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Documents
Instructions
Updated: 11/2024
Purpose
Form 2065-A must be sent to:
- give notice of eligibility for all Community Care Services Eligibility (CCSE) services to the person applying for services;
- give notice of ineligibility for CCSE services;
- give notice of suspension for CCSE services;
- notify the person of the right to a fair hearing and to request a conference;
- notify the person of a change in eligibility or the amount or level of service;
- give notice of a transfer between one type of personal attendant service to another;
- notify the person and provider of the monthly amount of copayment or room and board payment, or both, that the person must pay;
- remind the person that all changes financial, location, and medical condition must be reported to the Texas Health and Human Services Commission (HHSC) caseworker within 10 calendar days; or
- give notification of the retroactive payment plan and dates of prior Medicaid eligibility and advise the person or provider of provider reimbursement, if appropriate.
Procedure
When to Prepare
Prepare this form for all the situations listed above. The form must be sent to the person within specific timelines for the following situations:
| certified applications | within two business days after the decision |
| eligibility for or addition of a new service | within two business days after the decision |
| increases in amount of service | within two business days after the decision |
| decrease in copayment amount | within two business days after the decision |
| denied applications | within two business days after the decision |
| granting priority status | within two business days after the decision |
| suspension of services | within two business days after the decision |
| terminations | 12 calendar days before termination when adverse action is required |
| decrease in service units | 12 calendar days before decrease |
| increase in copayment amount | 12 calendar days before increase |
| ineligibility for or loss of priority status** | 12 calendar days before change |
Review the Community Care Services Eligibility (CCSE) Handbook, Appendix IX, Notification Effective Date of Decision, Appendix XVIII, Time Calculation, Section 2652, Changing the Service Schedule Between Reassessments, and Section 2811, Effective Dates for more details or exceptions.
**This applies only if the person requested priority status.
If the person returns Form 2065-A indicating a desire to appeal or verbally requests a hearing, the caseworker completes Form H4800, Fair Hearing Request Summary, to be entered in the Texas Integrated Eligibility and Redesign System (TIERS) Fair Hearings.
Number of Copies
The caseworker completes an original and enough copies for the person, the provider, if appropriate, and the case record. An additional copy may be needed by a residential care facility.
Transmittal
The caseworker sends the original and one copy to the person. A copy is also sent to the provider in these situations:
- Day Activity and Health Services (DAHS) facility for denial of a facility-initiated referral;
- Residential Care (RC) provider for notifications regarding the amount of the person’s copayment and room and board, or when the person is being denied due to failure to pay required fees; and
- Primary Home Care (PHC)/CAS provider when retroactive reimbursement is involved.
The caseworker files the remaining copy in the person's case folder.
Form Retention
The case record copy is retained for three years after the case is closed.
Detailed Instructions
Demographic
Date — The caseworker enters the date the form is completed and mailed to the person. This is the completion date and is considered as day zero for time frame calculation.
HHSC Caseworker — Enter the name of the caseworker.
Office Address, Area Code and phone No. — Enter the caseworker's office address, area code and phone number. Type or print information legibly.
Individual Name and Address — Enter the person's name and mailing address.
Notification Sections
Notification of Eligibility
Check this box if the person is being notified of service eligibility. Enter the amount of each specific service being approved, the unit of service per day, per week, per month and effective date of the service. Do not enter the number of days of service per week, except for DAHS.
| Program Name | Program Name (Spanish Translation) | Example Statement |
|---|---|---|
| Adult Foster Care or Residential Care | Cuidado Temporal de Adultos o Atención Residencial | You are eligible to receive one unit of Adult Foster Care (or Residential Care) per day, effective May 1, 2017. |
| Family Care | Servicios de Atención Familiar | You are eligible to receive 20 hours of Family Care per week effective May 1, 2017. |
| Community Attendant Services | Servicios de Ayudante en la Comunidad | You are eligible to receive 20 hours of Community Attendant Services per week effective May 1, 2017. |
| Day Activity and Health Services (DAHS) | Servicios de Salud y Actividades Durante el Día | You are eligible to receive Day Activity and Health Services five full days a week 10 units per week. In comments, explain: one unit equals a half day. If the person is authorized for half days, state the number of half days. Be sure the person knows the number of days per week they are authorized to attend DAHS. |
| Emergency Response Services | Servicios de Respuesta de Emergencia | You are eligible to receive one unit of Emergency Response Services per month, effective May 1, 2017. |
| Home Delivered Meals | Comidas a Domicilio | You are eligible to receive five Home Delivered Meals per week, effective May 1, 2017. |
| Primary Home Care (with a negotiated date) | Servicios de Atención Esencial en Casa | You are eligible to receive 20 hours of Primary Home Care per week effective the negotiated date. |
| Primary Home Care | Servicios de Atención Esencial en Casa | You are eligible to receive 20 hours of Primary Home Care per week effective May 1, 2017. |
Required Payments: Room and Board — Check this box if the person is being notified of a required room and board amount. Enter the amount of the payment and when it is to be paid. The first entry is for a partial month prorated amount and the second entry is for the ongoing monthly amount. If the person enters on the first of the month, both amounts are the same. Example: You must pay $210 on May 1, 2017, then $230 per month effective June 1, 2017.
Required Payments: Copayment — Check this box if the person is being notified of a required copayment. Enter the amount of the copayment and when it is to be paid. The first entry is for a partial month prorated amount and the second entry is for the ongoing monthly amount. If the person enters on the first of the month, both amounts are the same. Example: You must pay $210 on May 1, 2017, then $230 per month effective June 1, 2017.
Notification of Ineligibility, Termination or Suspension of Services
Check this box if a person is not eligible for a CCSE service or if a CCSE service is being terminated or suspended.
- Check the first box in this section if an application or request for a new service is being denied.
- Check the second box in the section if ongoing services are being terminated. Enter the name of the service being terminated and the last day the person will receive services. Enter the cause of ineligibility.
- Check the third box if services are being suspended. Enter the name of the service and the last day services will be delivered. Enter the reason for the suspension. In the comments section, provide more information about the suspension.
Review Appendix XVIII, Time Calculation, for more information.
Record the cause of ineligibility when completing Form 2065-AS (the Spanish version). Staff may use Attachment A of Form 2065-A for a Spanish translation if not fluent in Spanish.
Rule/Handbook Reference — Enter the rule reference, unless one is not available, then use CCSE Handbook reference reflecting the reason for denial or termination.
Your ________________services will continue without interruption — Check this box and enter the name of any other services the person is eligible for that are not being terminated and will continue.
Notification of Change
Check this box if a service plan change is being made. Enter the service being affected, the amount of service currently being received, the amount of service to be delivered once the change is effective and the effective date. For a reduction in service, the effective date is the first date the reduction will be in effect. Example: The service you have been receiving, 20 hours of Family Care, is changing to 15 hours of Family Care starting May 1, 2017.
Note: The completion date of Form 2065-A is counted as day zero. The next day is day one and 12 calendar days are allowed for a decrease notification. For decreases if the last day of any period is a Saturday, Sunday or legal holiday, the period is extended to include the next day that is not a Saturday, Sunday or legal holiday. Skeleton crew days are not legal holidays. Legal holidays are days when the agency is closed.
Notification of Change in Copayment/Room and Board
Check this box to notify the person of a change in the copayment or room and board amount, regardless of if an increase or decrease is involved. Enter the new amount, and the date that the payment of the new amount is effective. Example: Your copayment will change to $330 per month, beginning June 1, 2017.
Comments
Enter any appropriate comments about the person's eligibility.
Signature and Date— The HHSC caseworker must sign and date Form 2065-A. The date of the HHSC caseworker's signature should match the date Form 2065-A was completed and mailed, as shown in the date box at the top of the form.
Name — Enter the name of the person from Page 1.
Number — Enter the person's identification number. This is the individual number, Medicaid number or individual number assigned through TIERS or the Service Authorization System (SAS).
Request for Fair Hearing — The person checks the box if they wish to appeal. The person signs, prints their name, dates the form and returns it to the HHSC caseworker.
Name of Caseworker — Enter the name of the caseworker assigned to the applicant's or person's case.
Caseworker’s phone No. — Enter the phone number including area code of the caseworker.
Supervisor's Name and phone No. — Enter the name and phone number including area code of the caseworker's supervisor.
Program Manager's Name and phone No. — Enter the name and phone number including area code of the program manager.