- To notify the responsible party or authorized representative of a client who resides in a state facility about the approval of vendor payments to the institution, including the amount of the applied income/copay and whether applied income/copay is based on the projection of variable income and/or incurred medical expenses. If variable income and/or incurred medical expenses are considered in the vendor payment calculation, Form H1207-A is also used as notification of the month in which the special review of variable income/incurred medical expenses will be held and the months to be reconciled at that review.
- To notify the responsible party or authorized representative of a client who resides in a state facility of the right to appeal.
When to Prepare
Prepare Form H1207-A when a decision is made about the client's eligibility and vendor payments to a state facility.
Number of Copies
Prepare an original and two copies. If Form H0007-A is used, only the original and one copy are needed.
Send the original and one copy to the responsible party. Enclose a prepaid return envelope.
File the second copy in the case record.
Keep the copy according to the retention requirements of the case record.
This form may be typed or legibly handwritten.
Inside Address— Enter the name of the client and the appropriate mailing address.
HHSC Staff— Self-explanatory.
Office Address and Telephone Number— Enter the eligibility specialist's complete office address and telephone number. Include the TDD telephone number if the office is equipped with TDD.
The above-named state facility resident is eligible for assistance through ... Beginning— Enter the medical effective date of the state facility client.
The facility may require a payment of ...— Enter the amount of the vendor payment plan for the state facility client.
The above figure is a projected amount based on an average of the resident's income. An average is used because the resident's income from ...— Check this box if vendor payment plan is based on the projection of variable income. Enter the source(s) of variable income.
The above figure is a projected amount based on a deduction from the resident's income of certain allowable incurred medical expenses— Check this box if deductions for incurred medical expenses are considered in calculating the ongoing applied income amount.
To comply with federal regulations, this case is scheduled for review in ...— Enter the month (e.g., November 20YY) for which the special review of variable income/incurred medical expenses is scheduled.
At the review, the projected amount shown will be reconciled according to the resident's actual income and medical expenses for the months of ... through ...— Enter the months (from/through) for which variable income/incurred medical expenses will be reconciled at the review.
Page 2: HHSC Staff, Mail Code, Office Address, and Telephone No.— Enter the contact name, mail code, complete office address and telephone number. Include the TDD telephone number if the office is equipped with TDD.