TX HHS Form 1578. Qualified Income Trust (QIT) Copayment Agreement

The TX HHS Form 1578, Qualified Income Trust (QIT) Copayment Agreement, is a crucial document that helps individuals with disabilities or special needs receive Home and Community Based Services (HCBS) program services through the STAR+PLUS program. This form is typically filled out by applicants or their legally authorized representatives to ensure that copayments are paid on time.

The agreement outlines the responsibilities of the applicant, trustee, and provider in managing copayments for HCBS program services. Key features include the requirement for the trustee to pay providers directly, the need for timely payment (by the 10th day of each month), and the consequences of non-payment (termination of STAR+PLUS HCBS program services and Medicaid benefits). The form also includes spaces for signatures from the applicant, witness, and managed care organization staff person.

To ensure successful use of this form, it is essential to understand the requirements and responsibilities outlined in the agreement. Key points to note include:

• The trustee must pay providers directly for services purchased through copayment.
• Copayments must be paid by the 10th day of each month.
• Failure to pay copayments will result in termination of STAR+PLUS HCBS program services and Medicaid benefits.