TX HHS Form H1272-A. Spousal Impoverishment Assessment Letter

TX HHS Form H1272-A: Spousal Impoverishment Assessment Letter is a document used to determine the portion of combined countable resources that will be protected for a spouse who remains at home when one partner enters a medical care facility. This form helps solve the problem of ensuring that the spouse's financial needs are assessed and protected under the Medicare Catastrophic Coverage Act of 1988.

The key features of this form include reporting all resources owned by the couple, whether community or separate property, and providing verification for listed resources. The form also requires a self-addressed, stamped envelope to be enclosed for return purposes. Common scenarios of use include situations where one partner enters a medical care facility and the other remains at home.

This form should be used when an individual enters a medical care facility and their spouse remains at home. It is essential to complete and return this form to ensure that the spousal protected resource amount (SPRA) is accurately calculated and protected under the Medicare Catastrophic Coverage Act of 1988. Form H1272-A is not an application for Medicaid, but it will be used to determine resource eligibility when an application is received.