The department sends a Form H3087 each month to each certified case eligible for medical assistance benefits.
Each Form H3087 lists up to nine recipients on a case. The department can send up to three Forms H3087 in a single envelope for cases with more than nine recipients.
Exception: The department sends a separate Form H3087 to each recipient with lock-in status.
Recipients should keep Form H3087 with them at all times during the current month. Recipients show the form to the medical provider every time they need a service.
The form includes a client-specific indicator about eligibility for three, or more than three, prescriptions.
The department mails the only copy of Form H3087 to the recipient. A form retention schedule does not apply.
The department prints the following information:
Good Through — The latest date (month, day, year) that the form is valid. This is the ending date of the eligibility.
Limited — This is printed only if the recipient is in lock-in status and must receive nonemergency medical services from only one designated physician and/or one pharmacy. The name of the designated physician and/or pharmacy also is printed. Family planning services, and EPSDT medical screening, dental and hearing aid services for recipients under age 21 are exempt from the LOCKIN Program except when obtaining LOCKIN drugs through the Vendor Drug Program.
Emergency — This is printed only if the recipient is limited to coverage for an emergency medical condition.
Hospice — This is printed only if the recipient is enrolled in Hospice.
QMB — This is printed only if the department is providing coverage of Medicare deductible and coinsurance liabilities within Medicaid reimbursement limitations. The recipient is not eligible for regular Medicaid benefits.
MQMB — This is printed only if the department is providing regular Medicaid coverage as well as coverage of Medicare deductible and coinsurance liabilities within Medicaid reimbursement limitations.
PE — This is printed only if the recipient is presumptively eligible for Medicaid. The recipient's coverage is limited to medically necessary out-patient services and family planning services are covered. Labor, delivery, inpatient services, and EPSDT medical and dental services are not covered.
STAR Health Plan — This is printed only if the recipients are enrolled in the Medicaid Managed Care Program. Each recipient's provider, FQHC or HMO is named on the form.
Date Run — The date the form was printed.
BIN — This bank identification number is used by the Vendor Drug pharmacist for network routing; this number (610098) identifies HHSC.
TP — The type program for the case. This identifies the case as HHSC or SSI.
Cat — The case category.
Case No. — The case number.
ID No. — The recipient's Texas Medicaid identification number.
Name — The full name of the recipient.
Date of Birth — The recipient's month, day, and year of birth.
Sex — An "F" for female or "M" for male.
Eligibility Date — The beginning date of eligibility.
TPR — Third party resource. "P" shows that the recipient has private insurance. "M" shows that the recipient is eligible for Medicare.
Medicare No. — The recipient's Medicare (HIC) number, if known.
Information about limited services — A check mark means the recipient is eligible for the service. Also, reminders about THSteps' Medical and Dental Check-ups are included for each recipient under age 21.