- To document all eligibility procedure requirements for applications and recertifications for Medicare cost-sharing programs and Medicaid community-based programs, except waiver programs (TP 14/BP 13 and TP 19).
- To document eligibility and applied income for reviews worked under the streamline procedures.
When to Prepare
The worker completes Form H1201-EZ after a client or the bona fide agent signs and submits Form H1200-EZ for an application or complete review.
The worker may use Form H1201-EZ for complete review for cases that are worked under the streamline procedures.
Note: Form H1201-A can also be used for streamline reviews.
Number of Copies
The worker completes an original Form H1201-EZ and files it in the case record behind the corresponding Form H1200-EZ for an application or complete review.
The worker completes an original Form H1201-EZ and files it in the case record behind the corresponding streamline review form.
Form H1201-EZ is kept in the case record for three years after the case is denied.
Identifying Information — Self-explanatory.
Applications Only — Self-explanatory.
Financial Management — Self-explanatory.
Living Arrangement — Self-explanatory
Resources — Always enter the first day of the month that resources are verified. Under total resources enter the total of the countable resources and compare to the appropriate limits.
Income — Self-explanatory
Eligibility Test — All Type Programs Use this section to determine eligibility for all type programs. Compare to the appropriate individual or couple income limits.
Applied Income — Use this section for Type Programs 14 and 51.
- Enter the client's monthly countable income (excluding any mandatory payroll deductions from earned income and income taxes withheld from pension or benefit checks). Do not include any VA, A&A, HB, or Out of Pocket Medical exclusions. Include income of eligible spouse if a couple case.
- Enter any exclusions if any.
- Enter the $60 personal needs allowance ($60 for each spouse in couple cases). In ICF/MR cases (including state supported living centers), include the protected earned income allowance.
- Enter amount of Medicare premium if not MQMB or MSLMB eligible.
- Enter the monthly amount of any allowable incurred medical expenses including the monthly amount of premiums for assignable general health insurance policies being paid by client and eligible spouse.
- Enter amount of other IME deductions.
- Enter amount of applied income.
Action Taken — Self-explanatory. Note: For the Granted/Sustained and Denial boxes, click on the gray vertical line and a drop down arrow will appear. Click on the arrow and codes for the action taken (granted/sustained or denied) will appear.
Signature and Date — Self-explanatory.