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Effective Date: 


Note: This form is computer generated and no sample is provided.



Updated: 9/2017


To provide Supplemental Security Income (SSI) recipients:

  • notification that their Medicaid benefits are denied due to the denial of their SSI benefits;
  • information on potential eligibility for Medicaid without SSI;
  • instructions on how to apply for other types of Medicaid;
  • contact information for the Social Security Administration (SSA) if they want to appeal the SSA’s decision; and
  • contact information for legal advice.


When to Prepare

When the SSA notifies Texas Health and Human Services (HHS) that an SSI recipient's benefits are denied or suspended, TIERS automatically prints and sends H1296 to the SSI recipient. H1296 contains the last day of Medicaid coverage for the SSI recipient at the top of the notice. H1296 is a TIERS generated form that is printed with a cover sheet that contains the SSI recipient's name, address,  case number, and the date the notice was printed.

Note: TIERS does not generate Form H1296 if the SSI recipient is deceased.

Number of Copies

Every SSI recipient denied Medicaid receives one copy.


TIERS sends Form H1296 to the SSI recipient. The SSI recipient is advised via Form H1296 of their Medicaid denial and of the requirements needed for continued Medicaid coverage.

Mailing Cycle

Forms H1296 are mailed daily.

Form Retention

The department does not keep a copy of this form.