Form H1146, Medicaid Report

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Effective Date: 4/2006


Updated: 4/2001


To provide a method for transitional Medicaid households in TP 07 and TP 37 to report earnings, child care expenses, and household composition changes.



Form H1146 is a computer-produced form sent to transitional Medicaid households in the 3rd, 6th, and 9th months of their 12-month Medicaid period. It is a two-sided notice printed on card stock. The front side contains the report, instructions, due date, case information used to screen returned reports, and the client's mailing address. The back side provides eligibility information, reporting requirements, penalties, and the agency's local office address. The front side is folded for mailing to the client. The client completes the report, tears it off, and mails it back to the office. No envelopes are needed.

Number of Copies

One per case.


Form H1146 is mailed to transitional Medicaid households after cutoff in the 3rd, 6th, and 9th months of their 12-month Medicaid period.

Case Filing

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

Form Retention

See Texas Works Manager's Guide for retention requirements.

Detailed Instructions

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.

Information from the SAVERR data base at cutoff is printed at the top of the front side of the form. Local office staff use this information to screen the form after receipt. 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 and 10th 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.