Form H1146-M, Medicaid Report (Manual)

Instructions for Opening a Form

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Effective Date: 7/2004


Updated: 10/2001


  • To provide a method for transitional Medicaid households in TP 07 and TP 37 to report earnings, child care expenses, and household composition changes.
  • To provide local office staff with a replacement form if the reporting household loses, destroys, or does not receive the computer-produced Form H1146.



Form H1146-M contains the same questions and statements that appear on the computer-produced Form H1146.

When to Prepare

The head of household must complete Form H1146-M if the household reports loss, destruction, or nonreceipt of Form H1146.

Number of Copies

One per case.


Local office staff provide Form H1146-M and a postage-paid, return envelope to the household after cutoff in the 3rd, 6th, and 9th months of their 12-month Medicaid period.

Case Filing

File Form H1146-M on the right side of the case record on top of the most recent Form H1010-B.

Form Retention

See the Texas Works Manager's Guide for retention requirements.

Detailed Instructions

Using Report RA-58, Medicaid Report Form Case Listing, enter the months the report is to cover. The months are the three months immediately preceding the month the report is due. Also enter the report due date. The due date is seven workdays before state office cutoff in the report month. Local office staff also complete the "Agency Use Only" information to ensure correct handling of the form.

The head of the reporting household must provide the following information about the indicated three-month period:

  • the household members' gross monthly earnings,
  • child care expenses necessary for the employment of the caretaker relative,
  • household composition changes, and
  • address changes.

A complete form must include the above information and a signature. Verification is not required.

The reporting household must return the form to the local office no later than seven workdays before state office cutoff in the 4th, 7th, and 10th months of the 12-month Medicaid period.

Local office staff must monitor all forms using Report RA-58, Medicaid Report Form Case Listing.

Instructions for processing Form H1146 in the 4th month are different from those used to process forms received in the 7th and10th months. See A-845 for specific instructions on processing Form H1146 in the 4th, 7th, and 10th months,* and for information on restoring and reinstating benefits.

Ensure that action is taken on the household's food stamp case if the information reported affects food stamps.

* On the 7th and 10th months Medicaid Reports, ensure that earnings are reported for

  • stepparents in the home,
  • absent parents who have returned home, and
  • caretakers whose children's earnings caused TANF to be denied because the children were no longer eligible for earned income disregards.