Blank Texas H1200 Mbic PDF Form Get Texas H1200 Mbic Here

Blank Texas H1200 Mbic PDF Form

The Texas H1200 Mbic form is an application for the Medicaid Buy-In for Children program, designed to assist families with children who have disabilities. This program provides financial support for medical expenses to families whose income exceeds the limits for traditional Medicaid. By completing this form, families can access vital healthcare resources for their children, ensuring they receive the necessary medical attention.

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The Texas H1200 Mbic form is an essential tool for families seeking assistance through the Medicaid Buy-In for Children program. This program is designed to support children with disabilities whose families earn too much to qualify for traditional Medicaid. To be eligible, the child must be 18 years old or younger and meet specific disability criteria similar to those for Supplemental Security Income (SSI). Parents must also enroll their child in their employer's health insurance if it covers at least half of the costs. Income limits apply, and families may need to pay a monthly fee. Completing the form involves answering a series of questions about the child, their parents, and any siblings living in the household. It also requires submitting supporting documents, such as proof of income and medical expenses. Once submitted, the Texas Health and Human Services Commission will review the application and inform families of their eligibility within 45 days. For those who need assistance, free legal help is available, and resources can be found by contacting local benefits offices.

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Form H1200-MBIC
December 2016-E
Application for Benefits - Medicaid Buy-In for Children
About this program:
Medicaid Buy-In 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:
• The child must be age 18 or younger.
• The child must meet the same rules for a disability that are used to get Supplemental Security Income (SSI).
• 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.
• The family must meet income limits set by the program.
• 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.
• Proof of money from a job: Pay stubs or earning statements.
• Proof of money not from a job (veterans benefits, Social Security income, etc.): Award letters.
• 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: 1-877-447-2839. If your form is 2-sided, fax both sides.
Mail: Health and Human Services Commission, P.O. Box 149024, Austin, TX 78714-9024.
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 2-1-1 (toll-free).
2-1-1 also can answer questions about this program. When you call: (1) pick a language
(2) pick option 2.
1. Child applying for benefits
Child's Full Name
Social Security number
Is the child married?
Yes
No
Home Address - street and number
City
State
County of Residence
Home Phone
Form H1200-MBIC
Page / 12-2016-E
Mailing Address (if different) - street and number
City
State
County of Residence
Cell Phone
Date of Birth
Is the child:
Male
Female
Does the child live in Texas?
Yes
No
Does the child plan to stay in Texas?
Yes
No
Is the child a U.S. citizen?
Yes
No
If the child is not a U.S. citizen:
Is the child a refugee or legally admitted immigrant?
Yes
No
Is the child registered with the U.S. Citizenship and Immigration Services?
Yes
No
If yes, give immigrant registration number:
The child is (mark one or more):
American Indian or Alaska Native
Asian
Black or African-American
Native Hawaiian or Pacific Islander
White
Hispanic or Latino
2nd child applying for benefits
Child's Full Name
Social Security number
Is the child married?
Yes
No
Home Address - street and number
City
State
County of Residence
Home Phone
Mailing Address (if different) - street and number
City
State
County of Residence
Cell Phone
Date of Birth
Is the child:
Male
Female
Does the child live in Texas?
Yes
No
Does the child plan to stay in Texas?
Yes
No
Is the child a U.S. citizen?
Yes
No
If the child is not a U.S. citizen:
Is the child a refugee or legally admitted immigrant?
Yes
No
Is the child registered with the U.S. Citizenship and Immigration Services?
Yes
No
If yes, give immigrant registration number:
The child is (mark one or more):
American Indian or Alaska Native
Asian
Black or African-American
Native Hawaiian or Pacific Islander
White
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
2. Parents living with the child
Items marked “optional” can help us work your case better.
1st parent
Parent's Full Name
Social Security number (optional)
Do you live with the child?
Yes
No
Are you:
Male
Female
Date of Birth (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
No
Form H1200-MBIC
Page / 12-2016-E
If yes, give the attached "Employment Verification" (Form H1028-MBIC) 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.
Add Employer Remove Employer
Employer's Name
Employer's 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:
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
(this is usually a monthly payment)?
Yes
No
6. What is the insurance company's address?
2nd parent
Parent's Full Name
Social Security number (optional)
Do you live with the child?
Yes
No
Are you:
Male
Female
Date of Birth (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
No
If yes, give the attached "Employment Verification" (Form H1028-MBIC) 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.
Add Employer Remove Employer
Employer's Name
Employer's 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:
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
(this is usually a monthly payment)?
Yes
No
6. What is the insurance company's address?
Form H1200-MBIC
Page / 12-2016-E
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?
Yes
No
If no, skip this section.
If yes, give facts below. Add more pages, if needed. Items marked “optional” can help us work your case better.
Brother
Sister
Full Name
Social Security number (optional)
Date of Birth (optional)
Does this person have a job?
Yes
No
If this person has a job, give 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.)
If age 18 to 21:
Is this person in school or training for a job?
Yes
No
If yes, when will this person finish? You
will need to send proof that this person is in
school or training
Add Sibling Remove Sibling
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
No
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
No
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.
Form H1200-MBIC
Page / 12-2016-E
Type of money
Monthly amount
(before taxes are taken
out)
Who pays the money?
Monthly amount
(before taxes are taken
out)
Who pays the money? Who gets the money?
Money the child applying for benefits gets:
Money the parents, and brothers and sisters age 21 or younger, who live
with the child get:
Type of money
Monthly amount
(before taxes are taken
out)
Who pays the money?
Monthly amount
(before taxes are 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
$
$
7. Authorized representative
If you want, you can give someone the right to act for you (an authorized representative).
That person can:
• Give and get facts for this application.
• Take any action needed for the application process. This includes appealing an HHSC decision.
• Take any action needed to enroll in Medicaid or CHIP. This includes picking a health plan.
• Take any action needed to get benefits. This includes reporting changes and renewing benefits.
You can have only one authorized representative for all your benefits from HHSC. If you want to change your authorized representative:
(1) log in to your account on YourTexasBenefits.com and report a change, or (2) call 2-1-1 (after you pick a language, press 2). If you're
a legally appointed representative for someone on this application, send proof with the application.
Do you want to give someone the right to act for you - to be your authorized representative?
Yes
No
If yes, tell us about that person:
Name of authorized representative
Organization
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
No
Form H1200-MBIC
Page / 12-2016-E
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. Phone: 1-800-252-8683.
Agency Use Only: Voter Registration Status
Already registered
Client declined
Agency transmitted
Client to mail
Mailed to client
Other
Date
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:
• E-mail: HHSCivilRightsOffice@hhsc.state.tx.us.
• Mail: HHS Civil Rights Office, 701 W. 51
st
St., Suite
104, MC W-206, Austin, TX 78751.
• Phone (toll-free): 1-888-388-6332.
• Fax: 1-512-438-5885.
You also can contact the U.S. Department of Health and Human Services
(HHS).
• Mail: MIS, Office for Civil Rights - Region VI, 1301
Young St., Room 1169, Dallas, TX 75202.
• Phone: 1-800-368-1019 (toll-free) or 1-214-767-8940 (TTY).
• Fax: 1-214-767-4032.
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)
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
2-1-1 or your local HHSC benefits office.
• 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.
• 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.
• 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.
• 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.
Form H1200-MBIC
Page / 12-2016-E
11. Penalty statement
• 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.
• 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.
• 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.
Date
If the person above signed with an "X" or other mark, we need the signature of 2 witnesses:
Date
Date
⇓ Texas H1200 Mbic PDF

Document Specs

Fact Name Description
Purpose The Texas H1200 MBIC form is used to apply for the Medicaid Buy-In for Children program, which assists families in covering medical expenses for children with disabilities.
Eligibility Criteria To qualify, the child must be 18 years old or younger and meet the disability criteria similar to those for Supplemental Security Income (SSI).
Income Requirements Families must meet specific income limits set by the program to be eligible for benefits.
Health Insurance Requirement If a parent’s employer covers at least half of the health insurance costs, the parent must enroll the child in that insurance.
Application Process Applicants must fill out the form, provide necessary documentation, and submit it via fax or mail to the Health and Human Services Commission.
Decision Timeline The Health and Human Services Commission will notify applicants of the decision within 45 days of receiving the application.
Governing Law This form is governed by Texas Health and Safety Code, Chapter 32, which outlines the Medicaid program in Texas.
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