Form H1039, Medical Insurance Input

Instructions for Opening a Form

Some forms cannot be viewed in a web browser and must be opened in Adobe Reader on your desktop system. Click here for instructions on accessing your form.
Effective Date
h1039.pdf (92.64 KB)


Updated: 6/2006


  • To report private medical insurance information to state office.
  • To report changes in a client's private medical insurance.
  • To establish a central file on all private medical insurance information used in claims processing systems.
  • To furnish information for reports.
  • To report employer information to state office when private medical insurance is available to the client.


When to Prepare

After Form H1000-A/B turnaround is received with client numbers and the case number, the HHSC employee completes Form H1039 to report information for up to two insurance policies.

The HHSC employee submits Form H1039 to:

  • report a medical insurance policy.
  • report changes or corrections in existing medical insurance policy information.
  • add or delete a client from an existing medical insurance policy.
  • delete an insurance policy reported in error.
  • notify state office about available medical insurance.

Number of Copies

The HHSC employee completes an original and one copy.


The HHSC employee sends the original to:

Mail Code: 1354
P.O. Box 85200
Austin, Texas 78708-5200

and keeps the copy in the case record. Forms submitted with errors will be returned to the HHSC employee for correction.

Form Retention

TW staff will refer to the Manager's Guide for form retention information. The case record copy of Form H1039 is kept in nursing home case records for five years after the denial of the case. For Category 1, 3, and 4 (Long Term Care MAO) cases, file in the Third-Party Resources (TPR) section of the case record; for TANF and CSS Medical Programs cases, file in the Medical section. Note: When a client has been denied assistance for 27 months, the insurance information is deleted from the TPR master file.

Detailed Instructions

Use Form H1039 to report

  • initial policy and client information;
  • a change or correction;
  • a new policy;
  • a new client added to a case; and
  • when a recertification is processed for a client who has been denied benefits for at least one calendar month.

Note: When using a new Form H1039 to report new or changed information, complete all items on the form and enter the new or changed information in the appropriate fields or enter a pound sign (#) in the appropriate item if deleting.

Form H1000-A/B Updates — After the HHSC employee or Texas Medicaid and Healthcare Partnership (TMHP) adds a client to the TPR file, all case and client data, except deletion of the client, will be updated automatically as a result of Form H1000-A/B updates. Therefore, the HHSC employee must not use Form H1039 to update the case data or the client number or name, except as specified below in Deletions.

Deletions — A pound sign (#) is used to delete information reported on a previous Form H1039 and may only be used in the following situations:

  • A policy that was previously reported is not a medical insurance policy (example: life insurance). To delete, enter a pound sign on a new Form H1039 or on the copy of the Form H1039 used to report the policy.Enter the pound sign in Item 1, Company Name. This will remove information on that policy from all clients on the forms.

    Note: If deleting on a new Form H1039, enter the company's name.

  • An individual client was never covered by the policy reported. Enter a pound sign on a new Form H1039 or on the copy of theForm H1039 used to report the coverage in the Begin Date box for the appropriate client. This will remove the policy information for that client only.

    Note: Do not delete an insurance policy that is discontinued by the client or a client who is being denied from an active case.

(Case Name, Case No., etc.)

This section contains case identifying information. All items are self-explanatory and must be entered on Form H1039 exactly as reported on Form H1000-B. Do not submit a new Form H1039 to change any information in this section. This is done automatically by the computer after the HHSC employee submits Form H1000-A/B.


This section:

  • contains information about eligible clients on a case.
  • allows for reporting coverage that a client currently has, as well as available coverage for which the client is not enrolled.

Client No. — Enter the nine-digit client number from Form H1000-B, Item 32.

Client Name — Enter the client name as shown on Form H1000-B, Item 33 (last name, comma, first, space, middle name or initial). Note: Do not submit Form H1039 to report a change in client name. This is done automatically via Form H1000-B.


Complete this section for clients who have medical insurance coverage.

Policy No. (1 or 2) — Enter the appropriate policy number in the bottom section that provides information about the current insurance coverage.

Begin Date — Enter the beginning date of the coverage for this person. Enter this date in the order of month, day and year. If the specific day or month of this coverage is not known but the year is known, enter the closest approximation possible. For example, if the client states coverage began in the summer of 1997, this could be entered as 06-01-97.

End Date — Enter the specific date that coverage for this client ended. Note: It may be necessary to enter both a beginning date (Item 34) and an ending date (Item 35) simultaneously. This is appropriate in reporting short-term coverage. Enter 00-00-00 to remove erroneous dates.


Complete this section for clients who have medical insurance coverage available, but who are not enrolled.

Policy No. (1 or 2) — Enter the appropriate policy number in the bottom section that provides information about the insurance coverage.

Begin Date — Enter the date that this coverage became available for this client. Enter this date in the order of month, day and year. If the specific day or month of this coverage is not known, but the year is known, enter the closest approximation possible.

Signature/Date/Name/Telephone No. — The HHSC employee must sign the form, print the HHSC employee's name and enter the HHSC employee's telephone number and the date the form is completed.


This section is used to report information about two medical insurance policies. If the client has more than two policies, use additional forms.

If insurance is available but the client and/or family members are not enrolled, complete as many items as known.

If the client cancels one policy and buys another, enter the END DATE for the old policy for each client on a copy of Form H1039 used to report the policy. Report the new policy and coverage on a new Form H1039.

Item 1 — Insurance Company Name — Enter the name of the insurance company as reported by the client. Do not use initials for the name. If the policy has limited coverage, enter the type, if known, beside the company name, such as cancer only, surgery only, hospital only.

Item 2 — Ins. Co. Telephone No. — Self-explanatory.

Item 3 — Ins. No. — Make no entry. State office staff enter the five-digit insurance number assigned to the company by the state.

Item 4 — Insurance Company Address — Enter the address of the insurance company as reported by the client.

Item 5 — Policy Holder/Employee — If the insurance policy is a group policy, enter the name of the person to whom the policy was issued. Enter last name, first name, middle initial.

Item 6 — Policy Holder SSN — Enter, if known.

Item 7 — Policy Holder's Telephone No. — Enter, if known.

Note: Do not enter any telephone number other than the policy holder's telephone number.

Item 8 — Policy No. — Enter the policy or certificate number.

Item 9 — Group No. — Enter the group number, if applicable.

Item 10 — Complete to report an insurance premium that is, or could be, deducted from the policy holder's wages.

Item 11 — Answer the question about the policy holder needing help obtaining or keeping insurance coverage for self and/or family members.

Item 12 — Employer/Union Name — If the policy is issued through the client's employer or union, enter the name.

Item 13 — Employer/Union Telephone No. — Enter the employee or union telephone number.

Item 14 — Employer/Union Address — Enter the employee or union address.