Form H1024: Texas Health Steps Self-Declaration Notice Instructions

Form H1024, the Texas Health Steps Self-Declaration Notice, is a letter the Texas Health and Human Services Commission mails during Medicaid renewal when its records show a child in your household has an overdue Texas Health Steps checkup or the family has not completed the required Health Care Orientation.¹ Filling it out and sending it back lets you explain the situation — checkup done, appointment scheduled, or good reason for the delay — so coverage can be renewed by mail instead of forcing you into an eligibility office.²

This is not a denial notice. It’s a request for information before HHSC finalizes the renewal.

Why HHSC Sent It

Two things have to overlap for this form to show up: your household is up for Medicaid renewal, and HHSC’s tracking system has flagged something a caseworker couldn’t clear over the phone.¹ The flag is one of two things, sometimes both:

A Medicaid-certified child in the household has passed the date for a scheduled Texas Health Steps medical checkup.
The household never completed the Health Care Orientation (also called the Introduction to Health Care) that new Medicaid enrollees are asked to do.

Texas Health Steps provides free preventive medical and dental care for Medicaid-enrolled children and young adults age 20 and younger, following a set periodicity schedule.³ If a required checkup was missed at its recommended age, it needs to happen at the first opportunity.⁴ That’s what puts the case in front of a caseworker at renewal.

How to Fill Out the Form

The form arrives by mail with a return envelope. Only the sections that apply to your household will be marked. You respond to those and leave the rest alone.

The Texas Health Steps Section

If this section is checked, it will name the child whose checkup is overdue. Pick one of four options:²

The child had the checkup. Attach a receipt or a note from the doctor’s office showing the date if you have one; it clears the flag faster.
The child is scheduled for the checkup. Use this if an appointment is already booked.
There is a good reason the checkup didn’t happen. Write a brief explanation in the space provided. Transportation problems, a child’s serious illness, or trouble finding a provider with an opening are the kinds of reasons that fit here.
The child did not have the checkup and has no plans to. This confirms noncompliance and can lead to a penalty at renewal.

The Health Care Orientation Section

If this section is checked, the options mirror the Health Steps section:²

You received the Introduction to Health Care.
You are scheduled for the orientation.
You took your child to a doctor or clinic, or have an appointment to do so. A doctor visit counts as satisfying the orientation requirement.
There is a good reason for not completing it. Write the reason in the space provided.
You did not complete the orientation and your child has not seen a doctor or clinic.

The orientation is a one-time step meant to connect newly enrolled families with a provider. If your child has already seen a doctor since enrolling in Medicaid, that visit alone satisfies the requirement. You do not need a separate class.

How and When to Send It Back

Mail is the simplest route — use the return envelope HHSC included. You can also upload documents through your account at YourTexasBenefits.com, drop them off at a local HHSC benefits office, or send them by fax.⁵

Return it quickly. The standard verification window gives a household 10 days to provide requested information.⁶ Miss that window entirely and you may have to visit an eligibility office in person to finish the renewal.² Attachments aren’t strictly required, but a doctor’s printout or appointment confirmation cuts down on follow-up requests.

What Happens After You Return It

Once the caseworker has your form, your answer drives the next step. Saying the checkup happened, is scheduled, or was missed for a good reason generally clears the flag and lets the Medicaid renewal go through by mail. The caseworker updates the record and sets the next Texas Health Steps due date.⁶

Confirming noncompliance, or not returning the form at all, triggers the procedure for starting a Texas Health Steps penalty.⁶ A penalty does not automatically end your child’s Medicaid. Getting the overdue checkup on the calendar, even after the deadline on the form, is the most direct way to resolve the issue.

Scheduling the Overdue Checkup

If a missed checkup is what put you in this position, booking the appointment is the fastest fix. Any pediatrician or primary care doctor who accepts Medicaid can perform a Texas Health Steps checkup. If you don’t have a provider or need help finding one, call 2-1-1 and ask for a Texas Health Steps provider nearby. The checkup is free — there is no copay for Medicaid-enrolled children.

Dental checkups are part of Texas Health Steps starting at six months of age.³ If your child is due for a dental visit too, scheduling both at once avoids another round of notices at the next renewal.

If Your Benefits Are Reduced or Denied

If HHSC reduces or denies Medicaid based on Texas Health Steps noncompliance and you believe the decision is wrong, you have the right to request a fair hearing. The request must be filed within 90 calendar days of the action. To keep benefits going while the appeal is pending, file before the effective date shown on the Notice of Case Action (Form 2065-A) that came with the decision.⁷ You can request a hearing by calling 2-1-1, writing to occ_appeals_fairandfraudhearings@hhsc.state.tx.us, or visiting a local HHSC office.⁸

1
Texas Health and Human Services. Form H1024, Subject – Self-Declaration Notice
2
Your Texas Benefits. Form H1024 Self-Declaration Notice PDF
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Texas Health and Human Services. Texas Health Steps
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Texas Health and Human Services. Texas Health Steps Medical Checkup Periodicity Schedule
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Texas Health and Human Services. Benefits Application Next Steps
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Texas Health and Human Services. Texas Works Handbook
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Texas Health and Human Services. Appeals and Fair Hearings
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Texas Health and Human Services. Fair and Fraud Hearings