Downloading a Form to Your Computer

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Effective Date: 

Availability

 

The notice is prepopulated and automatically generated out of TIERS on the first of every month and mailed directly to the individual.

 

Instructions

Updated: 12/2016

 

Purpose

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.

 

Procedure

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.

 

Transmittal

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:

Medicaid Buy-In
P.O. Box 650868
Dallas, TX 75265-9843