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Effective Date: 



Updated: 12/2017


To notify an applicant of ineligibility and the right to appeal.


Complete the Notification of Ineligibility when an application is denied.

Note: When an application is denied based on income it would be good case work practice to send a qualified income trust (QIT) packet to the client/RP at the time of the denial.

Number of Copies

Complete an original and two copies. Complete three copies, if one is sent to the nursing/ICF-MR facility.


Send the original and one copy to the applicant at his address or that of his responsible party. Enclose a prepaid return envelope.

Send one copy to the nursing/ICF-MR facility if the applicant is a resident.

File one copy in the legal section of the case record.

Form Retention

Keep the case record copy according to the retention requirements of the case record.


The Notification of Ineligibility may be typed or legibly handwritten.

Inside Address— Enter the name of the applicant and his mailing address or that of his responsible party.

Date— Self-explanatory.

HHSC Staff— Self-explanatory.

Office Address and Telephone Number— Enter the caseworker's complete office address and telephone number. Include the TDD telephone number if the office is equipped with TDD.

Your application for assistance has been . . . It has been determined that: — Check the appropriate box(es) to indicate the program(s) for which the applicant is ineligible.

This decision is based on the policy found in section— Enter the section of the Medicaid Eligibility Handbook which addresses the policy on which the denial of assistance is based.

Reason for Ineligibility— Enter in English and Spanish the reason for denial, as found in Appendix I, the MAO Action Codes. Enter comments as applicable.

You are not eligible for payment of unpaid bills— Complete this information when the applicant is not eligible for prior medical coverage. Indicate the months of ineligibility for prior medical coverage.