TX HHS Form 8590. Request for Approval to Withdraw an Enrollment Offer

Form 8590 is an official Texas Health and Human Services Commission (HHSC) document used by Local Intellectual and Developmental Disability Authorities (LIDDAs). Its purpose is to request HHSC approval to withdraw an enrollment offer for the Home and Community-based Services (HCS) or Texas Home Living (TxHmL) programs when the enrollment process cannot be completed.

This form plays a critical role in managing limited waiver slots fairly and transparently. It documents why an offered enrollment did not move forward and ensures that HHSC can release the slot for another eligible individual.

When Form 8590 Is Required — and When It Is Not

Form 8590 must be submitted when a LIDDA has made a valid enrollment offer for HCS or TxHmL, but the process cannot be completed due to non-response, lack of required actions, or other qualifying reasons listed on the form.

This form should not be submitted if the person is deceased. In that situation, the LIDDA must notify the slot monitor by email and complete Form 8601 instead, marking the individual as deceased.

Who Is Authorized to Complete This Form

Only an authorized representative of the LIDDA may complete and submit Form 8590. Individuals receiving services, legally authorized representatives (LARs), providers, or family members do not complete this form themselves.

Legal and Regulatory Context

The use of Form 8590 is governed by Texas administrative rules related to the management of Medicaid waiver programs, specifically HCS and TxHmL. HHSC requires LIDDAs to document enrollment activity to ensure compliance with federal Medicaid requirements, proper slot utilization, and due process for individuals on interest lists.

Without this form, HHSC cannot formally approve the withdrawal of an enrollment offer, which would delay reassigning the waiver slot.

Section-by-Section Explanation

Section 1: LIDDA Information

This section identifies the submitting authority. It includes the LIDDA’s name, component code, contact person, phone number, and email address. Accuracy is essential because HHSC uses this information for follow-up and approval communication.

Section 2: Person’s Information

This section records details about the individual who received the enrollment offer, including program type (HCS or TxHmL), CARE ID, Medicaid number (if available), and key dates related to the enrollment offer and deadlines.

Section 3: Reason for Requesting Withdrawal

This is a required section where the LIDDA must select only one reason explaining why the enrollment offer cannot proceed. The reasons include non-response to offers, failure to return required forms, lack of participation in enrollment activities, or relocation outside Texas.

Each reason corresponds to specific HHSC expectations and timelines. Selecting the correct reason is critical to avoid rejection.

Section 4: Documentation of Attempts

This section documents the LIDDA’s efforts to contact the person or LAR. At least three contact attempts are required, listed in chronological order. If no in-person attempt was made, the LIDDA must clearly explain why.

This documentation demonstrates good-faith efforts and protects both the LIDDA and HHSC from disputes.

Section 5: HHSC Use Only

This section is completed by HHSC. It records receipt, approval status, and processing details. LIDDAs should not enter information here.

Common Reasons Enrollment Offers Are Withdrawn

• No response from the person or LAR within required deadlines
• Failure to return required choice or verification forms
• Non-participation in enrollment activities
• Relocation outside the state of Texas

Typical Mistakes to Avoid

• Selecting more than one reason in Section 3
• Submitting the form without documenting three contact attempts
• Using the form when the person is deceased
• Missing or incorrect enrollment deadline dates
• Failing to contact the slot monitor when required

Practical Tips for Completing Form 8590

• Verify all enrollment deadline dates before submission
• Document contact attempts immediately to avoid missing details
• Confirm whether HHSC has alternate contact information before citing non-response
• Ensure certified mail requirements are followed after approval

Real-Life Scenarios Where This Form Is Used

• A LIDDA offers an HCS slot, but the LAR never responds despite multiple phone calls and letters.
• An individual accepts a TxHmL offer but does not submit provider choice documentation.
• A family informs the LIDDA that the individual has moved permanently out of Texas.

Documents Commonly Referenced or Attached

• Form 8592, Deadline Notification
• Form 1067 or Form 1070 (program offer forms)
• Form 8601, Verification of Freedom of Choice
• Form 1049 or Form 1052 (provider choice forms)
• Certified mail receipt for withdrawal notice

Frequently Asked Questions

Is HHSC approval required to withdraw an enrollment offer?

Yes. HHSC must approve the withdrawal before the slot can be reassigned.

How many contact attempts are required?

At least three documented attempts are required unless a specific exception applies.

Can this form be used if the person is deceased?

No. A different notification process and form must be used in that case.

Who submits the form to HHSC?

The LIDDA submits the form and communicates with the slot monitor.

What happens after HHSC approves the request?

The LIDDA sends the withdrawal notice via certified mail and emails a copy to the slot monitor.

Micro-FAQ

• Purpose: Requests HHSC approval to withdraw an HCS or TxHmL enrollment offer.
• Who files: Local Intellectual and Developmental Disability Authorities.
• When filed: After enrollment deadlines pass without required action.
• Attachments: Contact documentation and related enrollment forms.
• Submitted to: Texas Health and Human Services Commission.

Related Forms

• Form 8592 – Deadline Notification
• Form 8601 – Verification of Freedom of Choice
• Form 1068 – Withdrawal of Offer for HCS
• Form 1069 – Withdrawal of Offer for TxHmL

Form Details

• Form Name: Request for Approval to Withdraw an Enrollment Offer
• Form Number: 8590
• Programs: HCS, Texas Home Living (TxHmL)
• Issued By: Texas Health and Human Services Commission
• Region: Texas
• Revision Date: February 2022