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- To document all eligibility and procedural requirements for Medicaid Eligibility for the Elderly and People with Disabilities (MEPD) applications and complete redeterminations.
- To serve as a budget sheet for determining eligibility and copayment.
When to Prepare
Prepare for MEPD applications and reviews as documentation when the system of record is the System for Applications, Verifications, Eligibility Reports and Referral (SAVERR).
The latest Form H1201 can be used to record contacts or special reviews between annual redeterminations.
Form H1202-B, MAO Worksheet – Other Changes, can be used to record original denials, denials that do not require Form H1200, Application for Assistance – Aged and Disabled, and special reviews not involving income (including variable income) and/or incurred medical expenses.
Form H1202-A, MAO Worksheet – Income Changes, can be used for special reviews involving income changes, including the rebudgeting/reconciliation of variable income and/or incurred medical expenses.
Number of Copies
Complete an original Form H1201and file it in the case record behind the corresponding application or redetermination form.
Keep in the case record for three years after the case is denied.
Note: Space is provided on all pages to record any necessary clearances or verifications.
Section 1 – General Information — Self-explanatory.
Section 2 – Applications Only — Self-explanatory.
Section 3 – Financial Management — Self-explanatory.
Section 4 – Resources — Check the "Doc. Filed" column if a verification document is filed in the case record. If the "Doc. Filed" column is checked, no further documentation is required. Enter the countable amount of resources by each type.
On page 3, for "Client's Countable Resources," enter the total of the countable resources listed in items 1 through 24 for the applicant/recipient or couple (if couple case or community-based companion case where deeming of resources is appropriate). In individual cases, community-based companion cases and couple cases, this amount is also entered under "Remainder" below. If eligibility for Qualified Medicare Beneficiary (QMB)/Specified Low Income Beneficiary (SLMB)/Qualified Individual (QI) is being tested, enter in "COMPARE WITH QMB/SLMB/QI RESOURCE LIMIT" the QMB/SLMB/QI applicant/recipient or couple (as appropriate) resource limit. Note: Medicare savings programs have different resource procedures. See Chapter Q, Medicare Savings Programs, in the MEPD Handbook.
Enter in "Combined Countable Resources (Spousal Impoverishment)" the combined countable resources of the institutionalized and community-based spouse. Remember that at assessment and throughout the initial eligibility period the following resources are excluded regardless of value – homestead, one automobile and household goods/personal effects.
Enter in "Subtract Protected Resource Amount if applicable" the spousal protected resource amount determined at assessment.
For "Remainder," in spousal impoverishment cases enter the difference between the entry under "Combined Countable Resources (Spousal Impoverishment)" and the entry under "Subtract Protected Resource Amount (SPRA) if applicable." Enter under "COMPARE WITH MAO RESOURCE LIMIT" the medical assistance only (MAO) resource limit for an individual.
In individual cases, community-based companion cases and couple cases, enter under "Remainder" the amount from "Client's Countable Resources" above. Enter under "COMPARE WITH MAO RESOURCE LIMIT" the MAO resource limit for an individual or couple, as appropriate.
Section 5 – Transfer of Assets — Complete this section to explain any transfer of assets and its effect on the client's eligibility. Note: Remember that §1915(c) waivers, state supported living centers and excess home equity have different requirements. See Chapter I, Transfer of Assets, Section F-3600, Substantial Home Equity, and Section F-3610, Persons Impacted by Substantial Home Equity Disqualification, in the MEPD Handbook.
Section 6 – Earned Income — Check the "Doc. Filed" column if a verification document is filed in the case record. Enter the amount of monthly gross earnings if the client or spouse has earned income. Documentation should show computation of monthly gross earnings.
Section 7 – Unearned Income — Check the "Doc. Filed" column if a verification document is filed in the case record. If the "Doc. Filed" column is checked, no further documentation is required for that item. Enter for client and spouse (if any) the amount of income by each type received.
Section 8 – Ongoing Title XIX Budget —
Federal Maximum Test — Use this section for Type Program (TP) 14 cases only.
A. — Enter the gross countable monthly income of the individual or eligible couple.
B. — Enter any allowable exclusions.
C. — Subtract item B from item A and enter the difference here.
D. — For an individual or spousal impoverishment case, enter three times the Supplemental Security Income (SSI) Federal Benefit Rate for an individual. The couple income limit is twice the individual income limit.
Three Months Prior (MAO/SLMB/QI) — If an application covers three months prior, enter the months involved and the client's/spouse's gross countable income for each month.
Eligibility Test – All Type Programs — Use this section to determine eligibility for all type programs. Use the "QMB" column to determine QMB eligibility and the "Other TPs" column to determine eligibility for all other programs.
A. — Enter the individual or eligible couple's gross countable monthly income.
B. — For TP 03, 18 and 22, enter the Retirement, Survivors and Disability Insurance (RSDI) amount to be excluded. For TP 51 (non-Status-in-Group Code "J" cases), enter the total cost-of-living adjustment to be excluded from pension or retirement benefits.
C. — Enter other exclusions as appropriate. Example: Earned income exclusions when the SSI, QMB, SLMB or QI income limit is used in testing eligibility.
D. — Subtract the sum of items B plus C from item A and enter the difference here.
E. – Compare With – Income Limit — Enter the QMB/SLMB/QI and/or MAO income limits for an individual or couple, as appropriate.
Section 9 – Third Party Resources — Complete this section about the client. If appropriate, send Form H1039, Medical Insurance Input.
Section 10 – Applied Income — Use this section for TP 14 and TP 51 only.
A. — Enter the client's monthly countable income (excluding any mandatory payroll deductions from earned income and income taxes withheld from pension or benefit checks).
B. — Enter the eligible spouse's monthly countable income (excluding any mandatory payroll deductions from earned income and income taxes withheld from pension or benefits checks).
C. — Enter any allowable exclusions.
D. — 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.
E. — Subtract the sum of items C plus D from the sum of items A plus B and enter the difference here.
F. — In spousal impoverishment cases, enter the community spouse's monthly income (less mandatory payroll deductions from earned income and income taxes withheld from pension and benefit checks).
G. — Enter the total of items E and F.
H. — If the community spouse's total monthly income (as entered in item F) is equal to or less than the current spousal monthly maintenance allowance, enter the current spousal monthly maintenance allowance. If the community spouse's total monthly income (as entered in item F) is more than the current spousal monthly maintenance allowance, enter the community spouse's total income (as entered in item F).
I. — In spousal impoverishment cases, enter the deduction for dependents as calculated to the right of this item.
J. — Enter the amount of the client's and eligible spouse's Medicare Part B premium, if not MQMB- or MSLMB-eligible.
K. — Enter the monthly amount of premiums for assignable general health insurance policies being paid by the client and eligible spouse.
L. — Enter the amount of any other allowable incurred medical expenses. Example: Payments for dentures.
M. — Enter the applied income amount for the client and spouse (if couple case). This is obtained by subtracting the sum of items H through L from item G. In couple cases, the difference is divided by two.
Section 11 – Additional Information — Self-explanatory.
Section 12 – Agency Action — Self-explanatory.
Form H4808 Date — Complete this section if Form H4808, Notice of Change in Applied Income/Notice of Denial of Medical Assistance, is sent, giving the date of the Form H1000-B, Record of Case Action, transmittal.
Additional Documentation — Use this section for any additional documentation that might be needed.
Signature — Self-explanatory.
Date — Self-explanatory.