Effective Date
Instructions
Updated: 10/2026
Purpose
- Serves as verification that a person requesting medical programs has undue financial or medical hardship that would cause serious deprivation.
- Identifies specific deprivation such as loss of necessary medical care that could endanger life or health or loss of basic living necessities. Necessities include food, clothing, shelter or other essentials of daily living.
Procedure
When to Prepare
Staff send the form to each household member with excessive lottery and gambling winnings. The household member completes all items on the form to show that they have undue hardship and provide proof.
Number of Copies
Complete an original.
Transmittal
Include the original in your revision notice.
Detailed Instructions
Section 1 – Personal Information
Applicant or Recipient’s Full Name — Enter the first and last name, and middle initial of the person requesting undue hardship.
Social Security No. — Enter the applicant or recipient’s Social Security Number of the person requesting undue hardship.
Date of Birth — Enter the applicant or recipient’s date of birth of the person requesting undue hardship.
Address — Enter the applicant or recipient’s street address, City and ZIP code of the person requesting undue hardship.
Area Code and Phone No. — Enter the applicant or recipient’s phone number of the person requesting undue hardship.
Reason for Undue Hardship Exemption Request — Enter the reason for the undue hardship request for excessive lottery or gambling winnings.
When large winnings are prorated over multiple months, they can artificially inflate income and terminate eligibility. Therefore an undue hardship exception may be considered if counting that prorated income would:
- Deny access to necessary medical care
- The person cannot afford needed care without Medicaid
- No other coverage or resources are available
- Loss of coverage would threaten health or life
- Leave the household unable to meet basic living needs
- Without Medicaid eligibility, the household would lack:
- Food
- Housing
- Clothing
- Other essentials
- Without Medicaid eligibility, the household would lack:
Signature and Date— The person requesting undue hardship signs and dates the form.
HHSC Agency Use Only – Decision
HHSC staff:
- Review the form and proof given.
- Check either approved or denied for the undue hardship exemption after the review.
- Enter the reasoning behind the decision which is supported by the proof received.
- Print their name and sign and date the form.