Form 2065-A, Notification of Community Care Services

Attachments

Effective Date: 12/2025

• 2065-a-attachment-a.pdf

Instructions

Updated: 12/2025

Purpose

Form 2065-A must be sent to:

• give notice of eligibility for all Community Care Services Eligibility (CCSE) services to the person applying for services;
• give notice of ineligibility for CCSE services;
• give notice of suspension for CCSE services;
• notify the person of the right to a fair hearing and to request a conference;
• notify the person of a change in eligibility or the amount or level of service;
• give notice of a transfer between one type of personal attendant service to another;
• notify the person and provider of the monthly amount of copayment or room and board payment, or both, that the person must pay;
• remind the person that all changes financial, location, and medical condition must be reported to the Texas Health and Human Services Commission (HHSC) caseworker within 10 calendar days; or
• give notification of the retroactive payment plan and dates of prior Medicaid eligibility and advise the person or provider of provider reimbursement, if appropriate.

Procedure

When to Prepare

Prepare this form for all the situations listed above. The form must be sent to the person within specific timelines for the following situations:

**This applies only if the person requested priority status.

For more details or exceptions, review the Community Care Services Eligibility (CCSE) Handbook:

• Appendix IX, Notification Effective Date of Decision
• Appendix XVIII, Time Calculation
• 2652, Changing the Service Schedule Between Reassessments
• 2811, Effective Dates

If the person returns Form 2065-A indicating a desire to appeal or verbally requests a hearing, the caseworker completes Form H4800, Fair Hearing Request Summary, to be entered in the Texas Integrated Eligibility and Redesign System (TIERS) Fair Hearings.

Number of Copies

The caseworker completes an original and enough copies for the person, the provider, if appropriate, and the case record. A residential care facility may need a copy.

Transmittal

The caseworker sends the original and one copy to the person. A copy is also sent to the provider in these situations:

• Day Activity and Health Services (DAHS) facility for denial of a facility-initiated referral;
• Residential Care (RC) provider for notifications about the amount of the person’s copayment and room and board, or when the person is being denied because of failure to pay required fees; and
• Primary Home Care (PHC)/CAS provider when retroactive reimbursement is involved.

The caseworker files the remaining copy in the person's case folder.

Form Retention

The case record copy is retained for three years after the case is closed.

Detailed Instructions

Demographic

Date — The caseworker enters the date the form is completed and mailed to the person. This is the completion date and is considered as day zero for timeframe calculation.

HHSC Caseworker — Enter the caseworker’s name.

Office Address, Area Code and Phone No. — Enter the caseworker's office address, area code and phone number. Type or print information legibly.

Person’s Name and Address — Enter the person's name and mailing address. 

Notification of Community Care Services Sections

Notification of Eligibility

Check this item if the person is being notified of service eligibility. In the comments box, enter the amount of each specific service being approved, the unit of service per day, per week, per month and effective date of the service. Do not enter the number of days of service per week, except for DAHS.

Required Payments: Room and Board — Check this box if the person is being notified of a required room and board amount. Enter the amount of the payment and when it is to be paid. The first entry is for a partial month prorated amount and the second entry is for the ongoing monthly amount. If the person enters on the first of the month, both amounts are the same. Example: You must pay $210 on May 1, 2017, then $230 per month effective June 1, 2017.

Required Payments: Copayment — Check this box if the person is being notified of a required copayment. Enter the amount of the copayment and when it is to be paid. The first entry is for a partial month prorated amount and the second entry is for the ongoing monthly amount. If the person enters on the first of the month, both amounts are the same. Example: You must pay $210 on May 1, 2017, then $230 per month effective June 1, 2017.

Notification of Ineligibility, Termination or Suspension of Services

Check this box if a person is not eligible for a CCSE service or if a CCSE service is being terminated or suspended.

• Check the first box in this section if an application or request for a new service is being denied. Enter the name of the service being denied and the reason for ineligibility.
• Check the second box in the section if ongoing services are being terminated. Enter the name of the service being terminated and the last day the person will receive services. Enter the cause of ineligibility.
• Check the third box if services are being suspended. Enter the name of the service and the last day services will be delivered. Enter the reason for the suspension. In the comments section, provide more information about the suspension.

Review Appendix XVIII, Time Calculation, for more information.

Record the cause of ineligibility when completing Form 2065-AS, the Spanish version. Staff may use Attachment A of Form 2065-A for a Spanish translation if not fluent in Spanish.

Rule/Handbook Reference — Enter the rule reference, unless one is not available, then use CCSE Handbook reference reflecting the reason for denial or termination.

Your ________________services will continue without interruption — Check this box and enter the name of any other services the person is eligible for that are not being terminated and will continue.

Notification of Change

Check this box if a service plan change is being made. Enter the service being affected, the amount of service currently being received, the amount of service to be delivered once the change is effective and the effective date. For a reduction in service, the effective date is the first date the reduction will be in effect. Example: The service you have been receiving, 20 hours of Family Care, is changing to 15 hours of Family Care starting May 1, 2017. Example: The service you have been receiving, 30 hours of Community Attendant Services, priority status, is changing to 30 hours of Community Attendant Services, non-priority status.

Note: The completion date of Form 2065-A is counted as day zero. The next day is day one and 12 calendar days are allowed for a decrease notification. For decreases if the last day of any period is a Saturday, Sunday or legal holiday, the period is extended to include the next day that is not a Saturday, Sunday or legal holiday.  Skeleton crew days are not legal holidays. Legal holidays are days when the agency is closed.

Notification of Change in Copayment/Room and Board

Check this box to notify the person of a change in the copayment or room and board amount, regardless of if an increase or decrease is involved. Enter the new amount, and the date the payment of the new amount is effective. Example: Your copayment will change to $330 per month beginning June 1, 2017.

Comments

Enter any appropriate comments about the person's eligibility.

Signature and Date— The HHSC caseworker must sign and date Form 2065-A. The date of the HHSC caseworker's signature should match the date Form 2065-A was completed and mailed, as shown in the date box at the top of the form.

Name — Enter the name of the person from Page 1.

Number — Enter the person's identification number. This is the individual number, Medicaid number or individual number assigned through TIERS or the Service Authorization System (SAS).

Request for Fair Hearing — The person checks the box if they wish to appeal. The person signs, prints their name, dates the form, and returns it to the HHSC caseworker.

Caseworker’s Name and Phone No. — Enter the name, area code and phone number of the caseworker assigned to the applicant's or person's case.

Supervisor's Name and Phone No. — Enter the name, area code and phone number of the caseworker's supervisor.

Program Manager's Name and Phone No. — Enter the name, area code and phone number of the program manager.