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Blank Texas H1200 Mbic PDF Template

The Texas H1200 Mbic form is an application used to request benefits from the Medicaid Buy-In for Children program. This program provides financial assistance for medical expenses to families with children who have disabilities and earn too much to qualify for traditional Medicaid. By completing this form, families can access vital healthcare support for their children under the age of 18.

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Contents

Form Example

Texas Health and Human	Form H1200MBIC
Services Commission	Cover Letter
	March 2011

Application for Benefits – Medicaid BuyIn for Children

About this program:

Medicaid BuyIn for Children can help pay medical bills for children with disabilities.

This program helps families who make too much money to get traditional Medicaid.

To get benefits:

ｸThe child must be age 18 or younger.

ｸThe child must meet the same rules for a disability that are used to get Supplemental Security Income (SSI).

ｸIf a parent’s employer pays at least half of the annual cost of health insurance, the parent must sign up and keep that insurance.

ｸThe family must meet income limits set by the program.

ｸThe family might have to pay a monthly fee.

How to apply:

1.Fill out this form. You can ask a friend or family member to help you.

2.Answer each question on the form. If a question does not apply to you, write “none” for the answer.

3.Sign and date Page 6.

4.Send copies of the following items (don’t send originals). We only need items that apply to your case.

ｸProof of money from a job: Pay stubs or earning statements.

ｸProof of money not from a job (veterans benefits, Social Security income, etc.): Award letters.

ｸMedical costs: Bills or statements from health care providers (doctors, hospitals, drug stores, etc.) from the past 6 months.

How to send in your application and items we need:

Fax: 18774472839. If your form is 2sided, fax both sides.

Mail: Health and Human Services Commission, P.O. Box 14600, Midland, TX 797114600.

After we get your form, we will check to see if you can get benefits. Someone might contact you if we need more information. We will let you know the decision within 45 days.

You can get free legal help if you need it. Call your local benefits office to find out where to get free legal help in your area.

Questions?

Call or visit an HHSC benefits office. To find an office near you, call 211 (tollfree).

211 also can answer questions about this program. When you call: (1) pick a language and then

(2) pick option 2.

Texas Health and Human

Form H1200MBIC

Services Commission

March 2011

Application for Benefits – Medicaid BuyIn for Children

1. Child applying for benefits

1st child applying for benefits

First name

Middle initial

Last name

Social Security number

Is the child married?

Yes

Home address – street and number

City, state, and ZIP

County

Home phone

Mailing address (if different) – street and number

City, state, and ZIP

County

Cell phone

Birth date (mm/dd/yy)

Is the child:

Does the child live in Texas?

Does the child plan to stay in Texas?

Male

Female

Yes

If the child is not a U.S. citizen:

Is the child a U.S. citizen?

Is the child a refugee or legally admitted immigrant?

Yes

Is the child registered with the U.S. Citizenship and Immigration Services?

Yes

If yes, give immigrant registration number:

The child is: (mark one or more)

American Indian or Alaska Native

Native Hawaiian or Pacific Islander

Asian

White

Black or AfricanAmerican

Hispanic or Latino

2nd child applying for benefits

First name

Middle initial

Last name

Social Security number

Is the child married?

Yes

Home address – street and number

City, state, and ZIP

County

Home phone

Mailing address (if different) – street and number

City, state, and ZIP

County

Cell phone

Birth date (mm/dd/yy)

Is the child:

Does the child live in Texas?

Does the child plan to stay in Texas?

Male

Female

Yes

Is the child a U.S. citizen?

If the child is not a U.S. citizen:

Yes

Is the child a refugee or legally admitted immigrant?

Yes

Is the child registered with the U.S. Citizenship and Immigration Services?

Yes

If yes, give immigrant registration number:

The child is: (mark one or more)

American Indian or Alaska Native

Native Hawaiian or Pacific Islander

Asian

White

Black or AfricanAmerican

Hispanic or Latino

If more than 2 children are applying for benefits, add more pages.

For HHSC staff use only

Application

Redetermination

Date Form Received	Case number

MBIC EDG number	MBIC EDG number

Form H1200MBIC

Page 2 / 032011

2. Parents living with the child

Items marked “optional” can help us work your case better.

1st parent

First name

Middle initial Last name

Social Security number (optional)

Do you live with the child?

Yes No

Are you:

Male

Female

Birth date (optional)

The following questions are about the 1st parent’s job and their job’s health insurance.

Do you want this parent’s employer to answer these questions?

Yes

If yes, give the attached "Employment Verification" (Form H1028MBIC) to your employer. Ask your employer to fill out the form and send it to us. If you need another form, make a copy.

If no, please give facts below. If this parent has more than one job, add more pages.

Employer’s name and address

Gross amount paid (before taxes are taken out)	How often are you paid? (once a week, twice a month, etc.)				Does your job have health insurance?
$					Yes	No

Does the child applying for benefits get health insurance coverage through your job?							Yes	No
If no, answer the following question, then go to the next section:
If your job has insurance and your child isn’t on it, what is the next date you could enroll your child?
If yes, answer the next 6 questions:
If yes, answer the next 6 questions:

1. What date did insurance coverage start?			4.	What is your policy number?

2. How much do you pay for the insurance?			5.	What is the insurance company’s name?
$

3. Does your employer pay at least half of the premium			6.	What is the insurance company’s address?
(this is usually a monthly payment)?	Yes	No

2nd parent

First name

Middle initial Last name

Social Security number (optional)

Do you live with the child?

Yes No

Are you:

Male

Female

Birth date (optional)

The following questions are about the 2nd parent’s job and their job’s health insurance.

Do you want this parent’s employer to answer these questions?

Yes

If yes, give the attached "Employment Verification" (Form H1028MBIC) to your employer. Ask your employer to fill out the form and send it to us. If you need another form, make a copy.

If no, please give facts below. If this parent has more than one job, add more pages.

Employer’s name and address

Gross amount paid (before taxes are taken out)	How often are you paid? (once a week, twice a month, etc.)				Does your job have health insurance?
$					Yes	No

Does the child applying for benefits get health insurance coverage through your job?							Yes	No
If no, answer the following question, then go to the next section:
If your job has insurance and your child isn’t on it, what is the next date you could enroll your child?
If yes, answer the next 6 questions:
If yes, answer the next 6 questions:

1. What date did insurance coverage start?			4.	What is your policy number?

2. How much do you pay for the insurance?			5.	What is the insurance company’s name?
$

3. Does your employer pay at least half of the premium			6.	What is the insurance company’s address?
(this is usually a monthly payment)?	Yes	No

Form H1200MBIC

Page 3 / 032011

3. Brothers and sisters living with the child

Does a child applying for benefits have any brothers or sisters who are:

(a)age 21 or younger, and (b) living in the same home? If no, skip this section.

Yes

If yes, give facts below. Add more pages, if needed. Items marked “optional” can help us work your case better.

Brother	Sister

First name			Middle initial	Last name

Social Security number (optional)			Birth date (optional)				Does this person have a job?
							Yes	No

If this person has a job, give employer’s name and address:						Gross amount paid		How often paid?
						(before taxes are taken out)		(once a week, twice a month, etc.)
						$

If age 18 to 21:					If yes, when will this person finish?
Is this person in school or training for a job?					You will need to send proof that this person is in school or training.
	Yes	No

Brother

Sister

First name		Middle initial	Last name

Social Security number (optional)		Birth date (optional)				Does this person have a job?
						Yes	No

If this person has a job, give employer’s name and address:					Gross amount paid		How often paid?
					(before taxes are taken out)		(once a week, twice a month, etc.)
					$

If age 18 to 21:				If yes, when will this person finish?
Is this person in school or training for a job?				You will need to send proof that this person is in school or training.
Yes	No

Brother

Sister

First name

Social Security number (optional)

Middle initial	Last name

Birth date (optional)

Does this person have a job?

Yes No

If this person has a job, give employer’s name and address:

If age 18 to 21:

Is this person in school or training for a job?

Yes No

Gross amount paid	How often paid?
(before taxes are taken out) (once a week, twice a month, etc.)

If yes, when will this person finish?

You will need to send proof that this person is in school or training.

Brother

Sister

First name

Social Security number (optional)

Middle initial	Last name

Birth date (optional)

Does this person have a job?

Yes No

If this person has a job, give employer’s name and address:

If age 18 to 21:

Is this person in school or training for a job?

Yes No

Gross amount paid	How often paid?
(before taxes are taken out) (once a week, twice a month, etc.)

If yes, when will this person finish?

You will need to send proof that this person is in school or training.

Form H1200MBIC

Page 4 / 032011

4. Other health insurance

The following question is about health coverage other than Medicaid, Medicare, or your job’s insurance:

Does anyone pay now, or has anyone paid in the past year,

for health coverage for the child applying for benefits?

Yes

If yes, tell us the following:

Name of insurance company

Policy number

Address of insurance company

Coverage start date	Coverage end date

5. Medical Bills

Medicaid sometimes can pay for medical services you got 3 months before you applied.

Does the child applying for benefits have medical bills for services they got in the past 3 months?

Yes

If yes, send:

(1)Copies of medical bills from the past 3 months.

(2)Proof of money you got (income) from the past 3 months.

6.Money not from a job

Tell us about any other types of money you get. If you need more room, add more pages.

Attach proof of the money you get (award letters or earning statements). We might not count some of the money you get.



	Money the child		Money the parents, and brothers and sisters age 21 or younger,
	applying for benefits gets:			who live with the child get:

	Monthly amount		Monthly amount
	(before taxes are		(before taxes are
Type of money	taken out)	Who pays the money?	taken out)	Who pays the money?	Who gets the money?

Social Security	$		$

Veterans benefits	$		$

Railroad retirement	$		$

Civil service	$		$

Pension	$		$

Annuity	$		$

Interest	$		$

Farm income	$		$

Mineral / Royalty	$		$

Gifts	$		$

Other income not	$		$
from a job	$		$
from a job

Form H1200MBIC

Page 5 / 032011

7. Authorized representative

An authorized representative can act for the person applying for benefits by:

ｸGiving and getting facts related to the application.

ｸTaking any action needed to complete the application process. This includes appealing an HHSC decision.

ｸTaking any action related to getting benefits. This includes reporting changes.

If the child applying for benefits has an authorized representative, tell us about that person:

Name of authorized representative

Mailing address

Phone

()

8.Signing up to vote

The following is for anyone age 17 years and 10 months or older:

Applying to register or declining to register to vote will not affect the amount of assistance that you will be provided by this agency.

If you are not registered to vote where you live now, would you like to apply

to register to vote here today? ..........................................................................................................................

Yes

IF YOU DO NOT CHECK EITHER BOX, YOU WILL BE CONSIDERED TO HAVE DECIDED NOT TO REGISTER TO VOTE AT THIS TIME. If you would like help in filling out the voter registration application form, we will help you. The decision whether to seek or accept help is yours. You may fill out the application form in private. If you believe that someone has interfered with your right to register or to decline to register to vote, or your right to choose your own political party or other political preference, you may file a complaint with the Elections Division, Secretary of State, P.O. Box 12060, Austin, TX 78711. Telephone: 18002528683

Agency Use Only: Voter Registration Status

Already registered		Client declined

Client to mail		Mailed to client

Agency transmitted

Other

Signature–Agency Staff

9. Legal information

Discrimination

If you think you have been treated unfairly (discriminated against) because of race, color, national origin, age, sex, disability, or religion, you can file a complaint. Contact us by:

ﾃEmail – HHSCivilRightsOffice@hhsc.state.tx.us.

ﾃMail – HHSC Civil Rights Office, 701 W. 51st St., Suite 104, MC W206, Austin, TX 78751.

ﾃPhone (tollfree) – 18883886332 or 18774327232 (TTY). Fax – 15124385885.

You also can contact the U.S. Department of Health and Human Services (HHS).

ﾃMail – HHS, Office for Civil Rights Region VI, 1301 Young St., Room 1169, Dallas, TX 75202.

ﾃPhone – 18003681019 (tollfree) or 12147678940 (TTY). Fax – 12147674032.

Social Security Numbers

You only need to give the Social Security numbers (SSN) for people who want benefits. If you don't have an SSN, we can help you apply for one if you are a U.S. citizen or a legal immigrant. Giving or applying for an SSN is voluntary; however, anyone who doesn't apply for an SSN or doesn't give an SSN can't get benefits.

We will not give your SSN to the Bureau of Citizenship and Immigration Services. We will use SSNs to check the amount of money you get (income), if you can get benefits, and the amount of benefits you can get. You won't have to give SSNs for any family members who are not eligible because of immigration status and who are not asking for benefits. (42 C.F.R. 435.910)

Form H1200MBIC

Page 6 / 032011

10. Statement of understanding

Facts HHSC Has About You

In most cases, you can see and get facts HHSC has about you. This includes facts you give HHSC and facts HHSC gets from other sources (medical records, employment records, etc.). You might have to pay to get a copy of these facts. You can ask HHSC to fix anything that is wrong. You do not have to pay to fix a mistake. To ask for a copy or to fix a mistake, you can call 211 or your local HHSC benefits office.

ﾃI have been advised and understand that this application or redetermination will be considered without regard to race, color, religion, creed, national origin, age, sex, disability or political belief.

ﾃI have been advised and understand that I may request a review of the decision made on my application or redetermination for benefits and may request a fair hearing, orally or in writing, concerning any action or inaction affecting receipt or termination of assistance.

ﾃIf my case is selected for review, I give my consent for HHSC to obtain information from any source to verify the statements I have made.

ﾃI understand that HHSC may give my name, address and phone number to telephone and electric utility companies to help them determine if I qualify for a reduction in my bills.

11.Penalty statement

ﾃMy answers to all of the questions, and the statements I have made, are true and correct to the best of my knowledge and belief.

ﾃI understand that if I obtain or assist another person in obtaining, medical assistance by fraudulent means, I may be charged with a state or federal offense; and I may also be held liable for any repayment of benefits fraudulently obtained.

ﾃI will let HHSC know within 10 days of any changes that could affect my eligibility. This includes changes in income, living arrangement or insurance (including health insurance premiums).

12.Sign and date the form

I certify under penalty of perjury that the information I have provided on this application is true and complete to the best of my knowledge. If it is not, I may be subject to criminal prosecution.

Sign here if you are applying for benefits. Or if you are the authorized representative.	Date
If the child applying for benefits is age 17 or younger, a parent must sign.

If the person above signed with an "X" or other mark, we need the signature of 2 witnesses:

Sign here if you are a witness

Date

Sign here if you are a witness

Date

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Common mistakes

Missing Signatures: Ensure that you sign and date Page 6. An unsigned form will delay processing.
Incomplete Information: Answer every question. If a question does not apply, write “none.” Leaving questions blank can lead to rejection.
Incorrect Documentation: Only send copies of required documents. Originals are not needed and may get lost.
Failing to Meet Income Limits: Double-check that your family's income meets the program's limits. Exceeding these limits will disqualify you.
Not Providing Proof of Health Insurance: If a parent’s employer offers health insurance, that insurance must be maintained. Failing to enroll can affect eligibility.
Incorrectly Reporting Child's Citizenship: Clearly indicate if the child is a U.S. citizen or a legal immigrant. Inaccuracies can cause significant delays.
Ignoring Additional Children: If there are more than two children applying, remember to add extra pages. Omitting children can lead to incomplete applications.
Not Following Up: After submission, keep track of your application. If you don't hear back within 45 days, reach out for updates.
Neglecting to Seek Help: If you have questions or need assistance, don’t hesitate to contact an HHSC benefits office or call 2-1-1 for guidance.

Key takeaways

Key Takeaways for Filling Out the Texas H1200 MBIC Form

The Texas H1200 MBIC form is for families seeking Medicaid Buy-In benefits for children with disabilities.
Eligibility requires the child to be 18 or younger and meet the disability criteria for Supplemental Security Income (SSI).
Parents must enroll in employer-sponsored health insurance if it covers at least half of the costs.
Income limits apply, and families may need to pay a monthly fee for the program.
Complete all sections of the form, and write “none” if a question does not apply.
Submit copies of necessary documents, such as pay stubs and medical bills from the last six months.
Applications can be sent via fax or mail, with a decision expected within 45 days.
Free legal assistance is available; contact your local benefits office for resources.

⇓ Texas H1200 Mbic PDF

Steps to Using Texas H1200 Mbic

Filling out the Texas H1200 Mbic form is an important step in applying for Medicaid Buy-In for Children. This program assists families with children who have disabilities but earn too much to qualify for traditional Medicaid. To ensure a smooth application process, follow the steps outlined below carefully.

Begin by obtaining the Texas H1200 Mbic form. You can find it online or request a copy from your local benefits office.
Fill in the child's information in the first section. Include the child's first name, middle initial, last name, and Social Security number. Indicate if the child is married, their home address, and contact numbers.
Provide the child's birth date and gender. Confirm whether the child lives in Texas and plans to stay there.
If the child is not a U.S. citizen, answer the questions regarding their immigration status. Provide the immigrant registration number if applicable.
Next, indicate the child's race and ethnicity by marking the appropriate boxes.
If more than one child is applying, repeat the process for each additional child in the designated section.
Move on to the parents' information. Fill out the details for the first parent, including their name, Social Security number, and whether they live with the child.
Answer questions about the first parent's job and health insurance. If applicable, provide the employer’s name and address, gross pay, and whether health insurance is available.
If the second parent is involved, repeat the same process for them, filling out their information and job details.
If the child has siblings living in the same household, provide their details in the designated section. Include their names, Social Security numbers, and employment information if applicable.
Address any other health insurance coverage the child may have by answering the relevant questions and providing the necessary details.
Indicate whether the child has medical bills from the past three months and prepare to submit copies of those bills along with proof of income.
Finally, list any additional sources of income for the child and the parents or siblings living with them. Attach any necessary proof of income.
Review the completed form for accuracy. Make sure all sections are filled out correctly.
Sign and date Page 6 of the form.
Gather copies of all required documents, ensuring you do not send originals.
Submit your application via fax or mail to the appropriate address provided on the form.

Once your application is submitted, the review process will begin. You may be contacted for additional information if needed, and a decision will typically be communicated within 45 days. Remember, assistance is available if you have questions or need help during this process.