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H1200 Febr2018

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What to do:
Medicaid for the Elderly and
People with Disabilities
Helps people who:
• Lost Supplemental Security
Income (SSI) benefits.
• Need to be in a nursing home or
other place of care.
or
• Have a disability.
Your Texas Benefits
How to apply for benefits for:
People age 65 and older
People with disabilities
There might be a better form to
use, if any of these apply to you:
• You no longer get SSI and you aren't
applying for the Medicaid Buy-In
Program. (H1200-EZ)
• You are applying only for a Medicare
Savings Program. (H1200-EZ)
• You live in a state supported living center.
(H1200-PFS)
• You live in a state hospital. (H1200-PFS)
To ask for these forms,
call 2-1-1 or 1-877-541-7905.
Most phone and fax
numbers on this form are
free to call. If you are deaf,
hard of hearing, or speech
impaired, you can call 7-1-1
or 1-800-735-2989.
Don't send this page with your form. Keep for
your records. Page A
1. Fill out this form.
2. Sign and date pages 19.
3. Send "Items we need"
listed on page D.
How to send it in:
Mail: Texas Health and Human
Services Commission,P O Box
149024, Austin, Texas, 78714-9024
OR to your local benefits office,
Call 2-1-1 to get the address.
Fax: 1-877-447-2839. If your
form is 2-sided, fax both sides.
In person: At a benefits office.
Call 2-1-1 to find one near you.
How to Apply
Helps people who already get Medicare. Helps
people pay Medicare costs. Costs can include
Medicare premiums, co-pays, and deductibles.
These programs also are known as:
• Qualified Medicare Beneficiaries (QMB).
• Specified Low-income Medicare
Beneficiaries (SLMB).
• Qualifying Individuals (QI-1).
• Qualified Disabled and Working
Individuals (QDWI).
Medicare Savings Programs
To apply for Medicare
You must apply for Medicare through
a different agency - the Social Security
Administration.
To learn more, visit www.Medicare.gov
or call 1-800-633-4227
Helps people who work and: (a) have a disability or
(b) are age 65 or older. Some people might have to
pay a monthly fee.
Medicaid Buy-In Program
Medicaid Buy-In for Children
is a
different program. It is for families who have a
child with a disability, but make too much money
to get traditional Medicaid.
To get the form for that program,
call 2-1-1 or 1-877-541-7905
and ask for Form H1200-MBIC
You can apply for
benefits online
If you would rather apply for benefits online,
go to www.YourTexasBenefits.com
This website also will allow you to:
After you fill out an online form,
you can check:
Texas Health and Human Services Commission (HHSC)
Call 2-1-1 or
1-877-541-7905.
Questions about this form
or about benefits
After you pick a
language, press 2 to:
• Ask questions about this form.
• Find where to get help
filling out this form.
• Check the status of this form.
• Ask questions about
benefit programs.
To learn more about benefits,
you also can go to
www.hhsc.state.tx.us
If you think anyone is misusing
HHSC benefits,
call 1-800-436-6184.
If you want to apply for SNAP
food benefits, cash help for
families (TANF), or Medicaid for
children and families, you need a
different form. To get that form,
call 2-1-1 (after you pick a
language, press 2). Or apply
online at
www.YourTexasBenefits.com
To apply for
other state benefits
Report waste,
fraud, and abuse
If you are approved to get
Medicaid, another state agency,
the Department of Aging and
Disability Services (DADS), might
help with your case.
DADS staff will find out what
long-term care services you can
get To see a list of services,
go to Form H1204, "Long Term
Care Options." It came with this
form. To learn more, call 2-1-1
(after you pick a language,
press 2, and then press 1).
Getting long-term
care services
Notice: Your estate might have to pay the state back
for services you get. To learn more, see page 19.
Don't send this page with your form. Keep for your records. Page B
• Sign and date page 19.
Helpful Tips
• Send "Items we need."
See Page D.
• Read the tips on the
left side of the page.
They can help you
save time.
• If you need more room to
answer any question, you
can add more pages.
These time saving
tips will tell you if
you need to fill out
a section.
Save Time
• The status of your form.
• Your interview time.
• Items we still need to get from you.
• If we got forms you sent to us.
• Benefit amounts (if you get benefits).
• Find out if you should apply for benefits.
• Find a benefits office near you.
Don't send this page with your form. Keep for your records. Page C
Legal Information
Your right to be treated
fairly
If you think you have been
treated unfairly (discriminated
against) because of race,
color, national origin,age, sex,
disability, or religion, you
can file a complaint.
Contact us at:
HHSCivilRightsOffice
@hhsc.state.tx.us or by:
• Mail:
HHSC
Office of Civil Rights
701 W. 51 st St.
MC W-206
Austin, TX 78751
• Phone:
1-888-388-6332
1-877-432-7232 (TTY)
• Fax (not toll-free):
1-512-438-5885
Citizenship and
Immigration Status
• You only have to give the
citizenship or immigration
status of people who want
benefits.
• If you are not a U.S citizen
or a legal immigrant, the
only benefits you might be
able to get are emergency
Medicaid services.
• Getting Medicaid long-term
care services could affect
your immigration status and
your chances of getting a
Permanent Resident Card
(green card).
• You might want to talk to an
agency that helps
immigrants with legal
questions before you apply.
• You only need to give the Social
Security numbers (SSNs) for people
who want benefits.
• Giving or applying for an SSN
is voluntary; however, anyone who
doesn’t apply for an SSN or doesn’t
give an SSN can’t get benefits.
• If you don’t have an SSN, we can help
you apply for one if you are a U.S.
citizen or a legal immigrant.
• You must be a U.S. citizen or a legal
immigrant to get an SSN.
• You can get benefits for your children if
they have an SSN and you don’t.
• We will not give SSNs to the Bureau of
Immigration and Customs Enforcement.
•
We will use SSNs to check the amount
of money you get (income), if you can
get benefits, and the amount of benefits
you can get.
(42 CFR §435.910)
Social Security Numbers
Do you think someone is being abused? If the abuse is in a
nursing home or other place of care, call 1-800-458-9858.
If the abuse is in a private home, call 1-800-252-5400.
Help you can get without filling out this form
Reporting abuse
If you have a complaint, first try talking to your caseworker
or their supervisor. If you still need help, call
1-877-787-8999.
How to file a complaint
Do you need help finding services? Call 2-1-1 or
1-877-541-7905. Pick a language, then press 1. Or visit
www.211Texas.org
Services in your area
Learn about services in your area, such as:
• Tax help
• Child care
• After-school programs
• Family violence programs
• Legal help
• Food banks
• Senior services
• Housing
• Help after a disaster
• Help with gas, electric,
and water bills
Alcohol and Drug Abuse Prevention Program
• Quitting.
• Dealing with a crisis.
• Keeping others from using drugs or alcohol.
Adult Education and Family Literacy Program
Are you afraid for your children's or your safety?
Call the hotline anytime at 1-800-799-7233
(1-800-799-SAFE). You can get help:
Family Violence Program
Do you want help learning to read or getting a GED? Do
you need help with job skills? Or learning to speak
English? Call 1-800-441-7323 (1-800-441-READ).
Do you or someone you know want to stop using
alcohol or drugs? Call 1-877-966-3784
(1-877-9-NO DRUG). You can get help:
• Getting a ride to a safe place.
• Finding shelter, legal help, and a job.
• Getting counseling.
Important Information for Former Military Service Members
Women and men who served in any branch of the United States Armed Forces, including Army, Navy, Marines, Air
Force, Coast Guard, Reserves or National Guard may be eligible for additional benefits and services. For more
information please visit www.tvc.texas.gov, the Texas Veterans Portal.
Items we need
Don't send this page with your form. Keep for your records. Page D
• Loans, repayments, and gifts (includes
someone paying bills for you) – Loan
agreement. Or statement from the person
giving or repaying you money, or paying
your bills. The statement must be dated
and have that person's name, address,
phone number, and signature.
• Bank accounts – Statements you received
this month and the past 3 months.
• Stocks, bonds, trusts, annuities – Trust
bond instrument, or current statements.
• Real estate, oil, gas, mineral rights –
Current tax statements, division orders,
deeds, promissory or mortgage note, or
royalty statements.
• Medical, dental, and private insurance
costs – Bills, receipts, statements, or
canceled checks from this month and the
past 3 months.
• Insurance policies – Life, burial,
and health insurance policies showing the
current value. We also might need your
spouse or ex-spouse's job-related health
insurance information and policies.
• Continuing care retirement community –
Admission contract.
• Social Security number –
Social Security card or statement.
• Citizenship – U.S. passport, Certificate
of Naturalization, U.S. birth certificate,
hospital record of birth, or Medicare card.
(If you are renewing benefits, we need this
only if your status changed.)
• Immigration status – Registration card
or papers from the U.S. Citizenship and
Immigration Services. We need copies of
the front and back of these forms. (If you
are renewing benefits, we need this only if
your status changed.)
• Legal representative – Power of attorney
papers, guardianship order, court order, or
similar court documents.
• Money from a job – The last 6 pay stubs or
paychecks, a statement from employer or
self-employment records.
• Social Security, pension, veterans
benefits, Supplemental Security
Income (SSI), workers' compensation,
unemployment, or other government
benefits – Award letter or pay stubs.
• Child support you pay – Divorce decree,
court order, or district clerk record showing
how much you pay.
• Child support you get – District clerk
record. Or letter from parent who pays
showing how much, how often, and the
date it is usually paid. The letter must
be dated and have the name, address,
phone number, and signature of the
parent who pays.
Look below for the items to bring or send with this form. We only need copies of these items. Keep
the originals for your records.
We only need items that apply to your case. For example, if you or your spouse don't have a bank
account, we do not need bank statements.
If you need help getting
these items, let us know.
Application for Benefits
Texas Health and Human Services Commission
You and
Your Spouse
Section A
You
The Person applying for benefits
Spouse
Your husband or wife
What benefits
are you
applying for?
Medicaid for the Elderly and
People with Disabilities
Medicare Savings Program
Medicaid Buy-In Program
None
Medicaid for the Elderly and
People with Disabilities
Medicare Savings Program
Medicaid Buy-In Program
First name
Middle name
Last name
Social Security
number
| | | - | | | - | | | | | | | - | | | - | | | |
only if you are applying for benefits
Birth date
month day year
month day year
Mailing address
City
State, Zip
Home phone
Cell or daytime
phone
( ) -
( ) -
Home address
City
State, Zip
County
E-mail
Try to fill out as
much of the form
as you can.
We need facts about
you and your spouse.
We need to know
about your spouse
even if:
• Your spouse does
not live with you.
or
• Your spouse does
not want benefits.
) like this
Fill in the circles (
People age 65 and older
People with disabilities
Please use dark ink. Please print. If you need more room, add pages.
Save Time
We need facts only
for a spouse who is
living.
If you are not
married, do not fill in
the sections marked
"Spouse."
Your Texas Benefits
Agency Use Only
Date received: __________________ Case/EDG number:
H1200
02/2018
Page 1
You Spouse
Live in Texas?
No
Yes
No
Yes
Plan to stay in Texas?
Yes No
NoYes
If you get money from Social
Security or railroad
retirement, list the number.
__________________________
Social Security claim number
__________________________
Railroad retirement number
__________________________
Social Security claim number
__________________________
Railroad retirement number
Gender
Female
Male Male
Female
Hispanic or Latino?
NoYes
NoYes
Mark one or more:
American Indian or Alaska Native
Asian
Black or African-American
Native Hawaiian or Pacific Islander
White
American Indian or Alaska Native
Asian
Black or African-American
Native Hawaiian or Pacific Islander
White
Mark one:
Single
Separated
Married
Divorced
Widowed
Married
Divorced
Widowed
Single
Separated
You Spouse
Are you a U.S. citizen? If
yes, go to Section C.
Yes No
If no, give facts below:
Yes No
If no, give facts below:
Are you a refugee or legally
admitted immigrant?
Yes No
Yes No
If you have a sponsor, write
their name.
__________________________
Sponsor's name
__________________________
Sponsor's name
Date you
entered the U.S.
month day year
| | | | /
/
|
month day year
| | | | / / |
Are you registered with the
U.S. Citizenship and
Immigration Services?
___________________________
If yes, immigrant registration number
No
Yes
___________________________
If yes, immigrant registration number
No
Yes
Whether or not you get Medicaid, the Department of Aging and Disability Services (DADS) can
see if you can get long-term care services. Services can include meals, nursing care, and help
with dressing and bathing. (See Form H1204, "Long Term Care Options." It came with this
form.)
You Spouse
Do you want DADS to find
out if you can get long-term
care services?
NoYes NoYes
If yes, do you have
intellectual or developmental
disabilities?
NoYes
NoYes
You and
Your Spouse
(continued)
Citizenship
Section B
Section C
Long - Term
Care
This section is only
for people who are
not in a nursing
home or other place
that gives nursing
care.
Save Time
Optional
Questions
Section A
Application for Benefits
Texas Health and Human Services Commission
H1200
02/2018
Page 2
You and your spouse
1. Do you want to give someone the right to act for you
to be your authorized representative?...............................................................
NoYes
If yes, tell us about
that person:
Other Relationship:
Guardian
Power of Attorney
Your authorized representative
If this person is filling out this application for you, they also must sign page 19.
This person is your:
You, the person applying for benefits
Sign here to show you agree to have the person listed above
as your authorized representative.
Name
Address
Phone
( ) -
The person who agrees to be your authorized representative must sign here. Date
Date
People Helping
You
Section D
If you want, you can give someone the right to act for you (an authorized representative).
That person can:
• give and get facts for this application.
• take any action needed for the application process. This includes appealing an HHSC
decision.
• take any action needed to enroll in Medicaid or CHIP. This includes picking a health plan.
• take any action needed to get benefits. This includes reporting changes and renewing
benefits.
By agreeing to act as your authorized representative, I agree to:
• fulfill all your responsibilities related to Medicaid;
• keep information about you private;
• obey state and federal laws about conflict of interest and keeping information private,
including:
o laws that protect information on people who apply for or receive Medicaid (42 CFR part
431, subpart F);
o laws about the privacy and safety of personally identifiable information (45 CFR
§155.260(f)); and
o laws barring the state from paying anyone other than your provider or you for Medicaid
services, except in a few circumstances (42 CFR §447.10).
You can have only one authorized representative for all your benefits from HHSC. If you want to
change your authorized representative: (1) log in to your account on YourTexasBenefits.com and
report a change, or (2) call 2-1-1 (after you pick a language, press 2). If you're a legally appointed
representative for someone on this application, send proof with the application.
Application for Benefits
Texas Health and Human Services Commission
H1200
02/2018
Page 3
1. When you come to our office, will you need special help or equipment? ..........
NoYes
Where you live
Where do you live?
You Spouse
Nursing home.
State supported living center.
State hospital.
Group home for people with intellectual or
developmental disabilities (ICF/MR).
Continuing care retirement community.
Your own home.
Rent house or apartment (including an
assisted living facility).
With someone else in their home.
House paid for by someone else.
Other
Nursing home.
State supported living center.
State hospital.
Group home for people with intellectual
or developmental disabilities (ICF/MR).
Continuing care retirement community.
Your own home.
Rent house or apartment (including an
assisted living facility).
With someone else in their home.
House paid for by someone else.
Other
Interview
Help
Section F
Your Home
or Where
You Live
You don't have to come to our office to be interviewed for these programs:
• Medicaid for the Elderly and People with Disabilities
• Medicare Savings Programs
• Medicaid Buy-In
No
Yes
Person helping you fill out this form
Is someone helping you or your spouse fill out this form? ..............................
Name Relationship or organization
Address Phone
( ) -
No
Yes
We can interview you if you want to be interviewed.
Do you want to come to our office for an interview? ..............................................
If yes, give facts below:
3. Will you need an interpreter? We can get one for you for free. .........................
Yes No
If yes, tell us about that person:
If yes, what do you need?
2. What language do you want to speak during the interview?
If yes, mark the one you need:
Spanish Vietnamese
American Sign Language Other
Section E
Name
Address
Phone
NoYes
If yes, tell us about
that person:
( ) -
2. Do you have an executor or court appointed administrator? ......................
People Helping
You
(continued)
Section D
Application for Benefits
Texas Health and Human Services Commission
H1200
02/2018
Page 4
Other people living with you
Tell us about everyone living with you. Do you and your spouse live together? .......
You Spouse
PERSON 1
|
| | | |
/
/
Name of person living with you
Relationship to you
Birth date
if a relative
Name of person living with you
Relationship to you
Birth date
if a relative
/
|
|
/
| | |
Name of person living with you
Relationship to you
Birth date
if a relative
/
PERSON 2
|
|
/
| | |
Name of person living with you
Relationship to you
Birth date
if a relative
/
/
|
|
| | |
Name of person living with you
Relationship to you
Birth date
if a relative
/
/
PERSON 3
|
| | | |
Name of person living with you
Relationship to you
Birth date
if a relative
|
/
|
/
| | |
No
Yes
You pay: Spouse pays:
If another person pays,
list their name:
Rent or house payment
$ $
Tax on home
$ $
Water and sewer
$ $
Electricity
$ $
Your Home
or Where
You Live
(continued)
Fill out this page
only if you live:
• In your own home.
• In a rent house or
apartment.
• With someone else
in their home.
• In a house paid for
by someone else.
Save Time
Will you stay there for less than 6 months?
NoYes
NoYes
Housing costs
Tell us the costs you have for the home you live in or plan to return to. List the average amount
each person pays every month.
If yes, you only need to list the people who live with both of you under "You."
If no, tell us about the people who live with each of you.
Section F
If you live in a nursing home or other place of care, write the place name below.
________________________________________
Name of place
________________________________________
Name of place
Application for Benefits
Texas Health and Human Services Commission
H1200
02/2018
Page 5
Medicare
Do you get Medicare? ..............................................................................................
NoYes
You Spouse
If yes, mark the type you get.
Part B
Part A
Part D Part BPart A Part D
If yes, what is your Medicare
premium (monthly cost)?
$
$
Other health insurance
Do you or your spouse have health insurance other than Medicare, Medicaid,
or CHIP? Include health insurance you had during the past year. ..........................
NoYes
Name of insured person (first, middle, last) Name of policy holder
Insurance company
Insurance company address
Policy number
How often is the premium paid?
Monthly Quarterly
Yearly
No
Yes
POLICY 1
Name of insured person (first, middle, last) Name of policy holder
Insurance company
Insurance company address
Policy number
How often is the premium paid?
Monthly Quarterly
Yearly
NoYes
POLICY 2
Section G
Medical Facts
$
$
/
/
//
// /
/
If yes, give facts below:
Do you get this insurance through a
job you have now or used to have?
If yes,employer's name
Do you get this insurance through a
job you have now or used to have?
If yes,employer's name
Coverage start date
Coverage end date
Type of coverage
How much is the premium?
Who pays the premium?
Coverage start date
Coverage end date
Type of coverage
How much is the premium?
Who pays the premium?
Natural gas or propane
$ $
Phone
$ $
Home insurance
$ $
Food
$ $
Application for Benefits
Texas Health and Human Services Commission
H1200
02/2018
Page 6
2. Do you have savings accounts? .................................................................
Other facts
1. Do you or your spouse get Medicaid benefits from another state? ..................
NoYes
2. Do you or your spouse get or expect to get money from:
• a lawsuit • personal injury settlement • an accident liability claim?
NoYes
Things you are paying for or own
Give facts about items you and your spouse own or are paying for.
NoYes
Medical Facts
(continued)
Section H
Things You
and Your
Spouse are
Paying for or
Own
(Resources)
Reminder:
If you need more
room, add more
pages.
1. Do you have checking accounts? ..................................................................
Account number Names on account
Bank or company name and address Value
NoYes
$
Account number Names on account
Bank or company name and address Value
$
ACCOUNT 1
Account number Names on account
Bank or company name and address Value
Account number Names on account
Bank or company name and address Value
ACCOUNT 2
$
$
ACCOUNT 1
If yes, which state? When did you last get benefits?
If yes, list the name, address, and phone number of your attorney, insurance
company, court, or person who has facts about the settlement.
If yes, give facts below:
If yes, give facts below:
ACCOUNT 2
Section G
Application for Benefits
Texas Health and Human Services Commission
H1200
02/2018
Page 7
3. Do you have certificates of deposit (CDs),
money market accounts, or IRAs? ................................................................
NoYes
Section H
Things You
and Your
Spouse are
Paying for or
Own
(continued)
By law, you must
tell us if you or
your spouse has
an interest in an
annuity or similar
instrument.
If you get Medicaid,
the state of Texas
becomes the
remainder
beneficiary of that
instrument.
Account number Names on account
Bank or company name and address Value
Account number Names on account
Bank or company name and address Value
ACCOUNT 2
$
$
ACCOUNT 1
4. Do you have savings bonds, stocks, or annuities? .........................................
NoYes
Account number Names on account
Bank or company name and address Value
ACCOUNT 1
NoYes
$
Account number Names on account
Bank or company name and address Value
NoYes
$
ACCOUNT 2
If this is an annuity, is the state of Texas
named the remainder beneficiary? ....................................................
If this is an annuity, is the state of Texas
named the remainder beneficiary? ....................................................
If yes, give facts below:
If yes, give facts below:
Application for Benefits
Texas Health and Human Services Commission
H1200
02/2018
Page 8
5. Did you close an account (investment, annuity, bank, etc.)
in the past 5 years? .......................................................................................
NoYes
6. Do you have signature authority on someone else's account? .....................
NoYes
7. Do you have a safe deposit box? ..................................................................
NoYes
$
$
8. Do you have a patient trust fund? ....................................................................
$
Section H
This question is
only for people in a
nursing home or
other place of care.
Save Time
Things You
and Your
Spouse are
Paying for or
Own
(continued)
NoYes
Name of closed investment or account Account number
ACCOUNT 1
$
//
Name of closed investment or account Account number
$
//
ACCOUNT 2
Account owner's name Account number
$
If yes, give facts below:
If yes, give facts below:
If yes, give facts below:
If yes
Name and address of bank or company that keeps the safe deposit box
Item
Value
ValueItem
Name and address of the place that keeps this fund for you Value
Amount you received
Company name and address that handled investment or account
Date closed
Amount you received
Company name and address that handled investment or account
Date closed
Value
Bank or company name and address
H1200
02/2018
Page 9
Application for Benefits
Texas Health and Human Services Commission
9. Do you have any cash on hand? ..................................................................
NoYes
10. Do you have life insurance? ......................................................................
NoYes
Insurance company name and address
Policy number Face value
POLICY 1
Insurance company name and address
Policy number Face value
POLICY 2
$
$
11. Do you have a burial space or plot? .............................................................
NoYes
$
12. Do you have a pre-need burial contract? .....................................................
NoYes
$
13. Do you have promissory or mortgage notes? ............................................
NoYes
$
Non - negotiable
Negotiable
14. Do you have any trusts? ...............................................................................
NoYes
$
15. Do you have any cars, trucks, boats, or other vehicles? ...............................
NoYes
$
$
Section H
Things You and
Your Spouse
are Paying for
or Own
(continued)
If yes, how much cash:
If yes, give facts below:
If yes:
If yes:
If yes, are they:
If yes:
If yes:
Name of cemetery Number of spaces
Value
Funeral home name and address Buyer or owner of contract
Value
Value
What kind? Value
Make / Model
Year
Make / Model
Year
Value
Value
Application for Benefits
Texas Health and Human Services Commission
H1200
02/2018
Page 10
20. Do you have any livestock (cows, horses, pigs, etc.) or poultry? ..................
21. Do you have any work equipment? ..............................................................
16. Do you have a home (including a mobile home)? .......................................
NoYes
$
NoYes
No one lives there
Someone lives there and they pay rent
Someone lives there and they don't pay rent
For sale
17. Do you have a life estate or remainder interest in property? ........................
NoYes
18. Do you own or share ownership of any other land, lots, or houses? ..........
$
$
19. Do you have any oil, gas, mineral, or surface rights? ..................................
No
$
$
No
livestock
poultry
$
livestock
poultry
$
No
$
$
Things You and
Your Spouse
are Paying for
or Own
(continued)
If yes:
If you are not living in your home right now,
do you plan to live in it again? ...................................................................
Don't forget, give us a copy of the latest tax statement.
Mark all that apply
to the home:
Number Current value
Number
Current value
Type Current value
Type Current value
Address of the home
Amount of land
Current value
No
If yes:
Yes
If yes:
Yes
If yes:
Yes
If yes:
Yes
Section H
Address or location
Amount of land Current value
Address or location
Amount of land
Current value
Address or location
Address or location
Amount of land
Amount of land
Current value
Current value
Application for Benefits
Texas Health and Human Services Commission
H1200
02/2018
Page 11
23. Do you have any personal property (fine china, silver, antiques, etc.) .........
Money or property you or your spouse sold, traded, or gave away
1. Did you sell, trade, or give away money (including income),
property, or anything else in the past 5 years? .............................................
3. Did you reduce the amount of benefits you get from any source? ................
22. Do you get any money or benefits now that you should
have gotten in the past? .............................................................................
NoYes
NoYes
$
$
24. Do you own or share ownership of anything not named in Section H? ........
NoYes
$ $
NoYes
What did you sell, trade, or give away?
ITEM 1
$
//
What did you sell, trade, or give away?
ITEM 2
$
//
NoYes
NoYes
Section H
Things You and
Your Spouse
are Paying for
or Own
(continued)
Don't list items you
use for daily living
needs.
Save Time
Section I
Money or
Property You or
Your Spouse
Sold, Traded, or
Gave Away
Examples:
• You were awarded money from an estate 2 years ago,
but you just started getting the money.
• You applied for SSI 3 years ago and they just decided that you should get benefits.
You are now getting paid for benefits you should have gotten 3 years ago.
If yes:
Type of money or benefits
Amount you were owed
$
If yes:
Item Current value
Item
Current value
If yes:
Item Current value
Item
Current value
If yes, give facts below:
2. Did you give up the right to get any money (including income)
or an inheritance? ........................................................................................
If yes, explain:
If yes, explain:
Market value
What did you get in return?
Who did you sell, trade, or give it to?
Date sold, traded, or given away
Market value
What did you get in return?
Who did you sell, trade, or give it to?
Date sold, traded, or given away
Application for Benefits
Texas Health and Human Services Commission
H1200
02/2018
Page 12
Money from jobs
Did you or your spouse get money in the past 3 months from:
(a) working for someone else, (b) training,
or (c) working for yourself? .............................................................................
Money you or your spouse might get from other programs
Are you waiting for an answer on an application for one of
the programs listed below? ..............................................................................
NoYes
You Spouse
Social Security.
Supplemental Security Income (SSI).
Veterans benefits.
Other benefits
Social Security.
Supplemental Security Income (SSI).
Veterans benefits.
Other benefits
NoYes
JOB 1
$
You
Your spouse
Who got the money:
before taxes
and
deductions
are taken out
Are you still working
at this job? ...............
NoYes
Twice a month
Once a month
Other:
Daily
Once a week
Every 2 weeks
/
/
/
NoYes
JOB 2
$
You
Your spouse
Who got the money:
before taxes
and
deductions
are taken out
Are you still working
at this job? ...............
NoYes
Twice a month
Once a month
Other:
Daily
Once a week
Every 2 weeks
//
/
NoYes
Section J
Money Coming
into Your Home
(Income)
If yes, mark the programs below:
If yes, give facts below:
Did you work for yourself? ...................
If no, list the person or place that paid the money.
How often are you paid?
How often are you paid?
If no, list the person or place that paid the money.
Did you work for yourself? ...................
Hours worked
Amount paid
Start date
Last payment date
(month/year)
Start date
Hours worked
Amount paid
Last payment date
(month/year)
Application for Benefits
Texas Health and Human Services Commission
H1200
02/2018
Page 13
If yes, what is the claim number?
If yes, what is the monthly amount?
NoYes
If yes, what is the monthly amount?
If yes, what is the monthly amount?
$
$
If yes, what is the monthly amount?
If yes, what is the monthly amount?
Yes No
1. Do you get Social Security? ......................................................................
2. Do you get Supplemental Security Income (SSI)? ....................................
$ $
Yes No
3. Do you get veterans benefits?.................................................................
4. Did you, your spouse, parent, or deceased child ever
serve in the armed forces? .............................................................................
NoYes
Name Service number
Is this person related to:
You Your spouse
/
/
//
If yes, what is the monthly amount?
You Spouse
NoYes
If yes, what is the monthly amount?
$
$
5. Do you get railroad retirement? ................................................................
NoYes
If yes, what is the claim number?
If yes, what is the monthly amount?
$ $
6. Do you get civil service retirement payments? ......................................
Money Coming
into Your Home
(continued)
Section J
Other money
Give facts about other money you or your spouse get.
If yes, what is the claim number?
If yes, what is the monthly amount?
If yes, what is the claim number?
If yes, what is the monthly amount?
$
$
You Spouse
If yes, tell us about the person who served.
We will use these facts to find out if you can get their veterans benefits.
What is their relationship to you?
Service start date
Service end date
Application for Benefits
Texas Health and Human Services Commission
H1200
02/2018
Page 14
If yes, what is the claim number?
If yes, what is the monthly amount?
NoYes
If yes, what is the claim number?
If yes, what is the monthly amount?
$
$
7. Do you get any other retirement income? ............................................
SpouseYou
If yes, what is the company name?
If yes, what is the monthly amount?
NoYes
If yes, what is the company name?
If yes, what is the monthly amount?
$ $
8. Do you have payments or annuities from private insurance? ................
If yes, how often?
NoYes
If yes, how often?
$
$
9. Do you get interest from any of the following sources? ........................
If yes, how often?
NoYes
If yes, how often?
$
$
10. Do you get dividends from stocks, bonds, or insurance? .....................
If yes, how often?
NoYes
If yes, how often?
$
$
11. Does anyone pay you rent? ...............................................................
Money Coming
into Your Home
(continued)
Section J
• checking account • savings account
• certificate of deposit (CD) • note payment • other
If yes, what is the amount you get?
If yes, what is the amount you get?
If yes, what is the amount you get?
If yes, what is the amount you get?
If yes, what is the amount you get?
If yes, what is the amount you get?
Application for Benefits
Texas Health and Human Services Commission
H1200
02/2018
Page 15
NoYes
12. Do you get any money from leases or royalties from
oil, gas, mineral, or surface rights? .........................................................
SpouseYou
If yes, what is the amount you get?
If yes, what is the amount you get?
Yes No
13. Do you get any money from farming? .......................................................
$
$
NoYes
14. Do you get the following types of money from
anyone else or anywhere else? ........................................................
• cash • gifts • payments you get for loaning money to someone else
• bills paid for you • child support • training • other
If yes, what type of money do you get?
If yes, who do you get the money from and why?
If yes, what is the amount you get?
$
Money Coming
into Your Home
(continued)
Section J
Medical bills from the past 3 months
If you or your spouse can't pay medical bills from the past 3 months, Medicaid might pay them.
We will look at the money you get and the things you own to find out if Medicaid might pay
them. If you have paid them, you might be able to get paid back by your health care provider
(doctor, hospital, clinic, etc.).
Do you have any medical bills for services from the past 3 months? ...........
If yes, what type of money do you get?
If yes, who do you get the money from and why?
If yes, what is the amount you get?
Your spouseYou
Medicine
Doctor
Hospital
Other
$
$
//
Address of medical service provider
NoYes
Yes No
Section K
Medical Costs
This section is only
for people applying
for the first time. If
you are renewing
benefits, you can
skip this section.
Save Time
$
If yes, write the name of the company that pays you.
If yes, what is the amount you get?
$
If yes, write the name of the company that pays you.
If yes, what is the amount you get?
$
If yes, give facts below:
Who got the services?
Type of Bill
Amount of bill
Amount paid
Date of service (mm/dd/yy)
Who provided the medical service?
If yes, we need to know about the money you got (income) and things you were paying for
or owned (resources) during those past 3 months.
Were they different from what you listed on this form? ..............................
If yes, how often?
If yes, how often?
Application for Benefits
Texas Health and Human Services Commission
H1200
02/2018
Page 16
Agency staff signature
Medical costs you paid in the past year
Did you or your spouse pay any medical bills in the past year? ......................
NoYes
Date paid Amount paid
$
/
/
Who got the services? Your spouseYou
Type of bill:
Doctor
OtherMedicine
Hospital
Date paid Amount paid
$
//
Date paid Amount paid
$
/
/
Date paid Amount paid
$
/
/
Signing up to vote
Applying to register or declining to register to vote will not affect the
amount of assistance that you will be provided by this agency.
If you are not registered to vote where you live now, would
you like to apply to register to vote here today? ........................................
NoYes
Signing Up
to Vote
(optional)
Section L
Fill out this section
only if you are in a:
• Nursing home.
• State supported
living center.
• State hospital.
• Group home
(ICF/MR).
• Home and
community-based
waiver program.
Section K
Medical Costs
(continued)
Save Time
Already registered
Agency transmitted
Mailed to client
Client to mail
Client declined
Other
Agency Use Only
Voter Registration
Status
Hospital
Who got the services? Your spouse
You
Type of bill: Doctor
OtherMedicine
Who got the services?
Hospital
Your spouseYou
Type of bill: Doctor
OtherMedicine
You
Hospital
Who got the services? Your spouse
Type of bill: Doctor
OtherMedicine
If yes, give facts below:
IF YOU DO NOT CHECK EITHER BOX, YOU WILL BE CONSIDERED TO
HAVE DECIDED NOT TO REGISTER TO VOTE AT THIS TIME. If you
would like help in filling out the voter registration application form, we will help
you. The decision whether to seek or accept help is yours. You may fill out the
application form in private. If you believe that someone has interfered with your
right to register or to decline to register to vote, or your right to choose your own
political party or other political preference, you may file a complaint with the
Elections Division, Secretary of State, PO Box 12060, Austin, Tx 78711.
Phone 1-800-252-8683.
Application for Benefits
Texas Health and Human Services Commission
H1200
02/2018
Page 17
Facts HHSC Has About Me
HHSC uses facts about people applying for
benefits to decide: (1) who can get benefits,
and (2) the amount of benefits. HHSC checks
facts with the federal Income and Eligibility
Verification System. If any facts don’t match,
HHSC will check other sources (banks,
employers, etc.). If anyone applying for
benefits has an immigration registration
number, HHSC must check with the U.S.
Citizenship and Immigration
Services’ (USCIS) system. HHSC will not
give anyone’s facts to USCIS.
In most cases, I can see and get facts HHSC
has about me. This includes facts I give
HHSC and facts HHSC gets from other
sources (medical records, employment
records, etc.). I might have to pay to get a
copy of these facts. I can ask HHSC to fix
anything that is wrong. I do not have to pay to
fix a mistake. To ask for a copy or to fix a
mistake, I can call 2-1-1 or my local HHSC
benefits office.
Medicaid health care providers (doctors,
drug stores, hospitals, etc.) might give out
facts about me to HHSC. This will allow
the providers to be paid by Medicaid.
Giving Out Facts About Me
If I choose not to tell the truth, I might:
If I Give False Information
• Be charged with a crime.
• Have to repay benefits.
The same is true if I let someone else use
my medical card or Medicaid ID.
If I get Medicaid, HHSC will keep medical
service payments I can get from other
sources, such as:
Medical Payments
I must tell HHSC about these sources. If I
don’t, I am breaking the law.
• My health insurance.
• Money I got because of injuries.
HHSC will only keep the amount of
medical support and service payments
allowed by law. I will work with HHSC to
get these funds.
I agree to let HHSC know, within 10 days,
about any changes to my case. This
includes changes in facts I give on this
form such as money I get, things I own or
are paying for, where I live, or insurance I
have (including health insurance
premiums).
Reporting Changes
Statement of
Understanding
Section M
Read this
section
before
signing.
HHSC can share facts about me
• When needed for me to get state health
care benefits.
• With phone and utility companies. They
will find out if my bill amount can be
lowered. HHSC will give them my name,
address, and phone number.
Asset Verification Consent
I know that my signature below and/or on the
application lets the HHSC get facts about
things I own (including money) from banks,
credit unions, or other financial institutions so
HHSC can decide if I can get Medicaid.
HHSC can keep checking these facts until:
• HHSC denies my application for Medicaid;
or
• I can't get Medicaid anymore; or
• I tell HHSC in writing that I do not want
HHSC to check these facts any more.
If I do not let HHSC get facts about me from
financial institutions, or I tell HHSC I do not
want it to check these facts anymore, I know
that HHSC may deny or stop my Medicaid.
HHSC will keep my facts private if they
were collected:
• By HHSC staff or contracted provider
staff.
• To find out if I can get state benefits.
Keeping My Facts Private
Application for Benefits
Texas Health and Human Services Commission
H1200
02/2018
Page 18
Your estate might have to pay the state back for services you get.
By signing below, I agree:
Did you...
1. Include the
"items we need"
listed on page D.
2. Sign and date
this page.
• To let HHSC and other state, federal, and local agencies
check, share, and get facts about me or my spouse.
• To let other people, businesses, and organizations share
facts they have about me or my spouse with HHSC.
• The facts to be checked and shared include anything that
helps decide: (1) who can get benefits, and (2) the amount
of benefits.
My Answers Are True: I certify under penalty of perjury that the
information I have provided on this application is true and
complete to the best of my knowledge. If it is not, I may be subject
to criminal prosecution. Sign below to show you agree:
SpouseYou
Sign here Date
Sign here Date
If you are a parent, guardian, authorized representative, court appointed administrator, executor, or have power of
attorney for this person, sign below:
//
//
Sign here (You must give proof of this right) Date
//
Sign here (You must give proof of this right) Date
//
Sign here if you are a witness (only needed if anyone above signed with an "X" or other mark). Date
//
Medicaid Estate Recovery Program:
If you get certain Medicaid long-term services, the state of Texas has the right to ask for money
back from your estate after you die. In some cases, the state might not ask for anything back.
The state will never ask for more money back than what it paid for your services.
Notice:
Printed name of witness
If you have a problem or complaint you should first discuss it with the Texas Medicaid Estate
Recovery Program. Many times they can explain specific policies or correct the problem
immediately. If your problem or complaint is not resolved to your satisfaction, you can contact
the HHS Office of the Ombudsman by calling 1-877-787-8999 or by making an online
submission at https://hhs.texas.gov/ombudsman.
The state can ask for money back from your estate only if:
1. you applied for and received certain Medicaid services on or after March 1, 2005; and
2. you were age 55 or older when you got the services.
To learn more about Texas Medicaid Estate Recovery Program, including frequently asked
questions, please visit https://hhs.texas.gov/MERP. You also may email questions to
merp@hhsc.state.tx.us.
Application for Benefits
Texas Health and Human Services Commission
H1200
02/2018
Page 19
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