TX HHS Form H1207-A. Notification of Eligibility Special Medicaid Program (State Facilities)

The Notification of Eligibility Special Medicaid Program (State Facilities) form, also known as Form H1207-A, helps determine the eligibility of state facility residents for assistance through the Health and Human Services Commission. This form is used in situations where a resident's income varies from month to month, making it difficult to accurately calculate their projected payment.

The form requires specific information, including the name and address of the state facility, the resident's case number, and their monthly charges at the facility. It also outlines conditions for eligibility, such as the requirement that the resident's income be used to pay part of their monthly charges. Additionally, the form highlights follow-up actions, including a review scheduled in compliance with federal regulations.

Key features of this form include the use of a projected payment amount based on an average of the resident's income, which takes into account varying medical expenses and income from month to month. The form also emphasizes the importance of reporting any changes in circumstances that may affect eligibility for continued assistance. By completing Form H1207-A, state facility residents can ensure they receive the necessary support and services.

• This form is used to determine eligibility for assistance through the Health and Human Services Commission.
• The form requires specific information about the state facility resident's income, medical expenses, and monthly charges.
• A review is scheduled in compliance with federal regulations to reconcile projected payments based on actual income and medical expenses.