Revision 12-4; Effective December 1, 2012
Use the current Form H1020, Request for Information or Action, for missing information.
MBI Program forms include:
- Form H0051, Premium Payment Notice – Used to inform the client that the MBI premium is due.
- Form H0052, Refund Notice – Used to notify the client that a partial premium payment has been received which will be returned in 60 days, since the full month's premium must be received in one payment.
- Form H0053, Potential Eligibility Notice – Used to notify the client of potential eligibility for the MBI program.
- Form H0054, Eligibility Notice – Used to notify the applicant of the eligibility for the MBI program.
MBI has its own Form H1200 series application – Form H1200-MBI, Application for Benefits – Medicaid Buy-In. This form provides applicants a designated application that collects information specifically for the MBI program. Form H1200 marked as MBI will continue to be accepted as an application for MBI.
The Form H1200-MBI application, available in both English and Spanish, is at:
Appendix XXXIX, MBI Screening Tool and Worksheets, is used to assist in completing the processing of the MBI application.
Revision 16-3; Effective September 1, 2016
Your Texas Benefits Medicaid ID card will only be replaced if the card is damaged, lost or stolen. If an individual requests a replacement of their Your Texas Benefits Medicaid ID card, issue a Form H1027-A.
Note: Inform the recipient to call 1-855-827-3748 for a replacement card.