Texans can dial 2-1-1 (option 6) for information on COVID-19 and local community resources on health care, utilities, food, housing and more. More COVID-19 information.
Downloading a Form to Your Computer
Fillable forms cannot be viewed on mobile or tablet devices. Follow the steps below to download and view the form on a desktop PC or Mac.
- Right Click for PC or Ctrl + Click for Mac on the PDF link and click “Save link as” from the menu.
- Select the folder you want to save the file in and then click "Save."
- Navigate to the folder you saved the file in and Right Click for PC or Ctrl + Click for Mac, then select "Open With" from the menu and select Adobe Acrobat Reader DC.
Note: Open the PDF file from your desktop or Adobe Acrobat Reader DC. Do not click on the downloaded file at the bottom of the browser since it will not open the PDF in Adobe Acrobat Reader DC. It will try to open the file in the browser that results in the same browser error message.
If still having trouble viewing or downloading a form, click here.
The notice is prepopulated and automatically generated out of TIERS on the first of every month and mailed directly to the individual.
To notify applicants they must:
- mail the Medicaid Buy-In premium by the 20th of the month for Medicaid eligibility to continue for the following month; and
- return the prepopulated coupon attached to the bottom of the notice, along with a full month's premium, in the enclosed postage-paid envelope.
When to Prepare
The notice is prepopulated and automatically generated out of the Texas Integrated Eligibility Redesign System (TIERS) on the first of every month and mailed directly to the individual. In situations where the individual has lost Form H0051 and/or the envelope, Medicaid for the Elderly and People with Disabilities (MEPD) staff with TIERS access will print Form H0051 from Correspondence, View History Corres, on the left navigation bar. MEPD staff may mail Form H0051 or give it directly to the individual, along with a postage-paid envelope, if the individual is in the office. If the individual requests that Form H0051 be mailed, enclose a prepaid envelope. Postage-paid envelopes will be available in all field offices.
Number of Copies
Staff with TIERS access can print a copy, if an individual requests one. Staff may mail it or give it directly to the individual.
The notice is automatically generated out of TIERS monthly and mailed directly to the individual, along with a postage-paid envelope addressed to the following:
P.O. Box 650868
Dallas, TX 75265-9843