N-9000, Notices and Forms

Revision 20-2; Effective June 1, 2020

Form H1200-MBIC and new forms have been created for this program. Most of the new forms are pre-populated by the system. These forms are also available in this handbook. If a form is completed manually from this handbook, follow the instructions for that particular form.

Even though a new application has been created for this program, also accept the Form H1200, Application for Assistance – Your Texas Benefits, as an application for the Medicaid Buy-In for Children (MBIC) program.

Use the current Form H1020, Request for Information or Action, for missing information. The H1020 instructions are updated to include MBIC program-specific information.

Appendix XLIX, Medicaid Buy-In for Children Forms Chart, outlines the:

  • form name;
  • purpose of each form;
  • naming convention of each form in TIERS; and
  • naming convention of each form in this handbook.

TIERS generates Form TF0001-MBIC for all eligibility notices. The MBIC program has seven notices that will use the TF0001 format in TIERS. Because the TF0001 is a TIERS-generated form, MBIC eligibility notices have a different number in this handbook. The form content is the same.

N-9100, Replacement Medicaid Card

Revision 22-3; Effective September 1, 2022

A recipient will only receive one Your Texas Benefits  Medicaid card, which is intended to be the recipient’s permanent card. A recipient’s Your Texas Benefits Medicaid card will only be replaced if the card is damaged, lost or stolen. 

Related Policy

Your Texas Benefits Medicaid Card, R-2300