TX HHS Form H1207. Notification of Eligibility - Special Medicaid Programs

The TX HHS Form H1207, Notification of Eligibility - Special Medicaid Programs, helps individuals determine their eligibility for specific Medicare benefits. This form is typically used by those who have determined that they meet the requirements for Qualified Medicare Beneficiary (QMB), Qualified Disabled and Working Individuals (QDWI), or Specified Low-Income Medicare Beneficiary (SLMB) programs.

This notification form requires individuals to provide their name, address, and other relevant information. The form also outlines the conditions under which Texas will pay for Medicare premiums, deductibles, and coinsurance fees. Additionally, it emphasizes the importance of maintaining accurate records and notifying the agency of any changes in circumstances that may affect eligibility.

The form also includes follow-up actions, such as completing a yearly review to determine continued eligibility. If an individual is dissatisfied with their decision, they can request a hearing by completing page 2 of the form or contacting the issuing agency, Texas Health and Human Services (HHS). Key points and requirements include:

• Eligibility for QMB, QDWI, or SLMB programs
• Payment of Medicare premiums, deductibles, and coinsurance fees
• Maintenance of accurate records
• Notification of changes in circumstances that may affect eligibility
• Yearly review to determine continued eligibility