M-9000, Notices and Forms

Revision 21-4; Effective December 1, 2021


Form H1200-MBI, Application for Benefits – Medicaid Buy-In. 

Application form for the Medicaid Buy-In (MBI) program. MBI applicants may also submit Form H1200, Application for Assistance — Your Texas Benefits, and write in “MBI” on the top of the form.

Missing Information

Form H1020, Request for Information or Action

Use to request missing information or verification.


Use Form H0053, Medicaid Buy-In Potential Eligibility Notice, to notify an applicant of potential eligibility for the MBI program. 

Use Form H0054, Medicaid Buy-In Eligibility Notice, to notify an applicant of eligibility for the MBI program. 

Complete the form by entering the benefit month(s), the certified person, the monthly premium amount(s), the premium due date and all other required information. 

Note: After the MBI potential eligibility EDG is disposed, Form TF0001, Notice of Case Action, is automatically generated. Do not send the TF0001 to the applicant as the system-generated notice has incorrect information.  Suppress the TF0001 and send a manual Form H0053. The Form H0053 provides instructions on how MBI recipients send in their first premium payment.


Form TF0001 is automatically generated and sent to batch when an MBI EDG is denied. Staff must confirm the Form TF0001 includes the correct MBI denial reason. If the incorrect reason is listed, manually add the correct reason for denial in the comments section before generating the Form TF0001. 

Case in Ongoing Mode (Approved or Denied)

Form H0054, is used to notify a recipient of receipt of their premium payment, months of coverage and premium amount received.  

Related Policy

Missing Information Due Dates, B-6420
Denials, B-6500
Denial Reasons, M-8500
MBI Screening Tool and Worksheet, Appendix XXXIX