qualified medicare beneficiaries (qmb). medicaid for the...

4Your Texas BenefitstHow to apply for benefits for:

Medicare Savings ProgramsPeople age 65 and older

Helps people who already get Medicare. Helps peoplePeople with disabilities pay Medicare costs. Costs can include Medicarecxc premiums, co-pays, and deductibles.

These programs also are known as:

Medicaid for the Elderly • Qualified Medicare Beneficiaries (QMB).

and People with Disabilities • Specified Low-income MeLlicareBeneficiaries (SLMB).

Helps people who:• Qualifying Individuals (QI- I).

• Lost Supplemental Security• Qualified Disabled and WorkingIncome (SSI) benefits.

Individuals (QDWI).• Need to he in a nursing home or

____________________________________________

other place of care. To apply for Medicareor You must apply for Medicare through a different

• Have a disability, agency — the Social Security Administration.

To learn more, visit www.Medicarc.gov

There might be a better form to or call 1-800-633-4227.use, if any of theseapply toyou: .

You no longer get SSI and you aren’tapplying for the Medicaid Buy-In Medicaid Buy-In ProgramProgram. (H1200-EZ) c Helps people who work and: (a) have a disability

• You are applying only for a Medicare or (h) are age 65 or older. Some people mightSavings Program. (H1200-EZ) have to pay a monthly fee.

• You live in a state supported livingcenter. (H1200-PFS) Medicaid Buy-In for Children is a different

• You live in a state hospital program. It is for families who have a child witha disability, but make too much money to get(H1200-PFS)traditional Medicaid.

To ask for these forms,call 2-1-1 or 1-877-541-7905. To get the form for that program,

call 2-1-1 or 1-877-541-7905TEXAS and ask for Form H1200-MBIC.

.

Health and HumanServices Commission . .

How to Apply Most phone and faxnumbers on this form are

How to send it in: free to call. If you are deaf,

fl Mail: HHSC, PC Box 149024, hard of hearing, or speechAustin, TX 787 14-9024.

impaired, you can callCR to your local benefits office.What to do: Call 2-1-1 to get the address. 7-1-1 or 1-800-735-2989.1. Fill out this form. Fax: 1-877-447-2839. If your2. Sign and date page 19. form is 2-sided, fax both sides.3. Send Items we need” listed In person: At a benelits office. Don’t send this page with your form

on page D. Call 2-1-1 to find one near you. Keep for your records. Page A

Questions aboutthis form orabout benefits

Call 2-11 or1-877-541-7905.

After you pick alanguage, press 2 to:

• Ask questions aboutthis form.

• Find where to get helpfilling out this form.

• Check the status ofthis form.

• Ask questions aboutbenefit programs.

To learn more aboutbenefits, you also can go towww,hhsc.state.tx.us

To apply for

Helpful Tips• Sign and date page 19.

• Send “Items we need.”See Page D.

• Read the tips on theleft side of the page.They can help yousave time.

• If you need more room toanswer any question, youcan add more pages.

• Write your SSN on the bottom of eachpage. This will help us track your form.

other state benefits

If you want to apply for SNAPfood benefits, cash help for families(TANF), or Medicaid for childrenand families, you need a differentform. To get that form, call 2-1-1

I (after you pick a language,press 2). Or apply online atwww.YourTexasBenefits.com

Report waste,fraud, and abuse

If you think anyone ismisusing HHSC benefits,call 1-800-436-6184.

Notice: Your estate mightfor services you get. To

Getting long-termcare services

I!iil1

If you are approved to getMedicaid, another state agency,the Department of Aging andDisability Services (DADS),might help with your case.DADS staff will find out whatlong-term care services you canget. To see a list of services, go toForm H1204, “Long Term CareOptions.” It came with this form,To learn more, call 2-1-1 (afteryou pick a language, press 2, andthen press 1).

have to pay the state backlearn more, see page 19.

You can apply for orrenew benefits onlineIf you would rather apply forbenefits online, go towww.YourTexa sB e nefit s - cornThis website also will allow you to:

• Find out if you should apply for benefits.• Find a benefits office near you.

• Renew benefits.

After you fill out an online form,you can check:

• 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).

)Save Timee

These timesaving tips willtell you if youneed to fill outa section.

I

-J

ITexas Health and Human Services Commission (HHSC)

Don’t send this page with your form. Keep for your records. Page B

If you think you have beentreated unfairly (discriminatedagainst) because of race, color,national origin, age, sex,disability, or religion, youcan file a complaint.Contact us at:HHSCivilRightsOfflce©hhscstate.tx.us or by:• Mail:

HHSCOffice of Civil Rights701W. 5L’St.MC W-206Austin, TX 73751

• Phone:1-883-388-63321-877-432-7232 (fly)

• Fax (not toll-free):1-512-438-5885

Citizenship andImmigration Status

• You only have to give thecitizenship or immigrationstatus of people who wantbenefits.

• If you are not a U.S. citizenor a legal immigrant, theonly benefits you might heable to get are emergencyMedicaid services.

• Getting Medicaid long-termcare services could affectyour immigration status andyour chances of getting aPermanent Resident Card(green card).

• You might want to talkto an agency that helpsimmigrants with legalquestions before you apply.

Social Security Numbers

l!l1a• You only need to give the Social

Security numbers (SSNs) for peoplewho want benefits.

• Giving or applying for an SSN isvoluntary; however, anyone who doesn’tapply for an SSN or doesn’tgive an SSN can’t get benefits.

• If you don’t have an SSN, we can helpyou apply for one if you ate a U.S. citizenor a legal immigranc

• You must be a U.S. citizen or a legalimmigrant to get an SSN

• You can get benefits for your children ifthey have an SSN and you don’t.

• We will nor give SSNs to the Bureau ofImmigration and Customs Enforcement.

• We will use SSNs to check the amountof money you get (income), if you can getbenefits, and the amount of benefits youcan get. (42 CFR §435.910)

Help you can get without filling out this formReporting abuse

Do you think someone is being abused? If theabuse is in a nursing home or other place ofcare, call 1-800-458-9858. If the abuse is in aprivate home, call 1-800-252-5400.

How to file a complaintIf you have a complaint, first try talking to yourcaseworker or their supervisor. If you stilt need

help, call 1-877-787-8999.

Services in your area

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

Learn abour services in your area, such as:• Food banks • Tax help

• Senior services • Child care• Housing • Alter-school programs• Help after a disaster• Help with gas, electric,

and water bills

Alcohol and Drug AbusePrevention Program

Do you or someone you know want to stopusing alcohol or drugs? Call 1-877-966-3784(1-877-9-NO DRUG). You can get help:• Quitting.• Dealing with a crisis.

• Keeping others from using drugs or alcohol.

Adult Education and Family Literacy ProgramDo you want help learning to read or gettinga GED? Do you need help with job skills?Or learning to speak English?Call 1-800-441-7323 (1-800-441-REAL)).

Family Violence Program

Are you afraid for your children’s or your safety?Call the hotline anyrime at 1-800-799-7233(1-800-799-SAFE). You can get help:• Getting a tide to a safe place.• Finding shelter, legal help, and a job.

• Getting counseling.

Lega1 InformationYour right tobe treated fairly

• Family violenceprograms

• Legal help

Don’t send this page with your form. Keep for your records. Page C

Items we needLook below for the items to bring or send with this formWe 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’thave a bank account, we do not need bank statements.

• Social Security number —

Social Security card or statement.

• Citizenship — U.S. passport, Certificateof Naturalization, U.S. birth certificate,hospital record of birth, or Medicare card.(If you are renewing benefits, we need thisonly if your status changed.)

• Immigration status — Registration cardor papers from the U.S. Citizenship andImmigration Services. We need copies ofthe front and back of these forms. (If youare renewing benefits, we need this only ifyour status changed.)

• Legal representative — Power of attorneypapers, guardianship order, court order, orsimilar court documents.

• Money from a job — The last 6 pay stubs orpaychecks, a statement from employer orself-employment records.

• Social Security, pension, veteransbenefits, Supplemental SecurityIncome (851), workers’ compensation,unemployment, or other governmentbenefits — Award letter or pay stubs.

• Child support you pay — Divorce decree,court order, or district clerk record showinghow much you pay.

• Child support you get — District clerkrecord, Or letter from parent who paysshowing how much, how often, and thedate it is usually paid. The letter musthe dated and have the name, address,phone number, and signature of theparent who pays.

• Loans, repayments, and gifts (includessomeone paying bills for you) — Loanagreement. Or statement from the persongiving or repaying you money, or payingyour bills. The statement must be datedand have that person’s name, address,phone number, and signature.

• Bank accounts — Statements from thismonth and the past 3 months.

• Stocks, bonds, trusts, annuities — Trustagreement, annuity contract, stockcertificate, bond instrument, or currentstatements.

• Real estate, oil, gas, mineral rights —

Current tax statements, division orders,deeds, promissory or mortgage note, orroyalty statements.

• Medical, dental, and private insurancecosts -. Bills, receipts, statements, orcanceled checks from this month and thepast 3 months.

• Insurance policies — Life, burial,and health insurance policies showing thecurrent value. We also might need yourspouse or ex-spouse’s job-related healthinsurance information and policies.

• Continuing care retirement community —

Admission contract.

If you need help gettingthese items, let us know.

Don’t send this page with your form. Keep for your records. Page D

Your Texas Benefits

Section A

You andYour SpouseTry to fill out asmuch of the formas you can.

We need facts aboutyou and your spouse.We need to knowabout your spouse

even ii:

H 120004/2015Page 1

People age 65 and olderPeople with disabilities Please use dark ink. Please print. llyou need more room, add pages.

Fill in the circles (0) like this

You SpouseThe person applying for benefits Your husband or wife

What benefits are 0 Medicaid for the Elderly and 0 Noneyou applying for? People with Disabilities 0 Medicaid for the Elderly and

0 Medicare Savings Program People with Disabilities0 Medicaid Buy-In Program 0 Medicare Savings Program

0 Medicaid Buy-In Program

First name

Middle name

Last name

• Your spouse doesnor live with you. Social Security number

or

• Your spouse doesnor want benefits.

Ill-I I I- I I I I-I I H Ionly if you are applying for benefits

Save Time;10We need factsonlyfora spousewho is living.

If you are notmarried, do notfillin the sections marked:.“Spouse.”

Biflhdate rn/I I/H Imonth day year month day year

Mailing address

City

State, ZIP

Homephone ( ) - ( )Cellordaytime ( ) - ( )phone

Home address

Cityp—.———_______________

State, ZIP

County

E-mail

TEXASa Health and I lumanServices Commission

Agency Use OnlyDate received:

_________________________________

Case/FOG number:

________________________________

Application for benefitsTexas Health and Human Services Commission

Section A

You andYour Spouse(continued)

You SpouseLiveinTexas? OYes ONo OYes ONo

PlantostayinTexas? OYes ONo OYes ONo

if you get money fromSocial Security or Social Security claim number Social Security claim numberrailroad retirement,list the number. Railroad retirement number Railroad retirement number

Gender 0 Male 0 Female 0 Male 0 FemaleHispanic orLatino? Oles ONo OYes ONoMark one or more: 0 American Indian or Alaska Narive 0 American Indian or Alaska Native

OAsian 0 Asian0 Black or African-American 0 Black or African-American0 Native Hawaiian or Pacific Islander 0 Native Hawaiian or Pacific Islander0Wiire 0 White

Markone: OMarried OSingle0 Divorced 0 Separated0 Widowed

OptionalQuestions

Section B

Citizenship

___________ You Spouse

Areyouau.S.citizen? des ONo OYesONolfyes, go to Section C. no, give facts below: If no, give facts below:

Are you a refugee or• legally admitted 0 Yes 0 No 0 Yes 0 No

immigrant?

If you have a sponsor,write their name. Sponsors name Sponsor’s name

enteredtheU.S. - ELH RH /LL in— month day year month day year_____

Are you registered 0 Yes 0 No 0 Yes 0 Nowith the U.S.

: Citizenship and

[ Immigration Services? If yes, immigrant registration number If yes, immigrant registration number

Section C

Long-termCare

Save Tinie

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 fonn.)

This section is onlyfor people who are notin a nursing home orother place that givesnursing care.

You Spouse

Do you want DADS tofind out if you can get OYes ONo OYes ONolong-term care services?

Ifyes,doyouhave OYes ONo OYes ONointeTlectual ordevelopmentaldisabilities?

Social Security number:Application for benefits

-—

_____________

Texas Health and Human Services Commission

Hi 200

04/2015

Page 2

Section D

PeopleHelping You

Social Security number:

II you want, you can give someone the right to act for you (an authorized representative).

Thur person can:• Give and get facts for this application.• Take any action needed for the application process. This includes appealing an RHSC decision.• Take any action needed to enroll in Medicaid or CHiP. This includes picking a health plan.• Take any action needed ro get benefits. This includes reporting changes and renewing benefits.

You can have only one authorized representative for all your benefirs from HHSC. If you wanr rochange your aurhorized representative: (I) log in to your account on YourTexasBenefits.com andreport a change) or (2) call 2-1-1 (afteryou pick a language) press 2). liyou’re a legally appointed

Frepresentative for someone on this application, send proof with the application.

You and your spouse1. Do you want to give someone the right to act for you —

to he your authorized representative? 0 Yes 0 NoIf yes, tell usabout that person:

Name

Address

(Phone

This person is your: 0 Guardian 0 Power of Attorney 0 Other Relationship:

_________________

Your authorized representativeIf this person is filling out this application for you, they also must sign page 19.

The person who agrees to be your authorized representative must sign here. Date

You, the person applying for benefits

sign here to show you agree to have the person listed above Dateas your authorized representative.

2. Do you have an executor or court appointed administrator’ 0 Yes 0 NoIf yes, tell usabout that person:

Na me

Address

(Phone

Person helping you fill out this form

Is someone helping you or your spouse fill out this form? 0 Yes 0 No

If yes, tell us about that person:

Name Relationship or organization

Address Phone

________________________________

Hi 200Application for benefits 04/2015

____

[ Texas Health and Human Services Commission Page 3

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

We can interview you if you want to he interviewed.

Do you want to come to our office for an interview? 0 Yes 0 NoIf yes, give facts below:

1. When you come to our office, will you need specia’ help or equipment?... 0 Yes 0 No

If yes, what do you need?

_________________________________________________

2, What language do you want to speak during the interview?

3. Will you need an interpreter? We can get one for you for free C Yes 0 No

If yes, mark the one you need:O Spanish 0 VietnameseO American Sign Language 0 Other

____________________________________________

I you Live n a nursing home or other place of care, write the place name below.

Name of place Name of place

Will you stay there for less than 6 months?

OYes ONo OYes ONo

Section E

InterviewHelp

Section F

Your Homeor WhereYou Live

Where you live‘Where do you live?

You

0 Nursing home. 0 Nursing home.0 State supported living center. 0 State supported living center.0 State hospital. 0 State hospital.0 Group home for people with intellectual 0 Group home for people with intellectual or

or developmental disabilities (ICF/MR). devdopmental disabilities (ICF/MR).0 Continuing care retirement community. 0 Continuing care retirement community.0 Your own home. 0 Your own home.ORent house or apartment (including an ORent house or apartment (including an

assisted living facility), assisted living facility),OWith someone else in their home. OWith someone else in their home.0 House paid for by someone cisc. 0 House paid for by someone else.0 Other C Other


Hi-i I -I Application for benefitsTexas Health and Human Services Commission

Hi 20004/20 15Page 4

Section F

_________

Your Homeor WhereYou Live(continued)

Fill out this pageonly if you live:

• In your own home.

• In a rent houseor apartment.

• With someoneelse in their home.

• ma housepaid for bysomeone else.

Other people living with youTell us about everyone living with you. Do you and your spouse live together7 0 Yes 0 NoIf 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.

SaveTimer

You Spouse

Name of person living with you Name of person living with you

. Relationshiptoyou Relationshiptoyou

Birth date Birth dateif a relative / / if a relative


. Relationship to you Relationship to you

Birth date Birth dateifarelative I ifarelative / /1


Relationship to you Relationship to you

Birth date / I Birth dateif a relative / / if a relative

Housing costsTell 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.

You pay: Spouse pays: pays,

Rent or house payment $ $Taxon home $ $--- pWater and sewer $ $Electricity $ $Natural gas or propane $ $----------

Phone___ $ $rr

Home insurance $

___

Food


1 1

CsApplication for benefits


H 120004/2015PageS

Section G

Medical FactsMedicareDo you get Medicare?.0 Yes 0 No

You Spouse

if yes, markthe OPartA 0 Part B 0 Part 0 OPartA 0 Part B 0 Part Dtype you get.

If yes, what is yourMedicare premium(monthly cost)?

Other health insuranceDo you or your spouse have health insurance other than Medicare, Medicaid,or CHIP? Include health insurance you had during the past year 0 Yes 0 No

If yes, give facts below:

Name of insured person (first, middle, last) Nameof policy holder

Insurance company Insurance company address

I / / /Policy number Coverage start date Coverage end date Type of coverage

$ How often is the premium paid?

How much is the premium? Who pays the premium? 0 Monthly 0 Quarterly 0 Yearly

Do you get this insurance through ajob you have now or used to have’ OYes 0 No If yes, employer’s name

Name of insured person (first, middle, last) Name of policy holder

Insurance company Insurance company address

I / / /Policy number (overage start date Coverage end date Type of coverage

$ Howoftenisthepremiumpaid?

How much is the premium? Who pays the premium? 0 Monthly 0 Quarterly 0 Yearly

Do you get this insurance through ajob you have now or used to have’ OYes 0 No If yes, employer’s name

Social Security number: H1200

__________

-

— Application for benefits 04/2015L__ -- - Texas Health and Human Services Commission Page 6

Section G

Medical Facts(continued)

Section H

Things Youand YourSpouse arePayingfor or Own(Resources)

Reminder:

If you needmore room,add more pages.

Other facts1. Do you or your spouse get Medicaid benefits from another state? aYes a No

If yes, which state? When did you last get benefits?

Things you are paying for or ownGive facts about items you and your spouse own or are paying for.

1. Do you have checking accounts? 0 Yes 0 NoIf yes, give facts below:

2. Do you have savings accounts?

Value


Application for benefits

___________________


2. Do you or your spouse get or expect to get money from:a lawsuit • personal injury settlement • an accident liability claim? 0 Yes 0 No

If yes, list the name, address, and phone number of your attorney, insurance company,court, or person who has facts about the settlement.

Account number

Bank or company name and address

Names on account

Account number

$Value


Names on account

$

OYes ONo

Account number


Names on account

Account number

$Value


Names on account


I -

$Value

H 120004/2015Page 7

Section H

Things Youand YourSpouse arePayingfor or Own(continued)

By law, you musttell us if you oryour spouse hasan interest in anannuity or similarinstrument.

If you get Medicaid,the state of Texasbecomes theremainder beneficiaryof that instrument.

Sotial Security number:

H -

H 120004/2015Page 8

3. Do you have certificates of deposit (CDs),money market accounts, or IRAs? 0 Yes 0 No


Account number


Names on account

Account number

$Value


Names on account

_____

$Value

4. Do you have savings bonds, stocks, or annuities? C Yes 0 No


Account number


Names on account

$

If this is an annuity, is the state of Texas named the remainder beneficiary’ C Yes 0 No

Value

Account number Names on account

$Bank or company name and address Value

If this is an annuity, is the state of Texas named the remainder beneficiary7 0 Yes 0 No

- Application for benefits

____________________


Spouse arePayingfor or Own(continued)

5. Did you close an account (investment, annuity, bank, etc.)in the past 5 years? 0 Yes 0 No


$: Name of closed investment or account Account number Amount you received

/ /Company name and address that handled investment or account Date closed

!

6. Do you have signature authority on someone else’s account7 0 Yes

&t: —

ONo


SAccount owner’s name Account number Value


7. Do you have a safe deposit box7 0 Yes 0 No


Name and address of bank or company that keeps the safe deposit box

$Name and address of the place that keeps this fund for you Value


Texas

Health and Human Services Commission

Section H

Things Youand Your

Name of closed investment or account

Company name and address that handled investment or account

$Account number Amount you received

/ /Date closed

Item

Save Time

$

Item

This question isonlyfor people in anursing home orother place of care.


Value

SValue

8. Do you have a patient trust fund7 0 Yes 0 No

If yes:

H 120004/2015Page 9

l.

! 11. Do you have a burial space or plot? 0 Yes 0 No. Ifyes: $

Nameofcemetery Numberofspaces Value

—

12. Do you have a pre-need burial contract7 0 Yes 0 NoIf yes: $

Funeral home name and address Buyer or owner of contract Value

13. Do you have promissory or mortgage notes7 0 Yes 0 NoIf yes, are they: 0 Negotiable 0 Non-negotiable Value $

14. Do you have any trusts? 0 Yes 0 NoIf yes: $

What kind? Value

15. Do you have any cars, trucks, boats, or other vehicles? 0 Yes 0 NoIf yes:

Make I Model Year

Make / Model Year

$Value

$Value


-

- Application for benefits

_________________


H 120004/2015

Section H


9. Do you have any cash on hand7 0 Yes 0 No

If yes, how much cash: $

10. Do you have life insurance7 0 Yes 0 No


Insurance company name and address

, $Policy number Face value

Insurance company name and addressI $Policy number Face value

Page 10

C Uettion


Social Security number;

16. Do you have a home (including a mobile home)? 0 Yes 0 NoIf yes:

_______________________________ _________

$

_______

Address of the home Amount of land Current valueIf you are not living in your home right now,do you plan to live in it again? 0 Yes 0 No

Mark all that apply 0 No one lives there 0 Someone lives there and they pay rentto the home: 0 Someone lives there and they dont pay rent 0 For sale

Don’t forget, give us a copy of the latest tax statement.

17. Do you have a life estate or remainder interest in property? 0 Yes 0 NoL

.____

‘18. Do you own or share ownership of any other land, lots, or houses1 0 Yes 0 No

Ifyes;

$Address or location Amount of land Current value

SAddressorlocation Amountof land Currentvalue

L—-

19. Do you have any oil, gas, mineral, or suiface rights1 0 Yes 0 NoIf yes:

SAddress or location Amount of land Current value

SI Addressorlocation Amountof land Currentvalue

120. Do you have any livestock (cows, horses, pigs, etc.) or poult? 0 Yes 0 NoIf yes;

O livestock

_________ _____________

0 livestock

_________ _____________

o poultry Number Current value 0 poultry Number Current value

21. Do you have any work equipment? 0 Yes 0 NoIfyes: $

______________

$Type (urrentvalue Type Currentvalue

____________________________________

H 1200—

— Application for benefits 04/2015

_________________________________--

Texas Health and Human Services Commission Page 11

Type of money or benefits Amount you were owed

23. Do you have any personal property (fine china, silver, antiques, etc.) 0 Yes 0 NoIfyes: $

___________

$Item Currentvalue Item Currentvalue

24. Do you own or share ownership of anything not named in Section H’ DYes 0 NoIf yes:

$

__________________

$Item (urrentvalue Item Currentvalue

Money or property you or your spouse sold, traded, or gave away1. Did you sell, trade, or give away money (including income),

property, or anything else in the past 5 years? C Yes 0 No

If es, give facts below:

______________________

$

____________________

What did you sell, trade, or give away? Market value What did you get in return?

_______________

/ /Who did you sell, trade, or give it to? Date sold, traded, or given away

What did you get in return!

I I

If yes, explain:

3. Did you reduce the amount of benefits you get from any source7 0 Yes 0 No

If yes, explain:

Social Security number: H1200

—— Applicationforbenefits 04/2015


SectIon H

lEL


10Don’t list items you usefor daily living needs.

22. Do you get any money or benefits now that you shouldhave gotten in the past7 C Yes 0 NoExamples:

• You were awarded money from an estate 2 years ago,hut you just started getting the money.

• You applied for 551 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: $

Save Time

Section I

Money orPropertyYou or YourSpouse Sold,Traded, orGave Away

What did you sell, trade, or give away?$

Market value

Who did you sell, trade, or give it to? Date sold, traded, or given away

2. Did you give up the right to get any money (including income)or an inheritance’ DYes 0 No

Page 12

Section J

MoneyComing intoYour Home(Income)

Money you or your spouse might get from other programsAre you waiting for an answer on an application for one ofthe programs listed below7 0 Yes 0 NoIf yes, mark the programs below:

You Spouse

0 Social Security. 0 Social Security.0 Supplemental Security Income (SSI). 0 Supplemental Security Income (SSI).0 Veterans benefits. 0 Veterans benefits.0 Other benefits 0 Other benefits

Money from jobsDid you or your spouse get money in the past 3 months from:( a) working for someone else, (h) training,or (c) working for yourself? 0 Yes 0 No


•1

Who got the money: 0 You 0 Your spouse$ before taxes and

deductions are taken outHours worked Amount paid

I / /Start date Last payment date (month/year)

Did you work for yourself’ 0 Yes 0 No

Are you still workingatthisjob’ OYes ONo

How often are you paid?0 Daily 0 Twice a month0 Once a week 0 Once a month0 Every 2 weeks 0 Other:________

If no, list the person or place that paid the money.

IWho got the money: 0 You 0 Your spouse

$ beforetaxesanddeductions are taken out

Hours worked Amount paid

I / /Start date Last payment date (month/year)

Did you work for yourself’ 0 Yes 0 No

Are you still workingatthisjob’ OYes ONo

How often are you paid?0 Daily 0 Twicea month0 Once a week 0 Once a month0 [very) weeks 0 Other:_______

If no, list the person or place that paid the money.


___________________


Social Security number: H 120004/20 15

Page 13

Section J

MoneyComing intoYour Home(continued)


F-I

fUiI2w

Other moneyabout other money you or your spouse get.

_____-

You Spouse —1. Do you get Social Security1 0 Yes 0 No

$ $If yes. what is the monthly amount? If yes, what is the monthly amount?

______

2.Do you get Supplemental Security Income (SSI)? C Yes C No

$ $If yes, what is the monthly amount? If yes, what is the monthly amount?

3. Do you get veterans benefits? C Yes 0 No

If yes, what is the claim number? If yes, what is the daim number?

•$If yes, what is the monthly amount? If yes, what is the monthly amount?

4. Did you, your spouse, parent, or deceased child everserve in the armed forces C Yes 0 No

If yes, telL us about the person who served.We will use these facts to find out if you can get their veterans benefits.

: Is this person related to:Name Service number 0 You 0 Your spouse

/ / / /L5taft date Service end date What is their relationship to you?

L You -— —. Spouseyou get railroad retirement? 0 Yes 0 No

is $Ly,w!!atisthemonthIyamount? If yes, what is the monthlyamount?

______

6. Do you get civil service retirement payments7 0 Yes 0 No

If yes, what is the claim number?

$

_________

If yes,what is the monthly amount? If yes, what is the_monthiyamount?

_______________

H 1200—

Application for benefits 04/2015

_________________J

Texas Health and Human Services Commission Page 14

If yes, wtiat is the daim number?

S

_____ You Spouse-

If yes, what is the claim number? If yes, what is the claim number?

$ $

__

If yes, what is the monthly amount? If yes, what is the monthly amount?

8. Do you have payments or annuities from private insurance? 0 Yes 0 No

If yes, what is the company name?

[jf yes, what is the monthly amount?

Do you get interest from any of the following sources7 DYes 0 No• checking account • savings account• certificate of deposit (CD) • note payment • other

Is $If yes, what is the amount you get? If yes,what is the amount you get?

Llfyes,howorten?

__________

jjyowoften?

_______

10. Do you get dividends from stocks, bonds, or insurance7 C Yes ONo

S $If yes, what is the amount you get! If yes, what is the amount you get?

Ifyes,howoften? Ifyes,howoften?

Ti. Does anyone pTyou rent7 C Yes 0 No


Ifyes,howoften?- Ifyes,howoften? —

Section J

MoneyComing intoYour Home(continued)

7. Do you get any other retirement income’ 0 Yes 0 No

If yes, what is the company name?

$If yes, what is the monthly amount?

$If yes, what is the amount you get?

$If yes, what is the amount you get?

Application for benefitsH 1200

04/2015Page 15Texas Health and Human Services Commission

13. Do you get any money from farming’.0 Yes 0 No

S $If yes, what is the amount you get? If yes, what is the amount you get?

14. Do you get the following types of money fromanyone else or anywhere else? 0 Yes 0 No• cash • gifts • payments you get for loaning money to someone else• bills paid for you • child support • training • othet

If yes, what type of money do you get? If yes, what type of money do you get?

If yes, who do you get the money from and why? If yes, who do you get the money from and why?

S $If yes, what is the amount you get? If yes, what is the amount you get?

If you or your spouse can’t pay medical bills from the past 3 months, Medicaid might paythem. We will look at the money you get and the things you own to find out if Medicaidmight pay them. If you have paid them, you might he able to get paid back by your healthcare provider (doctor, hospital, clinic, etc.).

Do you have any medical bills for services from the past 3 months? DYes 0 NoIf yes, give facts below:


Address of medical service provider

If yes, we need to know about the money you got (income) and things you werepaying for or owned (resources) during those past 3 months.Were they different from what you listed on this form? DYes 0 No

-— Application for benefits

Texas

Health and Human Services Commission

Section J You

MoneyComing intoYour Home(continLLed)

12. Do you get any money from leases or royalties fromoil, gas, mineral, or surface rights1 0 Yes 0 No

Spouse

SIf yes, write the name of the company that pays you.

II yes, what is the amount you get?S

If yes, how often?

If yes, write the name of the company that pays you.

If yes, what is the amount you get?

If yes, how often?

Section K Medical bills from the past 3 months

Save Time

Medical Costs

This section is onlyfor people applying forthefirst time.If you are renewingbenefits, you canskip this section.

Who got the services? 0 You 0 Yourspouse Type of bill: 0 Doctor 0 Hospital 0 Medicine 0 Othet

$ $ If

______

Amount of bill Amount paid Date of service (mm/dd/yy) Who provided the medical service?

Hi 20004/2015

Page 16

Section L

Signing Upto Vote(optional)

Signing up to vote

Applying to register or declining to register to vote will not affect theamount of assistance that you will he provided by this agency.

If you are not registered to vote where you live now, wouldyou like to apply to register to vote here today’ 0 Yes

IF YOU DO NOT CHECK EITHER BOX, YOU WILL BE CONSIDERED TOHAVE DECIDED NOT TO REGISTER TO VOTE AT THIS TIME. If youwould like help in filling out the voter registration application form, we will helpyou. The decision whether to seek or accept help is yours. You may fill out theapplication form in private. If you believe that someone has interfered with yourright to register or to decline to register to ‘ore, or your right to choose your ownpolitical party or other political preference, you may file a complaint with theElections Division, Secretary of State, P0 Box 12060, Austin, TX 78711.Phone 1-800-252-8683.

ONo

Voter Registration c Client declined n Client to mail u Other

: Agency Use Only: c Already registered n Agency transmitted c Mailed to client

StatusAgency staff signat

Social Security number:- Application for benefits

___________


Section K

Save Time

Medical costs you paid in the past yearDid you or your spouse pay any medical bills in rhe past year? C Yes 0 NoIf yes, give facts below;

/Date paid

Medical Costs(continued)

Fill out this sectiononly if you are in a:

• Nursing home.State supportedliving center.State hospital.

• Group home (ICF/MR).Home andcommunity-based

L_!!ram I

$Amount paid

Who got the services?

Type of bill: 0 Doctor

OYou OYourspouse

OHospital 0 Medicine 0 Other

/ / $ Who got the services? OYou QYcurspouse —

Datepaid Amountpaid Typeofbill: ODoctor OHospital 0 Medicine 0O

I / $!

Datepaid Arnountpaid Typeofbill: ODoctor OHospital 0 Medicine 0 Other

/Date paid

$Amount paid

Who got the services?

Type of bill: Ofloctor

OYou OYourspouseOHospital 0 Medicine 0 Other

H 120004/2015

Page 17

Section M

Statement ofUnderstanding

Read thissectionbeforesigning.

Facts HHSC Has About MeHHSC uses facts about people applying forbenefits to decide: (1) who can get benefits,and (2) the amount of benefits. HHSCchecks facts with the federal Income andEligibility Verification System. If any factsdon’t match, HHSC will check other sources(banks, employers, etc.). If anyone applyingfor benefits has an immigration registrationnumber, HHSC must check with the U.S.Citizenship and Immigration Services’(USCIS) system. HHSC will not giveanyone’s facts to USCIS.

In most cases, 1 can see and get facts HHSChas about me. This includes facts I giveHHSC and facts HHSC gets from othersources (medical records, employmentrecords, etc.). I might have to pay to get acopy of these facts. I can ask HHSC to fixanything that is wrong. I do not have to payto fix a mistake. To ask for a copy or to fix amistake, I can call 2-1-1 or my local HHSCbenefits office.

Keeping My Facts PrivateHHSC will keep my facts private ifthey were collected:

• By HHSC staff or contractedprovider staff.

• To find out if I can get state benefits.

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 canbe lowered. HHSC will give them myname, address, and phone number.

Giving Out Facts About MeMedicaid health care providers (doctors,drug stores, hospitals, etc.) might give outfacts about me to HHSC. This will allowthe providers to he paid by Medicaid.

If I Give False InformationIf I choose not to tell the truth, I might:

• Be charged with a crime.

• Have to repay benefits.

The same is true if I let someone else usemy medical card or Medicaid ID.

Medical PaymentsIf I get Medicaid, HHSC will keep medicalservice payments I can get from othersources, such as:

• My health insurance.• Money I got because of injuries.

I must tell HHSC about these sources.If I don’t, I am breaking the law,

HHSC will only keep the amount ofmedical support and service paymentsallowed by law. I will work with HHSC toget these funds.

Reporting ChangesI agree to let HHSC know, within 10 days,about any changes to my case. This includeschanges in facts I give on this form such asmoney I get, things I own or are paying for,where I live, or insurance I have (includinghealth insurance premiums).


I I — I — Application for benefits

_______________J


Hi 20004/2015

Page 18

Notice:Your estate might have to pay the state back for services you get.Medicaid Estate Recovery Program:If you get certain Medicaid long-term services, the state of Texas has the right toask for money back from your estate after you die. In some cases, the state mightnot ask for anything back. The state will never ask for more money back than itpaid for your services.The state can ask for money back from your estate only if: (1) you applied for and receivedcertain Medicaid services on or after March 1, 2005, and (2) you were age 55 or olderwhen you got the services. To Learn more, call 1-800-458-9858.

By signing below, I agree: • To let HHSC and other state, federal, and local agenciescheck, share, and get facts about me or my spouse.

• To let other people, businesses, and organizations sharefacts they have about me or my spouse with HHSC.

• The facts to be checked and shared include anything that helpsdecide: (1) who can get benefits, and (2) the amount of benefits.

My Answers Are True: I certify under penalty of perjury that theinformation I have provided on this application is true and completeto the best of my knowledge. H it is not, I may be subject to criminalprosecution. Sign below to show you agree:

You Spouse

Sign here Date Sign here

__________________

Date

iiyou are a parent, guardian, authorized representative, court appointed administrator,executor, or have power of attorney ior this person, sign below:

Sign here (You must give proof of this right)/ / / I

Date Sign here (You must give proof of this rEght) Date

/ /Sign here if you are a witness (only needed if anyone above signed with an “X” or other mark).

Printed name of witness

Date

-Application for benefits


Did you...1. Include the

“items we need”listed on page D.

2. Sign and datethis page.

Social Security number: Hi 20004/2015

Page 19

qualified medicare beneficiaries (qmb). medicaid for the...

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