Note: This is a secure form and is not available through this site. This form must be ordered at a local HHSC office.
To provide a client with a document verifying the client's eligibility for Qualified Medicare Beneficiary (QMB) benefits. Form H1027-C is not to be used for any client who is eligible for Medicaid benefits under another Medicaid coverage group.
When to Prepare
Use Form H1027-C only in the following situations:
- A newly certified QMB client needs immediate access to Medicare cost-sharing benefits and the eligibility specialist has submitted Form H1000-A/B, but no client number has been assigned.
- A QMB client needs immediate access to Medicare cost-sharing benefits, but has lost, not received or has no access to a current Form H3087 (Medicaid Identification).
For B, above, eligibility specialists must verify current eligibility. Prior to issuance of Form H1027-C, eligibility specialists must verify eligibility by
- contacting the data communications unit (DCU), or
- checking the SAVERR files through LAN/UNISCOPE inquiry.
If verification is impossible because of computer problems, follow regional procedures to verify eligibility.
Note: Do not issue Form H1027-C
- based on presumed or predicted eligibility, or
- if the client is eligible for regular Medicaid benefits.
Do not issue Form H1027-C routinely. Only intake screeners or TANF, Medicaid, Community Care for Aged and Disabled (CCAD) foster care or adoption assistance eligibility specialists and supervisors are authorized to complete the form.
Note: Before issuing the form, the eligibility specialist completing Form H1027-C must obtain supervisory approval indicating verification of current eligibility.
Upon approval, the supervisor must sign and date Form H1027-C and return it to the eligibility specialist. If the supervisor does not work in the office where the form is issued, the lead eligibility specialist may approve Form H1027-C. Approval may also be obtained from the supervisor by telephone. If approval is obtained by telephone, enter "Approved by," the supervisor's name and the initials of the person obtaining the approval.
Complete Form H1027-C in ink, or type it.
Note: Refer to Item 4540 in the Medicaid Eligibility for the Elderly and People with Disabilities Handbook or Item 2130 in the Case Manager Community Care for Aged and Disabled Handbook for additional information regarding the issuance of Form H1027.
Number of Copies
Prepare an original and one copy if giving Form H1027-C to the client in person. Prepare an original and two copies if the form must be mailed to the recipient.
Give the original to the client or the client's payee, guardian or other bona fide representative. DO NOT give the form to a medical provider. File the copy in the case record under Medical.
Mail Form H1027-C only if the recipient cannot pick up the form in person and the eligibility specialist would have to travel a considerable distance to deliver it.
If mailing is necessary,
- Date the affidavit section of an original and one copy.
- Instruct the recipient to
- sign the original and the copy,
- keep the original, and
- return the signed copy to the local office.
- Mail the original, copy and instructions with a stamped, self-addressed envelope.
- File the signed copy in the case folder when it is returned.
Keep the case record copy for three years after the case is closed or denied.
The following example is numbered for reference only. Actual forms do not have these numbers.
1. If the client is a newly certified QMB client and does not yet have a client number,
- check the box, and
- continue to Step 2a.
2. If the QMB client has a client number, but he has lost, not received or has no access to a current Form H3087,
- check the box, and
- continue to Step 2a.
2a. Complete the eligibility verification section to indicate when you verified eligibility, and whether you verified it by
- contacting the local data communications unit (DCU),
- checking the SAVERR client and case files through direct inquiry, or
- following regional procedures.
Note: You must look up Client Screen 1 on either LAN or UNISCOPE inquiry for the client to be listed on Form H1027-C. When accessing inquiry by case number, a "C" must be entered on the line next to the client name. Client Screen 1 will then appear. (See the following examples.)
- "QMB" is preprinted.
- Client Name: Enter the name of the certified member of the group.
Date of Birth: Enter the date of birth as shown on the certification document or LAN/UNISCOPE inquiry.
Client No.: Enter the nine-digit client number. For a newly certified client, enter "to be assigned."
Eligibility Dates: Enter the date (MM/DD/YYYY) the client became eligible for Medicaid benefits, and enter the last day of the month in which Form H1027-C is issued. Coverage is limited to the calendar month in which Form H1027-C is issued.
Medicare Claim No.: Enter the Medicare claim number (social security claim number) for the client.
NorthSTAR is a managed care behavioral health care plan for mental health and chemical dependency services. This pilot is currently available only in the Dallas Service Area. NorthSTAR eligibility information is not reflected on a client's Medical Identification form (Form H3087). It will NEVER be entered on Form H1027. Enrollment information is available on UNISCOPE Client Screen F for informational purposes only.
- Signature — Client and Date: The client to whom Form H1027-C is issued must read the affidavit portion of the form and sign and date both the original and the file copy. If the form is issued to a payee, guardian or other representative of the client, that person must sign in the appropriate space.
- Office Address and Telephone No.: Enter the office address and telephone number in this space at lower left corner.
- Worker Information: Enter the eligibility specialist's name and BJN. The eligibility specialist must sign and date the form.
- Supervisor Information: Enter the supervisor's name and BJN. The supervisor must sign and date the form. If the supervisor does not work in the office where the form is issued, the lead eligibility specialist may approve Form H1027-C.
Store local supplies of Form H1027-C in a locked file cabinet. For more information, refer to your regional security plan.