Documents

Instructions

Updated: 3/2011

Purpose

To serve as an application form for Medicaid Buy-In for Children (MBIC) benefits. Staff will also use Form H1200-MBIC for reviews. This program is processed in the Texas Integrated Eligibility Redesign System (TIERS).

Procedure

When to Prepare

The applicant/recipient or his/her authorized representative completes one copy of Form H1200-MBIC and returns it to the Document Processing Center (DPC) or the local office. If the local office receives this application, it should be forwarded to DPC.

Form Retention

The system retains a copy for the electronic case record. If the form needs to be completed manually, the form will need to be imaged and will then be available in the electronic case record.

Detailed Instructions

Section 1. Child applying for benefits– This section requests identifying information for each child applying for benefits. If more than two children are applying, additional sheets with the information may be attached.

For HHSC staff use only(Bottom of Page 1) – The following items are completed by staff after the form is returned:

Application or Redetermination  — Check the box to indicate whether the form is from an applicant or a recipient.

Date Form Received — Enter the date the completed form is received.

Case number  — Enter the case number in the system.

MBIC EDG number  — Enter the eligibility determination group (EDG) number in the system.

MBIC EDG number  — If more than one child, enter additional EDG numbers.

Section 2. Parents living with the child— This section requests identifying information about the parent or parents in the home. It also requests employment and employment-related health insurance information. Information must be completed for each parent. The identifying information for parents is self-explanatory.

Employment and health insurance information — This information can be provided by the employer or the parent.

Do you want this parent's employer to answer these questions? — The parent must check the yes or no box. If the parent checks yes, the parent must give Form H1028-MBIC, Employment Verification (attached to the Form H1200-MBIC application/review packet) to the employer to complete and return to HHSC. If the parent checks no, the parent must complete the employment and employment-related health insurance coverage section and provide verification of this information.

Section 3. Brothers and sisters living with the child — This section requests information about any brothers or sisters age 21 or younger living in the same home with the child(ren) applying. If no is checked, skip to Section 4. If yes is checked, complete the identifying information for each brother or sister who meets that criterion.

Section 4. Other health insurance— This section requests information about health insurance that is currently covering or may have covered any of the children applying for benefits. This may include health insurance paid for by a spouse or ex-spouse not in the home. Health insurance paid by a parent not living in the same household (e.g. divorce situation) as the child(ren) applying for benefits is treated like a third party insurance.  This is not considered employer-sponsored insurance.

Section 5. Medical bills— This section requests information about medical bills for medical services the child(ren) applying may have in the three months before the application date.

Section 6. Money not from a job— This section requests information about other money received by the child(ren) applying, parents, brothers/sisters (age 21 or younger) living with the child. An example of “other income not from a job” is child support received for the child(ren) applying or brothers/sisters (age 21 or younger) in the household.

Section 7. Authorized representative— Self-explanatory.

Section 8. Signing up to vote— Self-explanatory.

Section 9. Legal information— Self-explanatory.

Section 10. Statement of understanding— Self-explanatory.

Section 11. Penalty statement— Self-explanatory.

Section 12. Sign and date the form— If the applicant/applicants are age 17 or younger, a parent must sign the form. If the applicant/applicants have a legal guardian, only the legal guardian can sign on their behalf.

 


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