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

The Qualified Income Trust (QIT) Copayment Agreement is a form issued by Texas Health and Human Services (HHS), designed for individuals receiving STAR+PLUS Home and Community Based Services (HCBS) program services. The purpose of this agreement is to establish a copayment payment process between the applicant, their trustee, and service providers.

This agreement outlines the requirements for copayment payments, including the need for the trustee to pay service providers directly and the importance of timely payments by the 10th day of each month. Failure to comply with these requirements may result in termination of STAR+PLUS HCBS program services and Medicaid benefits. The applicant is responsible for notifying their trustee of this requirement and understanding the consequences of non-compliance.

The QIT Copayment Agreement is a crucial step in the application process for STAR+PLUS HCBS program services, as failure to sign this agreement and the individual service plan (ISP) may result in denial of the application or services. The managed care organization staff person and trustee must also sign and date the agreement, indicating their understanding and acceptance of the copayment payment terms.