Revision 12-1; Effective March 1, 2012


Form H1200-MBIC and new forms have been created for this program. Most of the new forms are pre-populated by the system. These forms are also available in this handbook. If a form is completed manually from this handbook, follow the instructions for that particular form.

Even though a new application has been created for this program, also accept any of the Form H1200 series or H1010 as an application for Medicaid Buy-In for Children (MBIC).

Use the current Form H1020, Request for Information or Action, for missing information. The H1020 instructions are updated to include MBIC program-specific information.

Appendix XLIX, Medicaid Buy-In for Children Forms Chart, outlines the:

  • form name,
  • purpose of each form,
  • naming convention of each form in TIERS, and
  • naming convention of each form in this handbook.

TIERS generates Form TF0001-MBIC for all eligibility notices. The MBIC program has seven notices that will use the TF0001 format in TIERS. Because the TF0001 is a TIERS-generated form, MBIC eligibility notices have a different number in this handbook. The form content is the same.


N-9100 Replacement Medicaid Card

Revision 12-1; Effective March 1, 2012


An individual will only receive one Your Texas Benefits (YTB) Medicaid card, which is intended to be the individual's permanent card. If the individual loses the card, they can get a replacement card by calling 1-800-827-3748.

For a temporary card replacement, use H1027-A, Medicaid Eligibility Verification, or Form H1027-B, Medicaid Eligibility Verification – MQMB. Use H1027-A to replace a lost YTB Medicaid card for MBIC only. Use Form H1027-B to replace a lost YTB Medicaid card for MBIC with QMB. A Form H1027-A or Form H1027-B is provided for the current month only.