To provide a client with a document verifying the client's eligibility for Qualified Medicare Beneficiary (QMB) benefits. Form H1027-C is not to be used for any client who is eligible for Medicaid benefits under another Medicaid coverage group.
Use Form H1027-C only in the following situations:
Note: Do not issue Form H1027-C
Do not issue Form H1027-C routinely. Only intake screeners or TANF, Medicaid, Community Care for Aged and Disabled (CCAD) foster care or adoption assistance eligibility specialists and supervisors are authorized to complete the form.
Note: Before issuing the form, the eligibility specialist completing Form H1027-C must obtain supervisory approval indicating verification of current eligibility.
Upon approval, the supervisor must sign and date Form H1027-C and return it to the eligibility specialist. If the supervisor does not work in the office where the form is issued, the lead eligibility specialist may approve Form H1027-C. Approval may also be obtained from the supervisor by telephone. If approval is obtained by telephone, enter "Approved by," the supervisor's name and the initials of the person obtaining the approval.
Complete Form H1027-C in ink, or type it.
Note: Refer to Item 4540 in the Medicaid Eligibility for the Elderly and People with Disabilities Handbook or Item 2130 in the Case Manager Community Care for Aged and Disabled Handbook for additional information regarding the issuance of Form H1027.
Prepare an original and one copy if giving Form H1027-C to the client in person. Prepare an original and two copies if the form must be mailed to the recipient.
Give the original to the client or the client's payee, guardian or other bona fide representative. DO NOT give the form to a medical provider. File the copy in the case record under Medical.
Mail Form H1027-C only if the recipient cannot pick up the form in person and the eligibility specialist would have to travel a considerable distance to deliver it.
If mailing is necessary,
Keep the case record copy for three years after the case is closed or denied.
The following example is numbered for reference only. Actual forms do not have these numbers.
|1.||If the client is a newly certified QMB client and does not yet have a client number,
|2.||If the QMB client has a client number, but he has lost, not received or has no access to a current Form H3087,
|2a.||Complete the eligibility verification section to indicate when you verified eligibility, and whether you verified it by
Note: You must look up Client Screen 1 on either LAN or UNISCOPE inquiry for the client to be listed on Form H1027-C. When accessing inquiry by case number, a "C" must be entered on the line next to the client name. Client Screen 1 will then appear. (See the following examples.)
Store local supplies of Form H1027-C in a locked file cabinet. For more information, refer to your regional security plan.