Downloading a Form to Your Computer
Fillable forms cannot be viewed on mobile or tablet devices. Follow the steps below to download and view the form on a desktop PC or Mac.
- Right Click for PC or Ctrl + Click for Mac on the PDF link and click “Save link as” from the menu.
- Select the folder you want to save the file in and then click "Save."
- Navigate to the folder you saved the file in and Right Click for PC or Ctrl + Click for Mac, then select "Open With" from the menu and select Adobe Acrobat Reader DC.
Note: Open the PDF file from your desktop or Adobe Acrobat Reader DC. Do not click on the downloaded file at the bottom of the browser since it will not open the PDF in Adobe Acrobat Reader DC. It will try to open the file in the browser that results in the same browser error message.
To obtain a case-specific policy clarification or interpretation for Texas Works (TW), Medicaid for the Elderly and People with Disabilities (MEPD), and Community Care Services Eligibility (CCSE).
Eligibility field staff use this form to request a case-specific policy clearance or interpretation. Prior to submitting a request for a policy clearance, eligibility field staff , supervisors, and the designated policy clarification contact (PCC) must review all applicable policy sources (e.g., handbooks, bulletins, and previous policy clarifications). If unable to determine the appropriate action, the requestor submits this form electronically to the Field Policy Unit or Case Analyst to request a case-specific policy clarification. Service Improvement Program (SIP) Coordinators and Specialists, Centralized Representation Unit (CRU) staff and others may also use this form to request a case-specific policy clarification. SIP, CRU, and CCSE should follow their established procedures for requesting case-specific policy clarifications from the Field Policy Unit or Case Analyst.
This form may also be used by other HHSC State Office staff, including Quality Control, Ombudsman, and legal or training, to request a case-specific policy clarification.
The requestor should ensure the form is properly completed and contains all relevant and essential information. The requestor will be contacted if additional information is needed.
If Field Policy staff or the Case Analysts determine that additional research or direction is needed, the request for clarification will be escalated to Program Policy for review.
Number of Copies
If the clarification is pertinent to the eligibility determination, image the request and subsequent response for the case record.
Electronically mail the form as an attachment to the designated mailbox per program area.
|TW||HHSC Texas Works Policy Support|
|Program Policy (For use by Field Policy or other HHSC state Office staff only)||HHSC AES PSAD|
Include a descriptive email title with the appropriate handbook section. (Ex: F-1231 Funds for a nonprofit organization or SNAP: A-1822 e-signature on 1808 valid). Use “Urgent” if an answer is needed within a day. (Ex: Urgent SNAP: A-231 SNAP HH Comp Joint).
Policy Clarification Requested by
Provide required information for the person initiating the request.
Policy Clarification Reviewed by
Provide required contact information for the supervisor who reviewed the PCR.
Complete Case Details
Provide the required case information, type of assistance, urgency and attorney information, as applicable.
Questions and Substantiating Documentation
Provide the question or specific clarification request and all substantiating documentation, including any explanation and information that could be important, in the available space. For example, include the program type, whether the person is under a transfer of resources penalty, the applicable household or budgeting situation (e.g., individual, couple, spousal), if it will impact the clarification. If the clarification involves a bulletin or another policy clarification, identify the bulletin or include the previous policy clarification and email responses. Provide all relevant and essential information (such as what, when, why, how, etc.) at the time of initial clarification request to avoid unnecessary delays.
- SPRA month is November 2018. Total resources as of Nov. 1, 2018, were $96,516.43; SPRA was $48,258.21. Worker was unable to expand the SPRA because the community spouse was receiving monthly earnings of $5,879.79. Total resources as of Dec. 1, 2018, were $86,294.16. The person was ineligible due to excess resources. Community spouse lost their job in January 2019. Case was certified in error on Feb. 9, 2019, with a medical effective date of Dec. 1, 2018, and is still active.
- Household consists of mom and her three children. Mom is applying for SNAP but has an open SNAP E&T sanction. Mom is now considered an ineligible student and TIERS is attempting to close her SNAP E&T sanction before the penalty period is over.
- Application for CAS on February 3, 2019. Form 3052 received from the physician is dated Oct. 19, 2017. Policy requires the Form 3052 include a statement that the person has a current medical need but does not address the date of the practitioner’s signature.
Specific Policy Question
Provide the specific policy question needed to address the case situation.
- What is the correct way to handle this case now?
- Do we deny it and ask the person to reapply, in which case we would only count the resources in the person’s name?
- Could we have expanded the SPRA in January or February after the spouse lost his job?
- Should the SNAP E&T sanction be closed?
- How old can a practitioner’s signature be on a F3052 for CAS?
Reviewed Policy Material Related to this Case-Specific Clarification: Identify all applicable handbook sections that the requestor, supervisor and PCC reviewed. Do not quote or cut and paste the entire sections of the handbook on the PCR form.
Complete the attorney section, if applicable. If an attorney has contacted the eligibility field staff, or if the person has an attorney involved, provide the attorney’s information along with any legal paperwork pertaining to the case that the attorney has prepared. All Legal documents should be reviewed by the regional attorney before the policy clarification request is submitted to the MEPD Policy Support mailbox.
- We reviewed MEPD Chapter E, Section 3110, Wages, and the entirety of Chapter J, Section 4000, Assessment and SPRA. Neither section addressed the questions we have.
- TWH A-1846, Reestablishing Eligibility During the Penalty Period, states a person can reestablish eligibility during the penalty period if the person becomes exempt. It’s unclear if reestablishing eligibility also applies to person who is now disqualified for another reason, such as being an ineligible student.
- In Section 3441.2, Reinstatement Procedures after Denial, it explains that the case worker must send an initial referral packet and initial Form 2101 referral to the selected provider. For Primary Home Care and Community Attendant Services, the provider must complete all pre-initiation activities, including obtaining a new Form 3052, Practitioner’s Statement of Medical Need. In Section 4673.6, Temporary Loss of Eligibility and Reinstatement Procedures, the same idea is repeated that says a new Form 3052 is needed even after a temporary loss of eligibility. In each of these instances, new paperwork including a new Form 3052 is required (as opposed to being able to use the existing Form 3052 that is already in the case folder).
Provide the proposed response to the question based on all research. This helps Field Policy or Program Policy follow the requestor’s train of thought and may save time in providing the response.
Questions related to the case-specific policy clarification: What is the correct way to handle this case now? Do we deny it and ask the individual to reapply, in which case we would only count the resources in the individual’s name? Or could we have expanded the SPRA in January or February after the spouse lost his job?
Response from Field Policy or Program Policy
Policy staff complete this section.
The applicable policy staff provides their contact information, the handbook and policy sections applicable to the response, and includes a case specific response to the requestor.
Responses for CCSE PCRs will be sent to all regions as previously agreed.