TX HHS Form H1200-MSP-C. Medicare Savings Program Notice

The H1200-MSP-C form, also known as the Medicare Savings Program Notice, is a crucial document issued by the Texas Health and Human Services Commission (HHSC). This form informs applicants whether they might qualify for the Medicare Savings Program (MSP), which helps eligible individuals cover Medicare Part A and Part B costs, including premiums, deductibles, and co-insurance. It is particularly relevant for those who have applied for SSA's Extra Help program.

Purpose of the Form

The primary purpose of the H1200-MSP-C form is to request additional information from applicants to determine their eligibility for the Medicare Savings Program. Completing and returning this form is essential for HHSC to review your case and provide potential financial assistance with Medicare costs.

Key Sections of the Form

1. Application Number and Case Details

This section provides your unique application number and identifies your case. It is important to reference this number in all correspondence to ensure accurate tracking.

• Typical mistakes: forgetting to include the application number when returning the form.
• Tip: Always double-check that the number on the form matches any letters received from HHSC.

2. Program Explanation

Here, the form explains the Medicare Savings Program and what it covers, including premiums, deductibles, and co-insurance for Medicare Part A and B. It also notes that your SSA Extra Help application allows the transfer of information to HHSC for this review.

• Common misunderstanding: Some applicants believe this is an automatic approval notice; it is a request for further information.

3. Applicant Instructions

The form lists the steps to complete the process:

• Fill out the attached Form H1200-EZ with accurate personal and financial information.
• Sign the completed form.
• Return the form via the pre-paid envelope included in the notice.

Failing to follow these instructions can delay eligibility determination or result in denial.

4. Contact Information

The form provides a phone number for questions. It is recommended to call if you have any doubts about completing the form correctly.

Practical Recommendations

• Complete the form as soon as possible to meet deadlines.
• Ensure all personal information matches official documents (SSA records, Medicare card, Social Security number).
• Attach any supporting documents that verify income or Medicare enrollment if requested.
• Keep copies of all documents for your records.

Examples of Real-Life Situations

• Mrs. Johnson, a 68-year-old retiree, receives a notice and completes the form to help cover her Medicare Part B premiums.
• Mr. Lee, a low-income veteran, uses the form to request assistance with deductibles and co-insurance costs for Part A hospitalization.
• Mrs. Ramirez, recently widowed, needs financial support to maintain her prescription drug coverage and submits the completed form promptly.

Documents That May Be Needed

• SSA Extra Help application or approval letter.
• Proof of income (tax return, pay stubs, social security benefits).
• Medicare card or other identification documents.

Frequently Asked Questions

When should I submit the form?

Submit the form as soon as you receive it, preferably before the stated deadline to avoid delays.

Who is eligible to fill out this form?

Applicants who may qualify for the Medicare Savings Program and have applied for SSA's Extra Help program.

Do I need to include supporting documents?

Yes, attach any requested proof of income or Medicare enrollment to facilitate the review.

What happens after submission?

HHSC will review the completed form and notify you of your eligibility for the Medicare Savings Program.

Can someone else complete the form for me?

Yes, a legally authorized representative may complete and submit the form on your behalf.

Micro-FAQ (Quick Answers)

• Purpose: Determine eligibility for Medicare Savings Program.
• Who files: Applicant or authorized representative.
• Deadline: Follow date specified on notice.
• Attachments: Income verification, SSA Extra Help documentation.
• Submitted to: HHSC using pre-paid envelope.

Related Forms

• Form H1200-EZ (Medicare Savings Program Application)
• SSA Extra Help Application (Prescription Drug Assistance)
• Other Texas Medicaid/Medicare Assistance Forms

Form Details

• Name: Medicare Savings Program Notice
• Form Number: H1200-MSP-C
• Region: Texas
• Date of Edition: 07-2015-E