, the referral, and the number of months since the previous application or certification period.

The first digit is the type application:

1 — Eligibility Determination – individuals who are not currently certified or individuals submitting untimely reapplications.

2 — Redetermination (Reapplication) – individuals submitting timely applications for continued benefits.

3 — Application reopened after denial using the same Form H1010-B.

The second digit is always "X."

The third digit is

0 — All initial applications, reapplications within 30 days from previous application, or later applications within 30 days after the end of the previous certification period.

1-8 — For one month, enter 1, for two months, enter 2, etc.

9 — Nine months or longer.

ITEM 80: Certification Date

SNAP

Enter the month, day, and year the certification period begins. The day is always 01, even if the whole allotment is prorated.

ITEM 81: MOS. CERT. (Months Certified)

SNAP

Enter the number of months of the certification period. This must be a two-digit number.

ITEM 82: Last ATP Date (Last Benefit Month)

SNAP

Enter the month and year that the individual receives his last benefits for the current certification period. This must correspond to Items 80 and 81.

ITEM 83: HH NO. (Household Number)

SNAP

Enter the number of certified persons in the household. This is the same as the number of eligible persons listed in Section II. Do not include status-in-group Codes G, K, or T. This must be a two-digit number.

ITEM 84: AID (Aid Type)

SNAP

Enter the code that refers to the type of SNAP case.

1 — NPA only. No members receive TANF. (Category 9)

2 — NPA mixed. Some members receive TANF or RCA and others do not. (Category 9)

3 — PA. All members receive TANF or some receive SSI and other others receive TANF. (Category 6)

5 — All members are refugees, other than Cubans or Haitians, receiving TANF or RCA. (Category 8)

ITEM 85: Test

SNAP

Enter a code to indicate the household's categorical eligibility/income test/shelter deduction..

B — Gross and net income tests and capped shelter deduction.

C — Categorically eligible household with capped shelter deduction.

E — Gross and net income test and uncapped shelter deduction. Use this code only if the member who is entitled to uncapped shelter costs is disqualified for intentional program violation.

M — Net test only, uncapped shelter deduction.

T — Categorically eligible household with uncapped shelter deduction.

SNAP-CAP

S — Supplemental Nutrition Assistance Program Combined Application Project (SNAP-CAP), entered by Centralized Benefits Services.

ITEM 86: PR (Intentional Program Violation Referral)

SNAP

Make no entry. A "Y" is printed during OIG's investigation to prevent the case from being purged.

ITEM 87: NON (Non H/H Members)

SNAP

Enter the code that identifies the non-participating or non-household member(s).

A — Attendant

B — Boarders

C — Ineligible alien

D — Ineligible student

E — Any combination of two or more of A, B, C, or D

If an attendant, boarder, or roomer is an ineligible alien, code him here and in Item 88.

ITEM 88: INELIG. (Ineligible)

SNAP

Enter the total number of persons living in the SNAP household who are not eligible for participation because they are ineligible aliens.

ITEM 89: SSI

SNAP

Advisors enter an "X" if every household member receives SSI. If one or more household members do not receive SSI, leave blank.

SAVERR enters an "A" when a case transfers to Centralized Benefits Services (CBS). CBS enters an "R" when transferring a case to the field.

ITEM 90: UTIL (Utility Expense Code)

SNAP

Enter the appropriate code to describe utility and telephone costs.

Do not prorate the utility and telephone standards for households with disqualified members or households sharing expenses.

ITEM 91: Action Code

SNAP

Enter the appropriate denial code. Leave blank unless the case is denied or is opened and closed on the same document. If an entry is made in Item 91, the advisor must also make an entry in Item 92. See C-221, Denial Codes, for denial codes.

ITEM 92: Action Date

SNAP

Enter the effective date of denial. If denying an application, enter the date you determine the case is ineligible. If the application is opened and closed or an active case is denied, enter the last day of the last month in which the household receives its final benefits. When making an entry in Item 92, also make an entry in Item 91.

ITEM 93: Texas Driver's License Number

SNAP

Enter the head of household's Texas driver's license number or Texas Department of Public Safety(DPS) ID number. If the head of household does not have a Texas driver's license or DPS ID, leave blank. Enter a leading zero for seven-digit license numbers.

ITEM 94: Reserved

ITEM 95: Code/Hold Date

SNAP

Enter the appropriate hold or release code under CD. Make no entry under DATE. SAVERR enters the month after cutoff as the hold effective month.

Hold Benefits

Advisor Hold Code

2 — Use to prevent SAVERR from issuing the next month's benefits. The hold is effective the first of the next SAVERR process month. Use code 2 when

• a change must be made effective the next month and the notice of adverse action expires between cutoff and the end of the month;
• an individual cannot be located; 
   
• the second or subsequent month's benefits must be held because of expedited certification pending verification; or
• a household member receives benefits pending receipt of a social security number.

Note: Entry of Code 2 does not prevent entry of information in other sections, including Section XI, to cancel benefits or issue benefits for the current processing month.

State Office Hold Codes:

A — Form H1000-B, submitted to deny a case, contains a fatal error that is not cleared by cutoff. The case remains on hold until the erroneous Form H1000-B is corrected and processed.

Z — The EBT account is dormant because the household has not accessed benefits for three consecutive months or six consecutive months when the most recent monthly issuance is less than $20.

Release Codes

O — Releases benefits effective the first of the next SAVERR process month. Release any held benefits, as necessary, by completing Section XI. Note: In case actions involving a hold Code A, enter a release code only if the case will not be denied.

ITEM 96: (Late Determination/Rescheduled Appointment Date)

SNAP

Make an entry if

• someone files an application, untimely reapplication or a timely application for a recertification, misses the first appointment, and schedules a subsequent appointment. Enter the date (mmddyy) of the latest appointment.
• expedited benefits are delayed because of a late determination caused by the applicant. Enter the date (mmddyy) that all the following have been completed:
  • Form H1010-B, Application for Assistance - Part B: Information We Need to Know, completed and signed,
  • individual or authorized representative interviewed, and
  • identification verified.

SSI/SNAP Prerelease Joint Application

If SSA does not notify HHSC of an individual's release until after the actual release date, enter the date (mmddyy) of notification.

ITEM 97: PASS Account Amount

SNAP

Enter PASS account amount.

ITEM 98A/B: Verification Requested/Received

SNAP

Make an entry in this item when:

• processing a timely recertification,
• the individual missed the first appointment,
• verification can be requested up to the 15th day of the month following the last benefit month, and
• Form H1020, Request for Information or Action, due date is after the last benefit month.

Use 98A to enter the date (mmddyyyy) the verification is requested.

Use 98B to enter the date (mmddyyyy) the verification is received. If no verification is received, do not enter a date.

The paper Form H1000-A, Notice of Application, Form H1000-B, Record of Case Action, or Form H1000-C, Secondary Client Input, does not correctly reflect the two separate items; however, advisors are able to enter both dates in Item 98.

Example: Item 98 09252000 10052000

ITEM 99: Ineligible Month/Combined Allotments

SNAP

Enter the appropriate code if the household is ineligible for the month of application or the second month.

1 — No benefit issued for month of application due to proration, but eligible for the second month as a combined allotment.

2 — Eligible for month of application but ineligible for the second month.

ITEM 100: PASS Account Code

SNAP

Enter the appropriate PASS account code.

E — Exempt from earned income

U — Exempt from unearned income

ITEM 101: (Prepared Meals Services Code)

SNAP

Enter the appropriate code to identify a household that qualifies to use SNAP benefits to purchase prepared meals from one of the following authorized meal providers:

C — SSI/elderly member authorized to purchase from communal dining facilities, meal delivery service, or contracted restaurant.

E — Homeless and either elderly or SSI recipient; authorized to purchase from every service(communal dining, meal delivery services, or homeless meal providers/contracted restaurants).

H — Authorized to purchase from homeless meal providers/contracted restaurants.

M — Household/disabled member authorized to purchase from meal delivery services.

ITEM 102: Reserved

ITEM 103: (Special Review Date)

SNAP

Enter the month and year for the special review (Example: 08-96).

ITEM 104: (Special Review Code)

SNAP

Enter the appropriate code to show the type of special review needed.

0 — State office assigned

1 — Employment Services/Work Registration

2 — School Attendance

3 — Reserved

4 — Management

5 — Income/Expense changes anticipated

6 — Living arrangement change anticipated

7 — Medical review

8 — Household change anticipated

9 — Other

To delete Items 103 and 104, enter pound (#) in 104.

ITEM 105 - 110: Reserved

C—520.7 Section VII, Items 111 - 126

Revision 02-6; Effective July 1, 2002

ITEM 111: Reserved

ITEM 112: First Case Number

All Programs

Enter the associated TANF, SNAP or Medical Programs case number.

ITEM 113: Second Case Number

All Programs

If Item 112 has an entry and there is another associated case, enter the second case number in Item 113.

ITEMS 114 - 117: Reserved

ITEMS 118 - 122

All Programs

State office uses Items 118-122 to determine discrepancies between income reported to the advisor and income reported by other agencies for the same person. Complete Items 119-122 when the earned income for a former month is not the same as the earned income entered in Item 42B for the ongoing budget. Note: Do not report unearned income that differs from entries in Item 44. If entries are made in Items 119-122 for TP 30 or 55 cases, make appropriate entries in Section XI for the Spend Down history file.

ITEM 118: Mo. Earned (Month Income Is Received)

All Programs

Make an entry in Item 118 only when making or changing an entry in Item 42-B or 44.

Enter a two-digit number to identify the earliest month of certification in which the amounts entered in Items 42B and 44 were received Example: If certification date is May 1, the ongoing budget is effective June 1, and income for May is the same as June, then enter "05."

Note: If zero is entered on Form H1000-B, Items 42B or 44, because income currently shown in these items terminates, enter the two-digit number to identify the first month the income was not received.

ITEM 119: First Budget Mo.

All Programs

Make a two-digit entry to identify the first month earned income was different than the current earned income entered in Item 42B. Make this entry even if earned income for this month totals zero.

ITEM 120: Earned Income First Month

All Programs

Enter the total amount of countable gross earnings for the household that corresponds to the month entered in Item 119. Make an entry even if the earned income for this month totals zero.

Exception: Enter the total amount of a disqualified person's earnings, even if budgeting only a prorated amount of his income.

ITEM 121: Earned Income Second Month

All Programs

Enter the total amount of countable gross earnings for all household members corresponding to the month entered in Item 122. Make an entry even if the earned income for this month totals zero.

Exception: Enter the total amount of a disqualified person's earnings, even if budgeting only a prorated amount of his income.

ITEM 122: Second Budget Mo.

All Programs

Enter the two-digit number to identify the second month in which total earned income received is different from the total of the amounts entered in Item 42-B. Make an entry even if the earned income for this month totals zero.

ITEM 123: Face-to-Face for HCO

TP 43, TP 44, TP 47 and TP 48

SAVERR enters code "N" for a caretaker required to have a Health Care Orientation (HCO). A caretaker who does not comply with the HCO requirement must have a face-to-face interview to renew Medicaid eligibility for the child. When a caretaker has a face-to-face interview to clear non-compliance, enter code "F" in Item 123.

ITEM 124: Reserved

ITEM 125: (Adults)

Medical Programs

Enter the number of adults included in the budget group. Include a minor parent who is SIG 0 on a TP 47 case. Make no entry for TP 45.

ITEM 126: (Children)

Medical Programs

Enter the number of children included in the budget group. Make no entry for TP 45. Include the unborn child in this entry for

• TP 40 cases; and
• TP 43, 44, 47, 48, 30, and 55 cases with "01" entries in Item 128 (B.P.).

Entries in Items 125 and 126 must agree with Item 66.

C—520.8 Section VIII, Items 127 - 152

Revision 10-3; Effective July 1, 2010

TANF and Medical Programs

Section VIII shows case information for TANF, foster care, Refugee Cash Assistance (RCA), and medical programs cases.

ITEM 127: T.P. (Type Program)

TANF

Enter the appropriate code to identify the type program for certifications and denials.

01 — Cash and medical assistance.

04 — Medical Assistance Only - Deceased – Medical assistance only because the applicant(s) dies after the date of application but before certification. Do not use this type program if surviving applicants are eligible to receive cash assistance.

07 — Medical Assistance Only - 12 or 18 Months – TANF or refugee cases that are denied cash assistance because of increased earnings, but are eligible for Medicaid coverage for 12 or 18 months after the last month of TANF eligibility.

11 — Medical Assistance Only - Three Months Prior, not currently eligible or a gap in coverage– TANF individuals eligible for three months prior medical assistance, but who are ineligible in the month of application and later months, or have a gap in coverage.

20 — Medical Assistance Only - Child Support – TANF cases that are denied cash assistance because of child support, but are eligible for Medicaid for four additional months.

29 — Medical Assistance Only – 12 or 18 months post Medicaid following the end of TANF state time limit.

37 — Medical Assistance Only - 12 or 18 Months – TANF cases that are denied cash assistance because of the loss of the 90% earned income deduction, but are eligible for Medicaid coverage for 12 or 18 consecutive months after the last month of TANF eligibility.

61 — TANF-SP cash and medical assistance.

71 — OTTANF – One parent household is eligible to receive OTTANF benefits.

72 — OTTANF – Two parent household is eligible to receive OTTANF benefits.

Note: To change the type program and case name, two transactions must be processed.

Category 05 is the RCA program. TP 08, 09, and 10 are foster care programs.

Medical Programs

Enter the appropriate code to identify the type medical program for certifications and denials.

40 — Pregnant woman

43 — Children under age one

44 — Children age six through 18

45 — Newborn children

47 — Dependent children ineligible for TANF because of applied income

48 — Children ages one through five

55 — Medically Needy (with or without spend down)

30 — Nonimmigrants and undocumented aliens

ITEM 128: B.P. (Base Plan)

Medical Programs except TP 40

Enter 01 to identify cases with a pregnant woman in the budget group.

ITEM 129: Grant Eff. Date

TANF

Enter the first day of the earliest month and year the individual is eligible for and is authorized to receive benefits in the same amount as shown in the ongoing budget. Use this item to authorize benefits for the current and previous months.

ITEM 130: RSDI Increase Reserved

ITEM 131: T.R. (Type Review)

TANF and Medical Programs

Enter one of the following codes on Form H1000-A, Form H1000-B and Form H1000-C.

C — Complete

I — Incomplete

N — Nonreview activity (case maintenance)

ITEM 132: Action Code

TANF and Medical Programs

Enter the code that describes the reason for the action taken on the case. See C-200 for Item 132 codes.

ITEM 133: 3 MO. I (Three Months Prior Indicator)

TANF and Medical Programs

Enter the total number of unduplicated calendar months of three months prior Medicaid eligibility. Not applicable for TP 45.

ITEM 134: 3 MOS. PRIOR APP. DATE (Three Months Prior Application Date)

TANF and Medical Programs

When providing prior coverage enter the month and year of the original file date. This date cannot be later than the medical effective date (Item 46) by more than three calendar months. Not applicable for TP 45.

TANF

Use Form H1000-B and Form H1000-C when the requested medical effective date (Item 46) is within six months of the current process month.

ITEM 135: Reserved

ITEM 136: 4 MOS. POST/End Date

TANF

Enter the last month and year for TP 07/20 Medicaid coverage.

TP 40

Enter the second month and year following the expected delivery date.

TP 45

State Office Data Control enters the last month of forced coverage.

TP 43, TP 44, TP 47 and TP 48

Make no entry. This is a computer-calculated end date. If a one or two-month Medicaid extension is needed, update the end date for two months or less in this item, and enter "I" in Item 131.

ITEM 137: SAV (Budget TP)

TP 30

Enter the Budget TP indicator used to determine income eligibility. This is a required entry when processing three months prior or simultaneous open and close situations. Do not make an entry when processing denials.

If the income exceeds the limits and the case is eligible based on TP 55 income criteria with spend down, enter 55.

ITEM 138: (Child Support Cooperation/Reason for Transfer to TP 07/20)

Enter the appropriate code to indicate child support cooperation or noncooperation.

R — Refusal without good cause to cooperate with child support for one or more absent parents.

C — Cooperation. Enter this code if Code R does not apply.

T — No proration when reinstating TANF after PRA cooperation.

ITEM 139: SPECIAL REVIEW

TANF and Medical Programs (except TP 40, TP 30 and TP 55 with Spend Down)

Enter the date of any contact planned before the date of the next periodic review, or the end of the budget period. For cases with a pregnant woman, enter the first day of the month following the month the pregnancy is anticipated to terminate.

ITEM 140: CODE

TANF and Medical Programs (except TP 40, TP 30 and TP 55 with Spend Down)

Enter the code for the type of special review needed.

1 — Employment Services/Work Registration (TANF only)

2 — School attendance

3 — (Reserved)

4 — Management

5 — Income/Expense changes anticipated

6 — Living arrangement change anticipated

7 — Medical review

8 — Household change anticipated. Note: Use to designate a review for cases with a pregnant woman

9 — Other

Q — Disability Hardship Exemption (TANF only)

To delete a special review date in Item 139, enter a pound sign in Item 140. This entry deletes the information in Items 139 and 140.

ITEM 141: PERIODIC REVIEW

TANF and TP 07, TP 20, TP 37 and TP 55 without Spend Down

Make no entry. This is a computer calculated and printed date of the next periodic review date. If incorrect, enter a new periodic review date in this item and "N" in Item 131.

TP 43, TP 44, TP 47 and TP 48

Make no entry. This is a computer-calculated date that reflects the next required periodic review. If the date is incorrect, enter a periodic review date in this item and "N" in item 131.

ITEM 142: HOLD CD: DATE

TANF and Medical Programs

Enter the appropriate hold or release code under CD. Make no entry under DATE. SAVERR enters the month after cutoff as the hold effective month.

Hold/Release Codes

Advisor

Hold Code 1

Use when the advisor cannot locate the individual and an investigation of the individual's location is pending. This code automatically denies the grant and Medicaid at cutoff of the hold month effective the first day of the hold month. Fiscal cancels any returned warrants and SODI cancels returned Form H3087, Medicaid Identification.

Release: Use Code 8 if the household does not have a new address. Use Code 9 if the household has a new address. Enter the new address on Form H1000-B.

Hold Code 2

Use when appointment of guardian is pending. SAVERR does not produce TANF benefits and Form H3087 until the advisor submits Form H1000-B releasing the hold.

Release: 9 – Enter the name of the guardian on Form H1000-B.

Hold Code 3

Use if changing the payee. SAVERR does not produce TANF benefits and Form H3087 until the advisor submits Form H1000-B releasing the hold.

Release: 0 – Enter the new payee information and complete Section XI on Form H1000-B to issue benefits for hold months.

Hold Code 4

Use when lowering benefits and the adverse action notice period expires between cutoff and the end of the month. SAVERR does not produce TANF benefits and Form H3087 until the advisor submits Form H1000-B releasing the hold.

Release: 0 – Use to release the hold after the adverse action expires. Enter the new budget and/or household composition and complete Section XI on Form H1000-Bto issue benefits for hold months.

Hold Code 5

Use when denying a case or transferring a case to TP 07 or TP 20 and Form H1000-B cannot be submitted because the adverse action period expires between cutoff and the end of the month.

When denying a case, SAVERR does not issue TANF benefits or Form H3087. SAVERR automatically denies the benefit and Medicaid at cutoff of the hold month effective the first day of that month. Fiscal cancels returned warrants and Data Control cancels returned Form H3087.

SAVERR automatically transfers a TP 01 case to TP 07 or TP 20 effective the first day of the next month. SAVERR produces Form H3087 when a case pending transfer is placed on Hold Code 5.

Release: Use Code 8 if the household does not have a new address, responds during the adverse action period, and qualifies for continued benefits. Use Code 9 if the household has a new address, responds during the adverse action period, and qualifies for continued benefits. Enter the new address on Form H1000-B.

State Office Use Only:

Computer-generated Codes

Hold Code A

Form H1000-B submitted to deny a case contains a fatal error not cleared by cutoff. The case remains on hold until the fataled Form H1000-B is corrected and processed. When the form is corrected and the case is denied, enter the correct Death/Denial Date in Item 47.

Release: Use Codes 8, 9 or 0 if the case is not denied.

Data Control Codes

Hold Code C

Form H3087 is returned with postal message: individual moved out of state. State office sends the advisor an RP-24B and sends the individual Form H1029, Notice of Case Action. Automatic denial of the grant occurs at cutoff of the hold month, effective the first day of the hold month. Automatic denial of Medicaid occurs effective the last day of the month before the hold. Apply this hold only when the message on the returned form H3087 indicates the individual has moved out of state.

Release: Use same release procedures described for Hold Code 1.

Hold Code D

Form H3087 is returned with postal message: deceased. State office sends the advisor RP-24B and holds returned warrants and Form H3087 until the advisor takes action to deny assistance or select a new payee.

Release: Use same release procedures described for advisor Hold Code 3.

Hold Code E

RESERVED

Formerly used when Form H3087 returned with postal message: unclaimed.

TANF

Advisor Codes

Hold Code 2

Use when appointment of a guardian is pending. SAVERR does not produce TANF benefits and Form H3087 until the advisor submits Form H1000-B releasing the hold.

Release: 9 – Enter the name of the guardian on Form H1000-B.

Hold Code 4

Use when lowering benefits and the adverse action notice period expires between cutoff and the end of the month. SAVERR does not produce TANF benefits and Form H3087 until the advisor submits Form H1000-Breleasing the hold.

Release: 0 – Use to release the hold after the adverse action period expires. Enter the new budget and/or household composition and complete Section XI on Form H1000-B to issue benefits for hold months.

State Office Use Only:

Computer-generated Codes

Hold Code 3

At least one refugee in a Category 05 case entered the United States more than eight months ago.

State office sends the advisor a RP-24B and holds warrants and Form H3087 until the advisor takes action to deny the case or delete the person(s) over the eight-month limit.

Release: 0 – Release benefits when deleting all people over the eight-month limit. Deny the case if all members are over the eight-month limit.

Hold Code 6

Case is automatically being denied or transferred to TP 20 because of receipt of child support.

Release: 0 – Use to release and make required entries in Section XI.

Hold Code H

Status-in-group Code 5 individual is age 19 or older. The effect is the same as Hold Code C.

Release: The release procedures are the same as Hold Code 1.

Hold Code L

Individual's state time limit is expiring and SAVERR cannot rebudget the TANF case. Advisor action to rebudget the case is required.

Release: 0 – Release hold and make required budget and Section XI entries.

Hold Code Z

The EBT account is dormant because the household has not accessed it for three consecutive months or six consecutive months when the most recent monthly issuance is less than $20.

Release: The release procedures are the same as Hold Code 1.

Fiscal Codes

Hold Code F

Warrant returned as undeliverable. The effect is the same as Hold Code C.

Release: The release procedures are the same as Hold Code 1.

Hold Code G

Warrant returned with message: deceased. The effect is the same as Hold Code D.

Release: The release procedures as the same as for advisor Hold Code 3.

Hold Code J

Warrant charged back.

Release: Hold is released only by Fiscal Division.

Data Control Codes

Code R

SDX Hold

SDX Release Codes

Code S

Mail benefits using address on SDX.

Code T

Denied

Code X

Deceased

Medical Programs

Advisor Codes

Hold Code 4

Pending assignment of protective payee.

Release: 0 – Release hold and enter protective payee information.

State Office Use Only

Computer-generated Codes

Code 3

Occurs at cutoff in the month:

• a SIG Code 4 child on a TP 44 case becomes age 19, and each following month until the advisor denies TP 44 coverage for the child;
• a SIG Code 4 child on a TP 47 or 55 case becomes age 19; or
• the corresponding case for the mother of the TP 45 child is placed on hold.

Release: Use Code 0.

TP 40

State Office Use Only

Computer-generated Codes

Code H

Occurs at cutoff in the month entered in Item 136. If the advisor does not take action, automatic denial will occur at the cutoff in the following month.

ITEM 143: F. ACT (Future Action)

TANF and Medical Programs

Enter the appropriate action code if placing the case on hold with Code 5.

Item 144 - 148: Reserved

Item 149: Code

TANF and Medical Programs

Use on earned income cases only. Enter C for a child care deduction. This entry requires an entry on the same line in Item 152.

To delete this entry, enter "C" in Item 149 and 0 in Item 152 on the appropriate line.

TANF

Enter 9 for

• a 90% earned income deduction up to $1400 per employed member. This entry requires entries on the same line in Items 151 and 152.
• 12 or 18 months additional Medicaid coverage. This entry requires an entry on the same line in Item 151.

Item 150: From Reserved

Item 151: Through

TANF

Enter the last month of the four-month period of the 90% earned income deduction on the line with Code 9. This also contains the TP 37 end date.

Item 152: Amount

TANF and Medical Programs

Enter the last month of the four-month period of the 90% earned income deduction on the line with Code 9. This also contains the TP 37 end date.

TANF

Enter the allowable amount of actual child care costs on the Code C line.

SNAP

Complete only for cases in which an individual receives or anticipates receiving a TANF child support disregard payment from the Office of the Attorney General (OAG). Enter an amount anytime you

• certify these cases for ongoing benefits, or
• make a change to Form H1000-B that will affect the budget, including disqualifications, changes in household composition, or shelter costs.

Enter six numbers indicating the amount of child support received from the OAG to be budgeted.(Example: $25 as 002500.) Enter 000000 if payments were previously reported and have now terminated.

These entries are no longer required if, for the two previous months, the OAG has not reported payments to the individual.

Always enter an amount in Item 56 if you enter an amount in this item.

C—520.9 Section IX, Items 153 - 160

Revision 02-3; Effective April 1, 2002

Item 153 - 160

All Programs

Make no entries in these items.

C—520.10 Section X, Items 161 - 178

Revision 02-3; Effective April 1, 2002

Case Classification (CC)

All Programs

The codes in Section X are not stored in the computer file. They are kept for individual transactions only and are used to complete management reports.

Item 161 - 163: Reserved

Item 164: Case County/Home Phone No.

All Programs

Enter the three-digit code for the individual's residence county, followed by a space. After the space, enter the individual's ten-digit telephone number, including the area code.

Notes:

• See C-350 for the county codes.
• Enter the county associated with the worker's BJN in Item 25.
• Enter only the individual's home telephone number. If the individual has no home telephone number, leave blank.

Item 165 - 167: Reserved

Item 168 - 170: Program Combination Code(s)

All Programs

Use program codes to indicate whether the case action associated with the Form H1000-A, Form H1000-B and Form H1000-C is worked alone or generically with other programs.

Items 171 - 178: Reserved

C—520.11 Section XI, Items 179 - 187

Revision 04-3; Effective April 1, 2004

TANF

Use this section instead of Form H1008, Authorization for Cancellation or Issuance of Public Assistance Warrants, to request benefits in situations described in the instructions for Item 180. Use Form H1008 to process all other requests for warrant actions. Use this section only for Category 2, TP 01 or 61 cases, or cases being transferred to TP 01 or 61.

Recoupment cannot be done on a benefit requested in Section XI.

SNAP

Use this section to request the issuance and cancellation of benefits.

When reporting a SAVERR or ATA issuance timely on Form H1000-A, Form H1000-B and Form H1000-C, complete Items 118-122 (if appropriate), 179, 180, 183, 184, 185, 186 (if appropriate), and 187.

When reporting an ATA issuance untimely, complete Items 118-122 (if appropriate), 179, 180, 181, 182, 183, 184, 185, 186 (if appropriate), and 187.

TP 55 and 30

Use this section on Form H1000-A with Item 46 to identify any eligible (non-spend down) or potentially eligible (spend down) prior coverage month(s). Use one line for each prior month. Use this section only for consecutive months, with or without spend down. A separate Form H1000-A will be required for any prior coverage months followed by a gap in eligibility. For this section, months with spend down are not considered gaps in eligibility.

Entries in this section for prior coverage cannot precede:

• the third month before the month in Item 08;
• the earliest month of medical coverage entered in Item 46 for any person.

Item 179: ISS/CAN (Issue/Cancel)

TANF

Enter one of the following codes to indicate the type of benefit being requested:

1 — Full month's amounts

2 — Additional benefits for a month; Form H1000-B use only

SNAP

Enter one of the following codes to indicate the method of issuance or to request a cancellation:

S — Untimely reporting EBT issuance via ATA to clear a discrepancy report RF-07E-1. This code can only be used with Code 1 or 3 in Item 180.

E — Requesting EBT issuance or timely reporting EBT benefits issued via the ATA.

N — Requesting cancellation of benefits.

5 — Historical Information: State-office entered. Used to identify a CCDMI as a certified mail issuance. No longer in use effective April 1, 2004.

C — Historical Information: State-office entered. Used to identify a CCDMI that was cancelled. No longer in use effective April 1, 2004.

TP 55 and 30

Enter the appropriate code for each prior month in which a case is eligible or potentially eligible.

N — Not eligible for Medicaid until spend down is met

E — Eligible for Medicaid without spend down

Make no entry for ineligible months. The months reported in this section must be consecutive months of eligibility, with or without spend down.

Item 180: Type ISS.

TANF

Enter the reason for authorization:

9 — Action Code 090, simultaneous open and close on Form H1000-A only. Use to request allowable warrants from Item 129, Grant Effective Date, through Item 47, Denial Date, if the amount equals Item 70, Recommended Grant.

B — Change in both household composition and money reflected in the budget

F — Additional benefits issued due penalty imposed in error

H — Change in household composition

M — Change in money reflected in the budget

Note: Use B, H, and M for certifications and reinstatements, action Codes 57 or lower, to request allowable benefits for the month(s) before the Item 129 entry. These codes identify why the prior amount is different from Item 70, Recommended Grant, amount.

Also use B, F, H, and M to issue additional amounts for months in which benefits have already been produced. These codes identify why the additional amount is requested.

Use these codes to issue a benefit for the current or previous month when releasing hold with Code 0 or 7 in Item 142.

O — Retroactive and/or current month's benefit when releasing a case from hold with release Code 0or 7 in Item 142. Use for a benefit amount equal to the grant amount to be printed in Item 70.

P — Budgeting process requires different payment month benefits. Enter Code 1 in Item 179. Use for a benefit amount different than the amount to be printed in Item 70.

R — (State office use only.) Identifies on the history file benefits produced when release Code 8or 9 is used to release a case from hold. These benefits will always be for the recommended grant amount previously on file, not a recommended grant amount changed at the time the hold is released on Form H1000-B and Form H1000-C.

T — Transfer from TP 07, 20 , 29, or 37 to TP 01 or 61 (Form H1000-B and Form H1000-C use only).Use to issue a benefit of the same amount for the previous month, if needed. The advisor must ensure that the benefit amount requested is equal to the new grant amount that is printed in Item 70. Use Form H1008 to request a benefit for a different amount or an earlier month.

SNAP

Enter one of the following codes to indicate the type of benefit requested:

Full Regular Ongoing Benefits or Replacement of These Benefits

A — Initial benefit (regular ongoing benefit).

E — Initial expedited benefit issued through

• SAVERR to meet timeliness requirements, or
• the ATA and reported timely in Section XI.

Also use for the second month on an expedited case when issuing the second month's benefits as a combined allotment and the first month's benefit cannot be issued because it prorates to less than $10.

H — Use to issue a benefit through SAVERR as a priority issuance to meet timeliness for a hearing officer decision. Do not use when timeliness can be met using another applicable code.

L — Restored full month's benefit for a past month.

1 — Use only to clear discrepancy report RF-07E-1, generated because the benefit was issued via the ATA and was not reported timely in Section XI. On inquiry, an issuance coded E by the advisor displays as a Code 1 if the benefit was issued via the ATA.

2 — Priority benefits issued through

• SAVERR to meet non-expedited application timeline requirements, or
• the ATA to meet non-expedited application timeliness requirements and reported timely in Section XI.

3 — Use only to clear discrepancy report RF-07E-1, generated because the benefit was issued via the ATA and was not reported timely in Section XI. On inquiry, an issuance coded 2 by the advisor displays as Code 3 if the benefit was issued via the ATA.

All issuances coded A, E, 2, or L in Item 180 must balance using Items 184, 185, 186 (if applicable), and 187.

Potential Item 180 code combinations for applicants receiving combined allotments are:

Additional Benefits for a Month

C — Supplemental benefits. Use when providing benefits in addition to initial benefits for the current month or following month if submitting Form H1000-A, Form H1000-B and Form H1000-C after cutoff.

D — Restoration benefits. Use when restoring partial benefits for a past month.

F — Supplemental or restoration benefits. Use when providing additional benefits for a month in which the household has already received one issuance coded C and/or one coded D.

P — Restore an erroneously expunged EBT benefit.

Destroyed Food

T — Replacement of destroyed food, that was purchased with SNAP benefits.

Historical Information: State office also uses this code to replace CCDMIs that are lost/stolen within the postal system. No longer in use effective April 1, 2004.

Every month must have an uncanceled A, E, 1, 2, 3, or L before an issuance coded C, D, F, P, or Tin Item 180 can be processed. To replace a canceled issuance, always use the same code in Item 180.

Only one type issuance Code C or D is allowed per month. Codes C and D issuances are allowed for the same month. Code C cannot be used for month already having a type code L issuance. Code F cannot be used unless type code C or D has been issued for the month.

Advisor entered cancellation

G — Use to cancel EBT benefit because the household has moved out of state. Use code N in Item 179.

State Office-entered

4 — Historical Information: CCDMI mailed out of state as a result of converting EBT benefits to coupons. No longer in use effective April 1, 2004.

5 — Historical Information: Benefits placed back in an EBT account after a CCDMI was returned and cancelled. No longer in use effective April 1, 2004.

These codes do not appear on Form H1000-B. These are in the benefit history file that is available through inquiry.

Item 181: ATP/Benefit No.

TANF and SNAP

Issuance numbers issued via EBT have two leading alpha characters (Example: AA12345).

TANF

Make no entry. SAVERR assigns issuance numbers.

SNAP

Make no entry if requesting an issuance or reporting an ATA issuance timely.

SAVERR assigns an issuance number when authorizing an issuance or when the EBT system reports an issuance.

Priority Issuance Numbers:

• Issuance numbers beginning with ZX indicate priority issuances processed via the ATA that were not reported on Form H1000-A, Form H1000-B and Form H1000-C within five days.
• A code X after an issuance number indicates SAVERR sent the benefit record to the vendor system as a priority issuance. SAVERR sends benefits as priority issuances only if the advisor uses code E in Item 179 and code E, H, or 2 in Item 180.

Item 182: Issue Date

TANF

Enter only on Form H1000-B and Form H1000-C when requesting a prorated benefit resulting from the transfer of a case from TP 07, 20, 29, or 37 to TP 01 or 61.

SNAP

Enter the date benefits were issued if canceling an issuance.

Enter the issue date if reporting an ATA issuance untimely to clear an RF-07/37E-1.

In the Issue Date (ISSUE DT) column, SAVERR inquiry displays an asterisk (*) for the second month's benefit of a combined allotment if it is issued before cutoff of the application month. This information does not appear on Form H1000-B. It is in the benefit history file that is available through inquiry.

Item 183: Benefit Month

TANF and SNAP

Enter the month and year for which the benefits are requested. Use a separate line for each benefit month entered.

SNAP

Historical Information: In the EFF column, SAVERR inquiry displays the date a CCDMI was processed instead of the benefit month. This information does not appear on Form H1000-B. It is in the benefit history file that is available through inquiry. No longer in use effective April 1, 2004.

TP 55 and 30

Enter the month and year for the prior coverage month in which a case is eligible or potentially eligible.

Item 184: Net Income

TANF, SNAP, TP 55 and 30

Enter the whole dollar amount of net income that applies to the benefit month in Item 183.

Item 185: Benefit Amount

TANF

Enter the benefit amount requested.

SNAP

Enter the amount of the benefit being issued. If recouping $8 from a $10 allotment, enter $2.00

TP 55 and 30

Enter the spend down amount for that month. Enter 0 if there is no spend down.

Item 186: Other Data (Initial Month and Code)

TANF

When issuing a benefit (prorated, full, or supplemental) in Section XI that is reduced because of a financial penalty, enter the penalty amount and penalty code in Item 186. If the benefit is reduced because of multiple penalties, enter the amount and Code U (multiple penalties). Enter the adjusted benefit amount (the benefit amount minus the penalty amount) in Item 185.

If a supplement is issued because a penalty was imposed in error, enter Code F in Item 180 and code (supplemental restored benefit) in Item 179.

SNAP

Do not recoup on a Section XI issuance or a prorated initial month's benefits. Enter the appropriate initial month code in this item and record the dollar amount.

If you are not prorating the initial month's benefits, leave this item blank. Make the following entries if you are prorating benefits:

For all issuances coded C, D, F, H, P, or T in Item 180, enter in the cents field the range code below that corresponds to the issuance amount in Item 185. Do not make an entry in the dollar field.

These codes are not needed for benefits coded A, E, L, or 2 since these type of benefits must correspond to entries in Item 184, Net Income and Item 187, Household Size.

Item 187: H.H. No. (Household Number)

TANF

Enter the household composition for the benefit requested.

Example: One adult and three children – 103.

SNAP

Enter the number of people in the SNAP household whose benefits are included in the issuance reported.

TP 55 and 30

Enter the household composition for the month.

For budget group with less than 10 children, enter 0 for the second digit.

These entries must correspond with Items 184 and 185.

C—520.12 Section XII

Revision 02-3; Effective April 1, 2002

All Programs

SAVERR completes this section to report the status of a denied application, the case status and the form effective date.

Item: (App. Code) (Action Code) (Action Date)

SNAP

SAVERR prints the denied application information in this section. This information appears only in Section XII, and not in Items 79, 91, and 92.

Item: Case Status

All Programs

This item shows the current status of the case: active, denied, or hold.

Item: Form Effective Date

All Programs

This item shows the form effective date of the previously submitted Form H1000-A, Form H1000-B and Form H1000-C.

On Form H1000-B and H1000-C with Sequence 02, the form effective date is the first of the month that the input document was entered on SAVERR.

On Form H1000-B and Form H1000-C with sequences 03 and above, the form effective date is the date the action reported on the previous Forms H1000-B and Form H1000-C becomes effective according the SAVERR cutoff cycles.

C—520.13 Section XIII

Revision 02-3; Effective April 1, 2002

TANF and SNAP

SAVERR records on the Form H1000-B turnaround the monthly benefit issuance history for the current and past 11 months.

TP 55 and 30 with Base Plan of 55

SAVERR prints the three months prior spend down on Form H1000-B turnaround.

Item: ISS/CAN/Results

TANF

This item records the authorization code from Item 180 and the benefit amount from Item 185.

SNAP

This item records the advisor entries from Items 179 and 185.

Item: Date

TANF

This item lists the month of eligibility for which the benefit was issued.

SNAP

This item records the month and year for which benefits are authorized (benefit month).

Item: Issued/No.

TANF

This item lists the number of issuances for the month of eligibility.

SNAP

This item records the number of issuances the household is issued for the month.

Item: Issued/Persons

SNAP

This item records the household size listed on the last benefit issued for the month.

Item: Issued/Amounts

TANF

This item lists the amount of benefits issued for the month.

SNAP

This item records the household's cumulative benefit allotment, including supplemental benefits and replacement issuances, less any cancelled benefits.

Item: Redeemed/No.

SNAP

This item records the cumulative number of issuances for the household.

Item: Redeemed/Persons

SNAP

This item is not used.

Item: Redeemed/Amount

SNAP

This item is a record of the amount of benefits issued monthly.

Item: CD

TANF

The code in this column indicates deductions made from recognizable needs. (R = Recoupment deduction)

SNAP

This item records the type of the last issuance processed in the month.

C—520.14 Section XIV, Items 188 - 191

Revision 02-3; Effective April 1, 2002

Item 188: Signature

All Programs

The advisor completing Form H1000-A, Form H1000-B and Form H1000-C signs and enters his unit number in this space.

Item 189: Date Signed

All Programs

Enter the date Form H1000-A, Form H1000-B or Form H1000-C is signed.

TANF

Exception: When certifying a TANF application, enter the certification date. This should be the date entered on the TANF worksheet. SAVERR prorates benefits for the first month of eligibility from this date or the 30th day after the file date, whichever is earlier.

Item 190: EMP No.

All Programs

Enter the employee number of staff signing Form H1000-A, Form H1000-B and Form H1000-C.

Item 191: TP Only

All Programs

Data Communications Unit use only. Make no entry.

Medical Programs

When the record of case action is received, the advisor or clerical reviewer edits, initials, and dates the form. If the turnaround document contains an error or warning message, the clerical reviewer must not initial and file it, but must immediately send it to the advisor.