Form H0005, Policy Clarification Request (PCR)

Instructions

Updated: 8/2025

Purpose

To get a case-specific policy clarification or interpretation for Medicaid for the Elderly and People with Disabilities (MEPD) and Texas Works (TW) programs.

Procedure

Eligibility field staff and stakeholders use this form to request a case-specific policy clarification or interpretation. Eligibility field staff and their supervisor must review all applicable policy sources such as handbooks, bulletins, and previous policy clarifications, before submitting a request for a policy clarification. If the appropriate action cannot be determined, the requestor submits this form electronically to the Field Policy Services and Support Unit to request a case-specific policy clarification. Service Improvement Program (SIP) coordinators and specialists, Appeals and Mitigation (A&M) staff, and others may also use this form to request a case-specific policy clarification. SIP and A&M staff should follow their established procedures to request case-specific policy clarifications from the field policy specialists (FPS) or case analyst.

Other HHSC state office staff, including Quality Management Support, Ombudsman, legal, or training, may also use this form to request a case-specific policy clarification.

The requestor ensures the form is completed accurately including all mandatory fields and relevant information. The requestor is contacted if more information is needed.

If the Field Policy Specialist determines that more research or direction is needed, the request for clarification is escalated to Program Policy for review.

Number of Copies

If the response on the clarification is pertinent to the eligibility determination, staff must image the request and subsequent response on the form into the electronic case record.

Transmittal

Email the form as an attachment to the designated mailbox per program area.

Include a descriptive email title with the appropriate handbook section. Example: F-1231, Funds for a nonprofit organization or SNAP: A-1822, E-signature on H1808 valid. Indicate Urgent if a response is needed within one to two business days. Example: Urgent SNAP: A-231, SNAP HH Comp Joint.

Detailed Instructions

*Program Type (Mandatory Field) — Select the program relevant to the policy clarification. If multiple programs should be selected, complete a separate request for each program.

Section 1 – Policy Clarification Requestor

Use this section to contact the person requesting policy clarification.  

Requestor’s Last and First Name — Enter the name of the person requesting the policy clarification.

Email Address — Enter the requestor’s email address.

Requesting Area — Select the area requesting the policy clarification.

Region No. — Enter the region requesting the policy clarification.

Date — Enter the date the policy clarification is requested.

Section 2 – Policy Clarification Reviewer

Supervisory or other reviewer staff complete Section 2 after reviewing the policy clarification request.

Reviewer’s Last and First Name — Enter the first and last name of the person reviewing the policy clarification. Check box to confirm the review.

Email Address — Enter the reviewer’s email address.

Section 3 – Complete Case Details

The requestor completes this section to provide case-specific details.

*Case Name (Mandatory Field) — Enter the head of household’s (HOH) name if the request is about the household. Enter the name for the eligibility determination group (EDG) if the request is about a specific EDG number. Enter General Question in the field if the request relates to a general question.

Client No. — Enter the number related to the client.

Application or Case No. — Enter the number related to the case.

EDG No. — Enter the number related to the specific program received by the client.

*File Date (Mandatory Field) — Enter the date the application, redetermination or change was received. Enter not applicable for General Question

*Type of Assistance (Mandatory Field) — Select at least one type of assistance (TOA) most relevant to the case and clarification request. Select Other and indicate all programs or a specific, unlisted TOA.

Urgent — Only select Yes when an expedited response is needed such as, cases with expedited processing time frames or cases that are past due. Select No for all other requests.

Reason for Urgency —Briefly explain the reason for the urgent request, if selecting Yes above. Examples of urgent scenarios include:

• SNAP Expedites
• Case action with final due date in the next two business days
• Complaints - HEART, legislative, Ombudsman
• Appeals and Mitigation with hearing scheduled

Section 4 – MEPD Only

If the requestor selected MEPD as the program type at the top of the form, the requestor completes Section 5 with any relevant attorney information.

External Attorney or Estate Planner— Provide the attorney’s information along with any legal paperwork about the case the attorney has prepared if:

• an external attorney has contacted the eligibility field staff; or
• the person has an attorney involved.

All legal documents should be reviewed by the regional attorney before the policy clarification request is submitted to the MEPD Policy Support mailbox.

Was the agency attorney consulted to review documents? — Select Yes or No.

Name of HHS Regional Attorney — Enter the HHS regional attorney’s name.

Area Code and Phone No. — Enter the HHS regional attorney’s phone number.

Regional Attorney’s Response - Include any electronic correspondence or documents with the request. — Enter a summary of the HHS regional attorney’s response. Either the program specialist or regional attorney can summarize information, as appropriate.

Section 5 – Policy Questions and Substantiating Documentation

The requestor completes Section 5 to provide case-specific research.

Policy Topic — Type a brief description of the policy subject. Example: Income Verification, Alien Status, Dependent Deduction Allowance.

Check the box to confirm SAVE inquiry was requested if the specific policy topic is about alien status. Include or attach a screenshot of SAVE response to the e-mail request.

Case Situation — Provide specific information on all relevant and essential information such as what, when, why, how. Include the program type, applicable household, or budgeting situation such as individual, couple, spousal, and any relevant bulletins or previous policy clarifications. Note: If the request is the result of an IT or Help Desk ticket, include the relevant email and reference number.

Examples:

• SPRA month is November 2018. Total resources as of Nov. 1, 2018, were $96,516.43; SPRA was $48,258.21. Worker could not expand the SPRA because the community spouse was receiving monthly earnings of $5,879.79. Total resources as of Dec. 1, 2018, were $86,294.16. The person was ineligible due to excess resources. Community spouse lost their job in January 2019. Case was certified in error on Feb. 9, 2019, with a medical effective date of Dec. 1, 2018, and is still active.
• Household includes mom and her three children. Mom is applying for SNAP but has an open SNAP E&T sanction. Mom is now considered an ineligible student and TIERS is attempting to close her SNAP E&T sanction before the penalty period is over.

Specific Policy Question — Provide the specific policy question needed to address the case situation.

Examples:

• What is the correct way to handle this case?
• Should the case be denied, and the person asked to reapply. In this case only the resources in the person’s name are countable?
• Could the SPRA be expanded in January or February after the spouse lost his job?
• Should the SNAP E&T sanction be closed?
• What time frame is a practitioner’s signature valid on Form 3052 for CAS?

Policy References Related to this Case-Specific Clarification — Identify all applicable handbook sections or policy material the requestor, supervisor and PCC reviewed. Do not quote or paste the entire sections of the handbook on the form. Include a proposed response on how the reviewed policy applies to the policy question.

Example: Per TWH A-340, Chart B, under Medical Programs I-551 with code DV, is not mentioned. Nor is it mentioned in any of the following policy. It is unclear if the code DV grants individual’s approval for medical benefits.

Section 6 – Field Policy Response

Select the appropriate Field Policy program area completing Section 7 to provide a response.

Field Policy Specialist — Enter the name of the program specialist providing the response.

Date of Response — Enter the date the response is completed.

Handbook Section(s) — Enter handbook sections used to provide the response.

Other Policy Sources — Enter any bulletins, broadcasts, job aids or other policy sources used to provide the response.

Case-Specific Response — Explain the case-specific relevance of the citations of any listed handbook sections or other policy sources.

Section 7 – Program Policy Response, if applicable

Program policy staff complete Section 7 to provide a response. If the question was escalated to program policy, this section contains the final response. If the question was not escalated to program policy, the answer in Section 6 i considered final.

Date of Response — Enter the date the response is completed

Handbook Section(s) — Enter handbook sections used to provide the response.

Other Policy Sources — Enter any bulletins, broadcasts, job aids or other policy sources used to provide the response.

Case-Specific Response — Explain the case-specific relevance of the citations of any listed handbook sections or other policy sources.