Form 5842, TxHmL Financial Eligibility Information

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Documents

Effective Date: 6/2023

Instructions

Updated: 6/2023

Procedure

The applicant must meet financial eligibility to be enrolled in the Texas Home Living (TxHmL) Waiver Program. The Local Intellectual and Developmental Disability Authority (LIDDA) will attempt to obtain information about the applicant’s financial eligibility status before processing enrollment in the TxHmL Program. The LIDDA must verify the applicant’s Medicaid status. If the applicant has not applied for Supplemental Security Income (SSI) through the Social Security Administration (SSA) or Medicaid through the Texas Health and Human Services Commission (HHSC), the LIDDA must direct them to apply to the SSA or HHSC as appropriate. The LIDDA must offer to assist the applicant with the application process. If the applicant has been denied SSI or Medicaid, the LIDDA will submit this form as per the detailed instructions below.

This form is to be used only for applicants who are being denied the TxHmL Program because of a denial of financial eligibility. The individual will be denied TxHmL Program services if they do not meet financial eligibility criteria for the TxHmL Program.

Detailed Instructions

If the applicant has been denied SSI or Medicaid, the LIDDA must complete Form 5842 and fax it to HHSC. A copy of the SSI denial letter from the SSA or the Medicaid denial letter from HHSC must be faxed with Form 5842.

Date — Enter the date the LIDDA sent the form to HHSC.

LIDDA Name — Print the name of the LIDDA that is coordinating the enrollment process.

Comp Code — Enter the three-digit component code for the LIDDA.

LIDDA Contact Name — Print the name of the LIDDA contact who is coordinating the enrollment process.

Area Code and Phone No. — Enter the area code and phone number of the LIDDA contact.

Applicant Name — Print the name of the applicant who is requesting enrollment in the TxHmL Program.

HCS or TxHmL Pre-enrollment Form Document Locator Number (DLN) — Enter the DLN from the HCS or TxHmL Pre-enrollment form submitted through the TMHP Long Term Care Online Portal.

Medicaid No. (if applicable) — Enter the applicant’s Medicaid number (if applicable).

Date of Birth — Enter the applicant’s date of birth.

Mailing Address — Enter the applicant’s mailing address, including city, state and ZIP code.

Applicant’s Name — Print the name of the applicant who is requesting enrollment in the TxHmL program.

Signature — Applicant or Applicant’s Legally Authorized Representative (LAR) — Obtain the signature of the applicant or the applicant’s LAR.

Printed Name — Applicant or Applicant’s LAR — Print the name of the applicant or the applicant’s LAR.

Date Signed — Enter the date the applicant or the applicant’s LAR signed the form.

Signature — LIDDA Contact (name listed above) — Enter the signature of the LIDDA contact who is coordinating the applicant’s enrollment in the TxHmL Program.

Job Title — Enter the job title of the LIDDA contact who is coordinating the enrollment.

Date Signed — Enter the date the LIDDA contact signed the form.