Form H4808
Instructions

Notice of Change in Applied Income or Copay/
Denial of Medical Assistance

04-2008

PURPOSE

  • To notify a  recipient of an impending increase or decrease in applied income/copay and the effective date of that change.
  • To notify an active recipient of the reason for the increase or decrease in applied income/copay (i.e., a change in regular monthly income, the projection of variable income/incurred medical/home maintenance expenses, or the deletion of variable income/incurred medical/home maintenance expenses from the budget.)
  • To notify the Individual of the month in which the review of variable income/incurred medical/home maintenance expenses is scheduled, if applicable, and the months to be reconciled at that review.
  • To provide an MAO recipient (including wavier and Community Attendant Services (CAS) recipients being denied for financial reasons) with written notice explaining the decision to deny assistance, the reason for the action, and when it will be effective. However, CBA/CCAD staff are responsible for notifying the provider agencies of the denial and its effective date. See Appendix XI in the Medicaid for the Elderly and People with Disabilities Handbook.
  • To notify the recipient of the right to a conference or hearing and to provide the opportunity for a recipient to request a hearing prior to the denial of assistance. The letter includes explanatory information about the hearing process and that continuation of assistance pending a hearing decision may be subject to restitution. The recipient may also request a conference, although Page 2 of Form H4808 is not designed to be used for this purpose.
  • To notify denied regular Medicaid Individuals that they will receive a certificate of insurance coverage from the Department of State Health Services.

PROCEDURE

When to Prepare

  • Prepare Form H4808 whenever there is an impending applied income change (increase or decrease) for an active institutionalized recipient.
  • Prepare Form H4808 whenever an active institutional, waiver, CAS or community-based case is to be denied.

Number of Copies

Complete an original and three copies for community-based denials.

Complete an original and three copies for applied income/copay changes and denials in institutional, waiver and CAS cases.

Transmittal

In community-based cases, the original and one copy are sent to the recipient at his address or that of his responsible party. Enclose a prepaid return envelope. The second copy is filed in the case record under the Legal Section. The third copy is sent immediately to the Department of Aging and Disabilty Services (DADS) staff.

In waiver and CAS cases being denied for financial reasons, the original and one copy are sent to the recipient at his address or that of his responsible party. Enclose a prepaid return envelope. The second copy is filed in the case record under the Legal Section. The third copy is sent to the waiver case manager or DADS case manager, as appropriate.

In institutional cases, the original and first copies are sent to the recipient at his address or that of his responsible party. Enclose a prepaid return envelope. The second copy goes to the facility.

  • If applied income is being lowered, send the facility's copy immediately.
  • If applied income is being raised, or if medical assistance is being denied, hold the facility's copy until the Form H1000-B input document effectuating the applied income change or case denial is submitted.

In situations where the Individual has elected hospice, as evidenced by receipt of the Form H3071, Recipient Election/Cancellation Notice, the case manager sends the nursing facility/ICF-IID facility copy of the Form H4808 to the hospice provider.

The third copy is filed in the case record under the Legal Section.

Form Retention

The case record copy is retained for three years after the case is closed or denied.

If there is a hearing, the hearing officer's copy is retained for six months after the appeal is completed.

DETAILED INSTRUCTIONS

Heading — Enter the name of the Individual and his mailing address or that of his responsible party.

Individual Name — Self-explanatory.

Individual No. — Enter the individual's nine-digit recipient/Medicaid number.

Date — Self-explanatory.

HHSC Staff — Self-explanatory.

Region — Self-explanatory.

Unit No. — Self-explanatory.

Office Address and Telephone No. — Enter the HHSC staff's complete mailing address and telephone number. Include the TDD telephone number if the office is equipped with TDD.

NOTICE OF CHANGE IN APPLIED INCOME OR COPAY

As a result of the review of ... it is determined that the amount you pay the nursing facility/provider each month will be ... — Check the appropriate box to indicate whether applied income/copay is being raised or lowered.

From $... — Enter the current applied income/copay amount as shown on the latest sequence of Form H1000-B.

to $... — Enter the new applied income/copay amount.

beginning ... — Enter the effective date of the ongoing applied income/copay change.

This is based on ... — Check all appropriate boxes.

A change in your regular monthly income ... — Check this box if the applied income/copay change results in whole or in part from a change in regular monthly income.

A projected amount, which considers ... — Check this box if applied income/copay is based on a projection of variable income/incurred medical/home maintenance expenses.

An average of your income ... — Check this box if applied income/copay is based on the projection of variable income.

because your income from ... — Enter the source(s) of variable income (e.g., oil royalties).

A deduction from your income for certain allowable medical/home maintenance expenses. — Check this box if the ongoing applied income/copay calculation includes deductions for incurred medical/home maintenance expenses.

To comply with federal regulations, your case is scheduled for review in ... — Enter the month (e.g., November 1992) when the special review of variable income/incurred medical/home maintenance expenses is scheduled.

At that time, the projected amount will be adjusted according to your actual income and medical expenses for the months of ... through ... — Enter the months (from/through) for which reconciliation will be performed at the review.

The deletion of variable income. — Check this box if variable income is being deleted from the budget.

The deletion of incurred medical expenses. — Check this box if incurred medical expenses are being deleted from the budget.

The deletion of home maintenance expense. — Check this box if incurred home maintenance expense is being deleted from the budget.

NOTICE OF DENIAL OF MEDICAL ASSISTANCE

As a result of the review of ... and the policy found in Section ... — If medical assistance is being denied, enter the section of the Medicaid for the Elderly and People with Disabilities Handbook which addresses the policy on which the denial of assistance is based.

... we have determined that after ... — Enter the last date of eligibility for the benefits being denied (e.g., June 30, 1992), considering computer processing deadlines and hold procedures.

... you WILL NOT be eligible for: — Check the appropriate box(es) to indicate the type(s) of assistance being denied.

Regular Medicaid Benefits — Check this box if the recipient is being denied regular Medicaid benefits.

Community Based Alternatives (CBA) Benefits or other waiver services — Check this box if the recipient is being denied CBA benefits or other waiver services.

Community Attendant Services (CAS) Funded Primary Home Care Benefits — Check this box if the recipient is being denied CAS benefits.

Vendor Payments to a State Supported Living Center — Check this box if the recipient is being denied vendor payments to a state supported living center.

One of the Medicare Cost Sharing Programs

Qualified Medicare Beneficiary (QMB) Benefits — Check this box if the recipient is being denied QMB benefits (or the “QMB” portion of MQMB benefits).

Qualified Disabled and Working Individuals (QDWI) Benefits — Check this box if the recipient is being denied QDWI benefits.

Qualifying Individuals (QI-1) Benefits — Check this box if the recipient is being denied QI-1 benefits.

Specified Low-Income Medicare Beneficiary (SLMB) Benefits — Check this box if the recipient is being denied SLMB benefits (or the “SLMB” portion of M-SLMB benefits).

Reason for Ineligibility: — Put the reason for ineligibility in both English and Spanish, using the wording for the appropriate denial code found in Appendix I of the Medicaid for the Elderly and People with Disabilities Handbook.

Provider, Vendor No., Effective Date: — To be completed by DADS staff.

Comments: — If medical assistance is being denied, give a brief (but specific) explanation of the reason for denial, using wording the Individual can understand.

Page 2: HHSC Staff, Mail Code, Office Address, and Telephone No. — Enter the name of the HHSC staff, mail code, complete office address and telephone number. Include the TDD telephone number if the office is equipped with TDD.