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 document all eligibility procedure requirements for applications and recertifications for Medicare cost-sharing programs and Medicaid community-based programs, except waiver programs (TP 14/BP 13 and TP 19).
- To document eligibility and applied income for reviews worked under the streamline procedures.
When to Prepare
The worker completes Form H1201-EZ after a client or the bona fide agent signs and submits Form H1200-EZ for an application or complete review.
The worker may use Form H1201-EZ for complete review for cases that are worked under the streamline procedures.
Note: Form H1201-A can also be used for streamline reviews.
Number of Copies
The worker completes an original Form H1201-EZ and files it in the case record behind the corresponding Form H1200-EZ for an application or complete review.
The worker completes an original Form H1201-EZ and files it in the case record behind the corresponding streamline review form.
Form H1201-EZ is kept in the case record for three years after the case is denied.
Identifying Information — Self-explanatory.
Applications Only — Self-explanantory.
Financial Management — Self-explanatory.
Living Arrangement — Self-explanatory
Resources — Always enter the first day of the month that resources are verified. Under total resources enter the total of the countable resources and compare to the appropriate limits.
Income — Self-explanatory
Eligibility Test — All Type Programs Use this section to determine eligibility for all type programs. Compare to the appropriate individual or couple income limits.
Applied Income — Use this section for Type Programs 14 and 51.
- Enter the client's monthly countable income (excluding any mandatory payroll deductions from earned income and income taxes withheld from pension or benefit checks). Do not include any VA, A&A, HB, or Out of Pocket Medical exclusions. Include income of eligible spouse if a couple case.
- Enter any exclusions if any.
- Enter the $60 personal needs allowance ($60 for each spouse in couple cases). In ICF/MR cases (including state supported living centers), include the protected earned income allowance.
- Enter amount of Medicare premium if not MQMB or MSLMB eligible.
- Enter the monthly amount of any allowable incurred medical expenses including the monthly amount of premiums for assignable general health insurance policies being paid by client and eligible spouse.
- Enter amount of other IME deductions.
- Enter amount of applied income.
Action Taken — Self-explanatory. Note: For the Granted/Sustained and Denial boxes, click on the gray vertical line and a drop down arrow will appear. Click on the arrow and codes for the action taken (granted/sustained or denied) will appear.
Signature and Date — Self-explanatory.