Appendices
Appendix I, Medicaid for Breast and Cervical Cancer (MBCC) Application Checklist
Revision 24-3; Effective Dec. 9, 2024
Note: Incomplete MBCC applications must not be submitted to BCCS.
MBCC Application (H-1034)
Answer all questions and fill in every blank on the H-1034 as follows:
- Verify the client’s legal name, date of birth and Social Security number are correct.
- Verify presumptive eligibility has been met.
- Verify the client has a biopsy-confirmed and qualifying diagnosis. See Appendix II, Medicaid for Breast and Cervical Cancer (MBCC) Guidelines.
- Verify the date of the diagnosis matches the collection date on the biopsy pathology report.
- Check for unpaid medical bills for services that were received three months before date of application submission — Indicate yes or no and months when they occurred if applicable.
- Do not mark in the HHSC Agency Use Only section.
Attach copies of the following supporting documents:
- The final pathology report with the biopsy-confirmed, qualifying diagnosis, with no highlighting
- Verification of identity, U.S. citizenship or legal immigrant status
Email HHSC Centralized Benefit Services (CBS) for additional information about citizenship and immigrant status.
If the client’s insurance is expired, terminated or does not cover cancer treatment, check for both of the following:
- Copy of insurance card
- Letter or explanation of benefits from insurance company
If the client’s qualifying diagnosis was more than one year ago, check for the following:
- Physician letter that specifies active treatment needed or
- Recent medical documentation that supports a need for active treatment
Note: Do not fax tax forms, pay stubs or any other financial documents. Clients may not self-declare income. Financial documents must be kept with the client chart.
Med-IT
Enter client details and patient navigation in Med-IT® as follows:
- Make sure enrollment status is correct:
- Active — client received BCCS services before the cancer diagnosis.
- MBCC Referred-In — client never received BCCS services, was diagnosed by a non-BCCS provider and was referred in for MBCC application only.
- Make sure the navigation module is complete.
- Bill with the appropriate patient navigation code.
Processing the H-1034
Fax or securely email the H-1034 to BCCS at 512-776-7203 or MBCCApps@hhs.texas.gov.
When the application is received, BCCS program staff:
- requests additional information if needed; and
- nurse consultants review and send the H-1034 to HHSC CBS.
Note: BCCS does not assist with or collect documents for MBCC applications following submission to CBS.
The status of a client’s application will be documented in the client’s Med-IT® record under enrollment notes when an application has been received and when it was sent to CBS for final eligibility determination. If there are no notes in the client’s enrollment record after three business days, you may send an email to mbccapps@hhs.texas.gov. Use the client Med-IT® identification number in the subject line. Exclude protected health information.
MBCC Application Status and Medicaid Number
Clients may call 211 for their application status and Medicaid number.