Texas Medicaid Estate Recovery Program Receipt Acknowledgement
This file provides information about the Texas Medicaid Estate Recovery Program and its impact on long-term care services. It explains how the program works, when the state may ask for money back, and the exceptions and hardships considered. The form also includes instructions on how to acknowledge receipt of the information.
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How do I fill this out?
To fill out this form, you need to provide the required details and acknowledge receipt of the information. Carefully read through the provided instructions and information about the Medicaid Estate Recovery Program (MERP). Ensure all necessary fields are completed before submitting the form to the appropriate authority.
How to fill out the Texas Medicaid Estate Recovery Program Receipt Acknowledgement?
1
Read the information about MERP carefully.
2
Fill in the required fields, such as your name and Medicaid ID or Social Security number.
3
Acknowledge receipt of the information by signing the form.
4
If applicable, have the responsible person sign and date the form.
5
Submit the completed form to the appropriate authority.
Who needs the Texas Medicaid Estate Recovery Program Receipt Acknowledgement?
1
Individuals applying for long-term care services paid by Medicaid need this form to acknowledge receipt of information about MERP.
2
Medicaid recipients over the age of 55 who are using long-term care services need this form to understand how MERP may impact their estate.
3
Family members or responsible persons of Medicaid recipients may need this form to provide their signature and relationship information.
4
Case managers and eligibility specialists need this form to ensure that Medicaid recipients have been informed about MERP.
5
Estate representatives and heirs may need this form for reference in case the state files a MERP claim.
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1
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2
Use the PDF editor to fill in the required fields and make any necessary changes.
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Save the edited PDF to your device.
4
Review the completed form for accuracy.
5
Submit the edited PDF to the appropriate authority.
What are the instructions for submitting this form?
To submit this form, fill out all the required fields and sign it. You can submit the form via email to merp@hhsc.state.tx.us, fax it to the appropriate number provided by your case manager, or mail it to the Texas Health and Human Services Commission at P.O. Box 13247, Austin, TX 78711-3247. For online submissions, visit the HHSC website and follow the instructions provided. It is advisable to keep a copy for your records and ensure all information is accurate before submission.
What are the important dates for this form in 2024 and 2025?
This form affects long-term care services received after the age of 55 and only if applied after March 1, 2005. These dates are essential for determining the applicability of the Medicaid Estate Recovery Program (MERP) to an individual's estate. Always check for the most current dates and guidelines with your case manager or the health plan provider.
What is the purpose of this form?
The purpose of this form is to inform individuals applying for long-term care services paid by Medicaid about the Medicaid Estate Recovery Program (MERP). It ensures that applicants understand how the program works, when the state may request repayment from their estate, and the exceptions and hardships considered. By signing this form, individuals acknowledge receipt of this important information and confirm their understanding of the program.
Tell me about this form and its components and fields line-by-line.
- 1. Name of Applicant or Individual: Enter the full name of the applicant or individual receiving long-term care services.
- 2. Medicaid ID or Social Security No.: Provide the Medicaid ID or Social Security Number of the applicant or individual.
- 3. Printed Name - Individual: Print the name of the individual acknowledging receipt of the information.
- 4. Signature: The individual must sign the form to acknowledge receipt of the information about MERP.
- 5. Date: Enter the date when the form is signed.
- 6. Printed Name - Responsible Person: If applicable, the responsible person should print their name.
- 7. Relationship to Individual: Specify the relationship of the responsible person to the individual, if not the individual themselves.
- 8. Printed Name - Case Manager: The case manager should print their name if they provided the form.
- 9. Signature: The case manager must sign the form if they provided it.
- 10. Date: Enter the date when the case manager signs the form.
What happens if I fail to submit this form?
Failure to submit this form will not result in denial of Medicaid services. However, the state may still file a claim against your estate after you die, unless exemptions or hardships apply.
- State Claim: The state may file a claim against your estate after you die.
- Exemptions and Hardships: Certain exemptions and hardships can prevent the state from filing a claim, so failure to submit the form may impact these considerations.
How do I know when to use this form?
- 1. Application for Long-term Care Services: Submit this form when applying for Medicaid-funded long-term care services to acknowledge receipt of MERP information.
- 2. Informing Heirs: Use this form to inform your estate representatives and heirs of the potential for state claims against your estate after your death.
Frequently Asked Questions
What is this form for?
This form is for acknowledging receipt of information about the Texas Medicaid Estate Recovery Program (MERP).
Who needs to fill out this form?
Individuals applying for long-term care services paid by Medicaid and their family members or representatives need to fill out this form.
How do I fill out this form?
Read the information about MERP, fill in the required fields, sign the form, and submit it to the appropriate authority.
Can I edit this form online?
Yes, you can use PrintFriendly's PDF editor to fill in and edit the form online.
Can I sign this form digitally?
Yes, PrintFriendly allows you to sign your PDFs digitally using our editor.
How can I share the completed form?
You can share the completed form via email or direct link using PrintFriendly's sharing feature.
Is there a toll-free number I can call for more information?
Yes, you can call the agency's toll-free number at 1-800-641-9356 for more detailed information.
What happens if I don't sign this form?
Your application for Medicaid services will not be denied if you choose not to sign the form; however, the state may still file a claim against your estate after you die.
Are there any exceptions for hardship?
Yes, the state may grant a hardship waiver in certain circumstances to prevent undue hardship for the heirs.
What are the important dates for this form?
This form affects only long-term care services received after the age of 55 and applies to applications submitted after March 1, 2005.
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