Form H1201-EZ, Medicaid Eligibility Client Declaration Worksheet

Instructions for Opening a Form

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Documents

Effective Date: 4/2009

Instructions

Updated: 8/2002

Purpose

  • 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.

Procedure

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 Retention

Form H1201-EZ is kept in the case record for three years after the case is denied.

Detailed Instructions

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.

  1. 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.
  2. Enter any exclusions if any.
  3. 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.
  4. Enter amount of Medicare premium if not MQMB or MSLMB eligible.
  5. 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.
  6. Enter amount of other IME deductions.
  7. 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.