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 notify an applicant that he is eligible for Medicaid.
- To notify an institutionalized applicant that he is eligible for nursing facility or ICF-MR coverage.
- To notify an applicant of his medical effective date (including prior coverage) and denial date, when applicable.
- To notify an institutionalized applicant of the amount of applied income he must pay to the nursing/ICF-MR facility.
- To notify an applicant that he is eligible for Medicaid Qualified Medicare Beneficiary (MQMB) benefits.
- To notify an applicant that he is eligible for Medicaid Specified Low-Income Medicare Beneficiary (M-SLMB) benefits.
- To notify an applicant of his right to appeal.
When to Prepare
The caseworker prepares Form H1230 when he approves an application for Type Programs 03, 11, 14 (except base plan 20) 18, 22, and 30.
Note: When preparing Form H1230 for a TP 30 client, include Form H1230-TP 30 Attachment.
Number of Copies
Complete an original and two copies. Complete three copies, if one is sent to the nursing/ICF-MR facility.
For Type Programs 03, 11, 18, 22, and 30 (Base Plan 13) send the original and first copy to the applicant at his address or that of his responsible party. Enclose a prepaid return envelope. File one copy in the case record.
For Type Program 14 (Base Plan 10 or 15) send the original and first copy to the applicant at his address or that of his responsible party. Enclose a prepaid return envelope. Send the second copy to the nursing facility and keep the third copy in the case record.
In situations where the client has elected hospice, as evidenced by receipt of the Form 3071, Recipient Election/Cancellation Notice, the caseworker sends the nursing facility/ICF-MR facility copy of the Form H1230 to the hospice provider.
Keep the case record copy according to the retention requirements of the case record.
Heading — Enter the name of the client and his mailing address or that of his responsible party.
Client Name — Self-explanatory.
Client No. — Self-explanatory.
Date — Self-explanatory.
Worker — Self-explanatory.
Office Address and Telephone No. — Enter the caseworker's complete office address and telephone number. Include the TDD telephone number if the office is equipped with TDD.
Your Medicaid benefits begin ... — Enter the medical effective date from Form H1000-A.
Your Medicaid benefits begin ... and end ... — Use this section only if a case is being opened and closed simultaneously. Enter the beginning and ending (inclusively) dates of Medicaid coverage.
Please ask each provider to write "RETROACTIVE MEDICAID" on the claim form. — Check this box if coverage is being granted for any month prior to the month in which the application is filed.
FOR NURSING HOME/ICF-MR MEDICAID — Check this box if the applicant resides in a nursing facility or ICF-MR facility.
Based on your income, you must pay ... — Enter the monthly applied income amounts and effective dates.
MEDICAID QUALIFIED MEDICARE BENEFICIARIES — Check this box if the applicant is also eligible for Medicaid Qualified Medicare Beneficiaries (MQMB) benefits.
Your benefits begin ... — Enter the effective date of MQMB benefits. Unless ensuring continuous QMB coverage for type program transfers or for clients who were receiving QMB benefits out-of-state, this date will always be the first day of the month following the month in which the Form H1201, MAO Worksheet, is signed.
Because your entitlement to Part A Medicare is not effective until ... — Enter the effective date of Part A entitlement.
MEDICAID SPECIFIED LOW-INCOME MEDICARE BENEFICIARIES — Check this box if the applicant is also eligible for Medicaid Specified Low-Income Medicare Beneficiaries (M-SLMB) benefits.
Your benefits begin — Enter the effective date of M-SLMB benefits. This date may be up to three calendar months prior to the month in which the application was filed, if all criteria are met.