PURPOSE

To notify denied Supplemental Security Income (SSI) applicants of their potential eligibility for three months prior medical coverage.

PROCEDURE

When to Prepare

If an SDX tape shows that an SSI applicant has unpaid medical bills for the three months before application, Management Information Systems (MIS) produces Form H1298-A. Form H1298-A is a computer-generated form. It contains the individual's name, address, Social Security number, date of application for SSI, and the three months before the month of application. MIS prints zeros in the client number field.

Number of Copies

MIS produces one copy of Form H1298-A.

Transmittal

MIS sends Form H1298-A to the denied SSI applicant. The SSI applicant is advised via Form H1298-A to contact the local department office if he wishes to apply for prior medical coverage.

Form Retention

HHSC does not keep a copy of this form.

DETAILED INSTRUCTIONS

Not applicable.